Question: I am 34 years old and a couple of years ago I had an onset of horrible anxiety now diagnosed as OCD (intrusive thoughts). I tried Paxil, with no luck, and was on Zoloft with about 50% control combined with therapy. Two months ago my therapist encouraged me to wean from Zoloft. I am now having terrible relapse and want to begin medication again. Have you had any experience with Effexor helping with OCD? Do you feel one SSRI is better at controlling OCD than another? Answer: There is limited research that compares one SSRI to another for OCD. There is some evidence that Anafranil (Clomipramine) is better because it combines the SSRI effect with a norepinephrine reuptake inhibitor effect. But Anafranil also has more side-effect issues. There was one study where people with OCD responded fairly well to Effexor XR. At doses of 150 to 225mg Effexor has the benefits of Anafranil without all the extra side-effects. I have patients who have benefited from all of the above but there’s no way to predict who will do best on what. It’s always important to also do the cognitive behavior techniques described in the book Brain Lock (available at Amazon.com). I prefer that people listen to the tape because the author not only tells you what to do he shows you how to talk to yourself. A lot of patients don’t get an adequate response to an SSRI or Effexor XR even after 12 or more weeks and even doing the Brainlock techniques. Often adding Clonazepam (also available as Klonopin wafers-quicker acting sublingual) or Abilify usually low dose of 2.5mg (or other atypicals) can help get symptoms under control. Sometimes stimulants help because they increase your control of what you focus on. The bottom line is you keep making adjustments until you find what works. In the rare instance that nothing works adequately you won’t have to wait long. There’s always something new coming.

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This article originally appeared in the Q&A section 06/17/2005.

Question: I am 34 years old and a couple of years ago I had an onset of horrible anxiety now diagnosed as OCD (intrusive thoughts). I tried Paxil, with no luck, and was on Zoloft with about 50% control combined with therapy. Two months ago my therapist encouraged me to wean from Zoloft. I am now having terrible relapse and want to begin medication again.
Have you had any experience with Effexor helping with OCD? Do you feel one SSRI is better at controlling OCD than another?
Answer: There is limited research that compares one SSRI to another for OCD. There is some evidence that Anafranil (Clomipramine) is better because it combines the SSRI effect with a norepinephrine reuptake inhibitor effect. But Anafranil also has more side-effect issues.

There was one study where people with OCD responded fairly well to Effexor XR. At doses of 150 to 225mg Effexor has the benefits of Anafranil without all the extra side-effects.
I have patients who have benefited from all of the above but there’s no way to predict who will do best on what.
It’s always important to also do the cognitive behavior techniques described in the book Brain Lock (available at Amazon.com). I prefer that people listen to the tape because the author not only tells you what to do he shows you how to talk to yourself.
A lot of patients don’t get an adequate response to an SSRI or Effexor XR even after 12 or more weeks and even doing the Brainlock techniques. Often adding Clonazepam (also available as Klonopin wafers-quicker acting sublingual) or Abilify usually low dose of 2.5mg (or other atypicals) can help get symptoms under control. Sometimes stimulants help because they increase your control of what you focus on.
The bottom line is you keep making adjustments until you find what works. In the rare instance that nothing works adequately you won’t have to wait long. There’s always something new coming.

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This article originally appeared in the Q&A section 06/17/2005.

Question: I am a 24 year old who has suffered anxiety and depression since the age 15. Nothing has worked. I have mostly taken Zoloft. Recently I have switched to Cymbalta. I am in my second week of Cymbalta and feel very keyed up, irritable, anxious, and feel as if I could loose my mind. My quality of life gets worse from day to day. I am pretty much begging someone to help me! I have tried therapy, psychologist, psychiatrist and a few other medicines. Could you please lend me some advice??
Answer: Without doing an evaluation or having a doctor patient relationship with you, I can’t give you specific medical advice. I can only discuss general principles.
First, make only one medication change at a time. When you stop one and start another at the same time you can’t be sure if you have problems due to side effects of the new medication or discontinuation of the original one.
When starting an SSRI (like Zoloft) or and SNRI (like Cymbalta) they can make anxiety symptoms worse for the first 2-3 weeks or longer.

In general it works better to use a benzodiazepine with them at least for the first 3-4 weeks (e.g., Alprazolam, Clonazepam, Lorazepam) See Best Meds for Anxiety
There are patients who don’t seem to tolerate any norepinephrine enhancing medication. They usually do better on Lexapro or Celexa, the most purely serotonin modulating antidepressants now available.

The following question addresses specific aspects of this patients case. However, the underlying principle is an important aspect of effective medication management. What are treatment options when a single medication, even at high doses, is not adequate?
Question: Hello, I am mostly looking for a second opinion, and this website is coming up on pretty much all search engines. I moved to Dallas about 1 yr. ago.
I was taking 300 mg Effexor XR and 45 mg Dexedrine (2 in am, 1 @ noon). I had to stop the dexedrine because I became pregnant. Now that’s over, and I chose a doctor in TX mostly based on proximity to my job, and that they took my insurance. However, now they have kept me on 300 mg Effexor, added 200 mg Provigil, 2 mg Lunesta, and Zoloft. I was told at the beginning that I was to take 150 mg Zoloft (I feel that Effexor is not working like it used to) and once I felt better, I would be weaned off Effexor, and only take the Zoloft. I did this for a couple weeks, but when I still didn’t feel better, they upped the Zoloft to 200 mg. A couple weeks after that I still do not feel better. I told the new Dr. that I do not want to become dependent on 2 antidepressants (I have tried to wean off Effexor 3 times now–with horrible withdrawal symptoms-enough to make me keep taking the medicine, even though I don’t feel it’s working).
The Dr. now wants to double my Zoloft to 400 mg. I am VERY hesitant to do this. (700 mg of antidepressants?) He did ask if there was any time I could remember feeling better and I told him about my previous Dr recommending 300 mg Eff w/45 mg of Dexedrine (I came to him on 75 mg Effexor, he tried methylphenidate 1st, but it gave me awful headaches, so switched to dex).
The new doc seems to really not like stimulant type drugs (emph. added), so they put me on Provigil. It was great at first (after giving birth and being off med. for about a year) but I think i have quickly built up a tolerance, because it is no longer as effective as it was. I am hoping that my intuition is correct, and that I do not require 700 mg of antidepressants, but that it is only the Dexedrine that is missing, and this new Dr. is wrong. I am absolutely terrified of becoming “hooked” on 2 antidepressants vs. 1, and have refused the 400 mg of Zoloft for now.
I am very hesitant to continue w/this Dr’s advice, when I have told him what worked for me in the past, and he has not told me anything regarding why that is not the appropriate treatment, or why he does not prescribe the Dexedrine, and continue to monitor my progress to make sure it is the right treatment option. (emph. added) Help!!
Answer: “If it ain’t broke, don’t fix it”. When a medication combination works well we don’t usually change it. If we have to stop, especially during pregnancy, we go back to it.
We sometimes have to combine antidepressants but it’s better if possible to take only one.
Provigil is totally different than stimulants like Dexedrine. It does have a tendency to develop tolerance because it induces the enzymes that break it down.
Going above approved doses of antidepressants is usually reserved for when all else fails.
Bottom line, I agree with you.

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This article originally appeared in the Q&A section10/26/2005.

Question: Can a series of major stress over a period of 3-4 years cause a person to become bipolar?

– Pat P.
Answer: If one has genetic predisposition, then a series of stressors can turn on the genes and induce depression, hypomania or both (mixed or dysphoric mania). Non-genetic personality factors and availability of social support also play a a significant role. In the absence of genetic predisposition, it takes a lot more stress overload to induce symptoms.
It’s analogous to the situation of high sodium diet and high blood pressure. It’s the combination of genetic predisposition plus high sodium that leads to hypertension, whereas neither alone do it.
For more info, see the blog on Jane Pauley and the overview of Bipolar Disorder.

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This article originally appeared in the Q&A section 12/16/2004. Revised 01/21/2006.

Thursday morning, I saw that James Frey, author of bestselling A Million Little Pieces, and his publisher were appearing on Oprah. I told my staff if she is still supporting him, I’m going to write her a letter.

My concerns were allayed from the opening bell. With Oprah’s first salvo, Frey seemed befuddled and dazed. He had no defense. He threw no counter punches except a lame response to her question, "Why didn’t you have it published as fiction?" He said meekly and unconvincingly, "I still consider it a memoir."

It’s not accurate to say it’s based on a true story. It’s more like inspired by his experience. His story seems contrived from the very beginning.

First, there’s the improbable plane ride. Then, there’s an implausible car trip with his parents to the rehab center, drinking all the way. Next, there’s a lack of supervision at the rehab center (which is considered the best in the world), a brief severe episode of DT’s (Not just seeing animals - but they were talking to him. DTs are not likely at his age and they occur with delirium and require aggressive medical treatment), treatment with both Librium and Valium (These are both long-acting benzodiazepines - an irrational and potentially dangerous combination), a double root canal without anesthesia, etc.

As Richard Cohen, one of Oprah’s guests and a Washington Post columnist, said, "The book doesn’t pass the smell test … How’d this guy get on an airplane? I can’t get on with a third piece of luggage."

How do you define character, class and leadership? It’s simple: Oprah Winfrey. Yesterday we were treated to a tour de force. It was a course in dealing with mistakes, betrayal and confrontation in one hour.

Oprah was apologetic and humble, but also strong and determined. She accepted responsibility for her mistake. She showed no defensiveness, and she demurred when complimented for the way she had handled the whole situation. She was very clear not just with what she thought about all the gross deceptions and manipulation but also about her feelings. When the publisher said to her "I think this whole experience is very sad. It’s very sad for you. It’s very sad for us." Oprah replied, "It’s not sad for me. It’s embarrassing and disappointing for me."

We’re not embarrassed. We’re proud and glad that we have at least one model we can point to and say, "That’s how you do it."

Question: A friend has been on Effexor XR for a few years now, but the doctor wants her to get on Welbutrin to help her stop smoking. Can she take both Welbutrin and Effexor XR together if she cuts the Effexor XR to 75 from 150, and will this give her the desired effect of both?

– Jeremy W.
Answer: Effexor XR and Wellbutrin XL or SR are usually tolerated well taken together. She may not need to decrease her dose of Effexor XR.
It is better to take Wellbutrin in the am and Effexor at suppertime or 6pm to avoid both peaking at the same time. She might want to at least monitor her BP, especially if she takes both in the am.

This combination is especially good for managing sexual side effects, delayed/absent orgasm and/or libido.
Wellbutrin may also help with possible weight gain on Effexor XR (or any SSRI/SNRI). For decreased craving for cigarettes, she will probably need 300 mg Wellbutrin and possibly 450 mg/day. The XL form is safer and better tolerated, but the SR form is in generic, and therefore, sometimes necessitated by cost issues.

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This article originally appeared in the Q&A section 04/01/2005. Revised 01/22/2006.

FAQs: Comparing Meds

Question: What is the association between Tics/Tourette’s and ADHD/stimulants?
Answer: Tics are sudden muscle movements, jerks, or spasms. They are most common in the head (eye blinking, facial twitches), neck (head turns), or arms/shoulders. They usually start in early childhood and tend to get better with age. They sometimes persist into adulthood, and ironically, the most severe cases are in adults. Tics occur in 1-2% of kids.
Tourette’s is a more severe form of tic disorder and includes some form of vocalization, not limited to speech. This may take the form of a cough or throat clearing. I have made the diagnosis in several people over the years who weren’t aware they had tics of Tourette’s Syndrome (TS). In TS tics usually precede vocalization by 1-2 years.
Both of these disorders are more common in kids/adults with ADHD or OCD. In fact, Tourette’s is 10x more common in people with OCD than in the general population. Tics/TS are genetically based and involve a hypersensitivity to dopamine.
Because stimulants (e.g., Adderall, Concerta) increase dopamine activity, and the most effective treatments for tics/TS are dopamine blockers (Haldol, Orap), it was previously thought stimulants were contraindicated. Also, since sometimes tics first show up in a child taking a stimulant, it has been thought that the stimulant was the cause. Current evidence does not support this. Some kids with tics/TS do better on Concerta, some better on Adderall, and some can’t take either without aggravating their tics.
Before using Haldol/Orap, I usually first try milder meds like clonidine (blood pressure med), Tenex, or milder dopamine blocking agents like Abilify or Risperdal.
It is important to be aware of the frequent association of tics/TS with ADHD and OCD and to recognize the symptoms are sometimes subtle because there can be adverse effects, especially social. Most of the time, symptoms can be well controlled.

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FAQs: ADHD

On average, it takes about ten days for antidepressants to start to work for major depression. The first 1-2 weeks is an adjustment period. At this time side effects will usually occur. The dose may need to be reduced for 3-4 days to allow adaptation to occur. Most side effects are short term and will go away, so patience is needed during this time.
Depression may not respond fully from medication for 6-8 weeks. Occasionally augmentation (adding another medication) may be needed for good response.
It is usually better to treat side effects than to change antidepressants if depression/stress symptoms are responding well. This is especially true for long term side effects.

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SIDE EFFECT TREATMENT
• Insomnia - Sonata, Ambien, Trazodone, Remeron
• Drowsiness - Stimulants, Wellbutrin, Provigil,
Phentermine
• Increased Appetite - Phentermine, Wellbutrin, Topamax
• Mood swings - Mood stabilizers
• Nausea - Remeron, Periactin, Zofran, Reglan
• Tremor - Inderal
• Sweating - Clonidine, Tenex, Cardura
• Anxiety/Nervousness - Xanax, Klonopin, Ativan, Buspar, Keppra, Neurontin
• Libido - Wellbutrin, Stimulants, Ginkgo, Testosterone (if low), DHEA
• Sexual Arousal - Viagra, Trazodone
• Orgasm - Wellbutrin, Yocon

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(This article originally appeared on this site 11-16-04 under the category Depression.)

The most common sexual side effect from SSRI’s is delayed orgasm. (more on SSRI’s ) For a lot of men this is not a problem - in fact can be helpful. This effect of SSRI’s is almost immediate - quickest for Effexor, then Lexapro, Celexa, Paxil, Prozac, and Zoloft. Delayed orgasm can be a problem for women - especially if it gets into hours/days (kidding on days). But absent orgasm is a problem for both.
A previous study showed that short acting Wellbutrin taken 1-2 hours before sex would correct orgasm problems in 40-45%. If Wellbutrin were taken regularly, another 20% or so would respond. If it works on a PRN (as needed) basis, why use it daily? Well, if you’re having sex very frequently, daily medication makes sense. If once a week, PRN makes more sense. Other things that have been used for anorgasmia include stimulants, Yocan (OTC or prescription), and Amantadine. Viagra, Cialis, and Levitra have also been helpful for some (probably by increasing degree of stimulation).
For treating problems with arousal in men, Viagra, Cialis, and Levitra have been effective for most - here PRN is the rule. Sometimes trazodone helps PRN for erectile dysfunction through its alpha blocking effect - since norepinephrine decreases arousal (a frequent problem with decongestants and sometimes stimulants).
Treating loss of libido requires daily treatment. Sometimes Wellbutrin or a stimulant can be helpful.