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.

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.

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.

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.