Medication - what next help

[welshdory]

Brief ish background

Female, 42. Long history of GAD, most recently accompanied by depression. My husband of 18 years passed away a year ago after a 2 year battle with a brain tumour. I have 2 kids with little family support.

I am feeling so down and unsure whether this is down to my medication not working (currently on 15mg escitralopram), grieving, being perimenopausal (I have also just started HRT) or just life in general.

I feel so low and mu doctor is very supportive but I feel like I need an idea of what meds to try next.

I've tried a number of different ones over the years and have always come back to escitralopram as it's the one that I seem to have tolerated best, with the least side effects. However I am feeling so down, I know its not working anymore and hasn't for a while.

Any suggestions please?. I am having counselling also.

Thanks in advance

[panic_down_under]

I am feeling so down and unsure whether this is down to my medication not working (currently on 15mg escitralopram), grieving, being perimenopausal (I have also just started HRT) or just life in general.

It is likely all of the above to varying degrees.

I've tried a number of different ones over the years and have always come back to escitalopram as it's the one that I seem to have tolerated best, with the least side effects. However I am feeling so down, I know its not working anymore and hasn't for a while.

Have the other ADs all been SSRIs and SNRIs? If so it might be time to give the older tricyclic antidepressants (TCAs) a try. They are often more effective than the newer meds and less likely to stop working. Their main side-effects are usually dry-mouth and constipation which are manageable.

Another possibly is augmenting escitalopram with a small dose, 20-30mg/day, of buspirone (Buspar). Buspirone is a GAD specific med which works well for some, but not for most. However, when taken with SSRIs it can boost their effectiveness and restore them to full function if they've stopped working. It also often moderates some SSRI side-effects. While there are no guarantees if it works it would produce the quickest result, possibly within 3 weeks. Your main problem is likely to be getting a prescription as the NHS apparently doesn't favour it.

[welshdory]

Thank you so much I really appreciate you taking the time to reply.

Which TCA would you recommend? Previously I was worried about weight gain (I'm already overweight) however now I just don't want to feel like this anymore

[panic_down_under]

Which TCA would you recommend?

Either amitriptyline or imipramine. Your GP will likely suggest amitriptyline whereas I'd lean a little to imipramine, but it's a coin toss.

Previously I was worried about weight gain (I'm already overweight) however now I just don't want to feel like this anymore

TCAs are more likely to cause weight gain because of the inhibition of histamine H1 and serotonin 5-HT2C receptors. Imipramine has a weaker impact on both than amitriptyline which may lower the potential weight gain, but it's unlikely to be a huge difference.

While it's written for doctors you may find the advice given in How to control weight gain when prescribing antidepressants (PDF) useful.

Increasing the amount of exercise will help too, not only for weight, but exercise has been shown to produce the same positive brain changes as antidepressants and the cognitive, behavioural (CBT, REBT, etc) and mindfulness therapies. You don't need to run a daily marathon, a 30 minute walk 3-4 times a week can do wonders for both.

[welshdory]

Hi I spoke to my doctor today and he wants to try switching me to duloxetine. Any experience with this one?

[panic_down_under]

Hi I spoke to my doctor today and he wants to try switching me to duloxetine. Any experience with this one?

I tried it back in the early 1990s. It didn't work for me, but then neither did SSRIs. At least it didn't make my manic as they did.

I rate the TCAs as better and they are often easier to quit, but I understand why he would prefer duloxetine. The NHS advises him that he can switch you from escitalopram to duloxetine overnight whereas it recommends a 2-4 week cross-taper from escitalopram to amitriptyline or imipramine, so a little more complicated to manage and it may take an extra couple of weeks for the new med to kick-in.