Treatment Resistant Depression

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.

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

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