ever use oral selegiline for treatment resistant depression?

[jamesearlejones]

long story, but after multiple failed other medication trials including MAOIs, I'm left considering selegiline for a patient. this individual does not wish to be on the emsam patch (not worth getting into the reasons). at higher doses, oral selegiline should have mao-a effects. anybody tried it? if so, how well did it work/how was it tolerated? how did you dose and titrate it?

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[whopper]

I saw one patient on it and she claimed it worked for her. The problem being that she was also on a medication regimen I found highly questionable such as being diagnosed with ADHD despite never having academic problems, being on more than 100% the maximum FDA recommended dosage of a stimulant, copious amounts of benzos, and she came to the PES asking for help for symptoms that appeared to be an Axis II disorder despite that she already had a psychiatrist.

In such a case as you mentioned, I wouldn't be against it. When things inside the box don't work, you need to start thinking outside the box, but there are many treatment approaches that are still considered more orthodox with more data support than selegilene.

Have you tried the combo of Mirtazapine and Venlafaxine? There is data showing that combination works even in ECT resistant patients.

 

[notdeadyet]

Have you tried the combo of Mirtazapine and Venlafaxine? There is data showing that combination works even in ECT resistant patients.

Ah, California Rocket Fuel... I've had good luck with that in refractory depression, particularly the rooted melancholic type. I'd go with that before non-patch selegiline too.

 

[PistolPete]

Can you guys explain the rationale behind California Rocket fuel? I understand you get serotonin and norepi activity with venlafaxine, and some indirect DA activity because of reuptake inhibition of norepi. But what does mirtazapine add to the combo? Why the 2 together?

 

[whopper]

You know what? As to the exact mechanics of why it's so efficacious, I'm not so sure because using the neurotransmitter reasoning, one would assume that Bupropion with Mirtazapine would yield better results.

I can, however, tell you I've seen studies showing the old California Rocket Fuel can work even in ECT treatment resistant patients to the degree where there's hope in such a dire circumstance. It's not going to work all the time, but it's something to consider in the treatment resistant patient.

Unfortunately the studies I have are from a conference and it was showed on a few charts, and I'd have to fish through several dozen pages to find the diagrams, and even if I find them I don't want to take the time to scan them in, put them on a website, to show everyone here because I have to present a lecture on Friday and want to focus on that for now, and I don't know if I can find them online.

I have, however, seen several docs criticize the term California Rocket Fuel saying that it's just a load of BS and there's no data supporting it. I've seen data supporting it, but I'll always tell others to be skeptical until you see the data yourself.

Just quickly perusing google I found this.

http://www.nhft.nhs.uk/mediaFiles/d...e of High Dose Venlafaxine (Review 05 13).pdf

http://www.researchgate.net/publica...ine_in_the_treatment_of_depression?ev=prf_cit

 

[jettavr6]

I just used Nardil for the first time in a case of treatment refractory depression... Amazing results.

 

[vistaril]

Can you guys explain the rationale behind California Rocket fuel?

A researcher/psychiatrist wrote a book about every psychotropic med in the world. It was popular amongst certain types of psychs. He gave that combo a catchy name in the book. And all of a sudden voila.....

 

[notdeadyet]

A researcher/psychiatrist wrote a book about every psychotropic med in the world. It was popular amongst certain types of psychs. He gave that combo a catchy name in the book. And all of a sudden voila.....

Stahl didn't come up with either the name nor the combination. I agree his book was likely the one that popularized it.

 

[FrasierMD]

Stahl didn't come up with either the name nor the combination. I agree his book was likely the one that popularized it.

interesting! who was behind it originally?

 

[notdeadyet]

interesting! who was behind it originally?

They've used the term (at least out her in California) for a while. No clue who coined it originally, but if there's one thing to be sure of with Stahl, if he came up with it, he'd make sure you know about it. Even in his book he quotes the term.

 

[CounselortoMD]

I saw one patient on it and she claimed it worked for her. The problem being that she was also on a medication regimen I found highly questionable such as being diagnosed with ADHD despite never having academic problems, being on more than 100% the maximum FDA recommended dosage of a stimulant, copious amounts of benzos, and she came to the PES asking for help for symptoms that appeared to be an Axis II disorder despite that she already had a psychiatrist.

In such a case as you mentioned, I wouldn't be against it. When things inside the box don't work, you need to start thinking outside the box, but there are many treatment approaches that are still considered more orthodox with more data support than selegilene.

Have you tried the combo of Mirtazapine and Venlafaxine? There is data showing that combination works even in ECT resistant patients.

I'm more than willing to bet that she came to your clinic because she "needed" more Adderall and Xanax, not because she needed a psychiatrist.

You didn't mention whether she was in pain management, but it would certainly be par for the course.

 

[Patient-1]

I'm more than willing to bet that she came to your clinic because she "needed" more Adderall and Xanax, not because she needed a psychiatrist.

You didn't mention whether she was in pain management, but it would certainly be par for the course.

 

[romanticscience]

I believe the venlafaxine+mirtazapine combo was one of the later arms of STAR-D


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[Blitz2006]

I believe the venlafaxine+mirtazapine combo was one of the later arms of STAR-D


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Correct, but if I'm not mistaken, it wasn't statistically significant, which is why I think some psychiatrists glaze over this combo?

Anyways, stupid resident question time.

Its safe to use Venlafaxine 225 mg + Mirtazapine 45 mg (Full doses?)? Are you guys ever worried about serotonin syndrome with this combo at full dose? I know that after 100 mg norepinephrine takes over serotonin in effexor, so it shouldn't be an issue right?

Also, whats the highest dose you guys go on Effexor. 225 mg is my understanding, but do you guys every go up to 300 or 375mg?

 

[Shikima]

Correct, but if I'm not mistaken, it wasn't statistically significant, which is why I think some psychiatrists glaze over this combo?

Anyways, stupid resident question time.

Its safe to use Venlafaxine 225 mg + Mirtazapine 45 mg (Full doses?)? Are you guys ever worried about serotonin syndrome with this combo at full dose? I know that after 100 mg norepinephrine takes over serotonin in effexor, so it shouldn't be an issue right?

Also, whats the highest dose you guys go on Effexor. 225 mg is my understanding, but do you guys every go up to 300 or 375mg?

300mg for a max with Effexor. Kinda like 60mg with Paxil. Hardest part for both of these medications is coming off of them when it is time (either from poop-out or improvement of symptoms).

 

[Blitz2006]

300mg for a max with Effexor. Kinda like 60mg with Paxil. Hardest part for both of these medications is coming off of them when it is time (either from poop-out or improvement of symptoms).

and you're 'happy' to prescribe full dose SNRI/SSRI with 45 mgs remeron?

 

[Shikima]

and you're 'happy' to prescribe full dose SNRI/SSRI with 45 mgs remeron?

I rarely combine it with Remeron. I use remeron for significantly stuck symptoms due to the weight gain. Kinda of like reserving Zyprexa for that trump card.

The question you need to ask yourself is this; "Self, am I treating mood symptoms or A2?"

 

[splik]

and you're 'happy' to prescribe full dose SNRI/SSRI with 45 mgs remeron?

sure why not? It's usually a safe combination. mirtazapine is primarily an alpha2 adrenoceptor blocker. serotonin syndrome is primarily mediated (supposedly) by overstimualtion of 5Ht2A receptors, which mirtzapine blocks. full dose of venlafaxine is 375mg if you ask me. I believe there was some evidence suggesting that this higher dose gave more traction in depressives unresponsive to lower doses.

Theoretically they are supposed to 'cancel out' the side-effects - so weight gain and sedation should be minimized by that is not my clinical experience. I tend to be keener on using bupropion + SRI/SNRI with my atypical depressives

 

[Liquid8]

Correct, but if I'm not mistaken, it wasn't statistically significant, which is why I think some psychiatrists glaze over this combo?

Anyways, stupid resident question time.

Its safe to use Venlafaxine 225 mg + Mirtazapine 45 mg (Full doses?)? Are you guys ever worried about serotonin syndrome with this combo at full dose? I know that after 100 mg norepinephrine takes over serotonin in effexor, so it shouldn't be an issue right?

Also, whats the highest dose you guys go on Effexor. 225 mg is my understanding, but do you guys every go up to 300 or 375mg?

I use this combination fairly often - I am comfortable with Venlafaxine up to 375mg and Mirtazapine up to 60mg at the most, although I have heard of people using doses up to 600mg and 120mg respectively.

As you're probably aware reducing SNRIs can be a difficult process for patients which can make things problematic if you're looking at switching from an SNRI, especially at higher doses. If I feel that a patient needs to withdraw slowly from an SNRI due to say, ineffectiveness, yet still needs antidepressant coverage I will often consider adding mirtazapine if not previously tried.