Psychiatry Med questions

[John1513]

Hello, what are your thoughts?

Cymbalta + Prozac ?

How about,

Wellbutrin + amitriptiline?

We all access to uptodate and Epocrates etc, but what do practicing psychiatrists think?

Let’s say for generic anxiety/depression.

Thank you for your time

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[MacDonaldTriad]

SNRI + SSRI? Why? There is no justification for this. It is possible to give patients not enough of 10 antidepressants and not get them better. You should maximize one before going to two and there is better evidence that augmentation is a better strategy than becoming a mixalogist. Buspar lithium, T3...

If you run into Wellbutrin + Elavil, you probably have someone who was put on Wellbutrin by a psychiatrist and then Elavil was added by someone else as a non-addicting hypnotic.

 

[Stagg737]

SNRI + SSRI? Why? There is no justification for this. It is possible to give patients not enough of 10 antidepressants and not get them better. You should maximize one before going to two and there is better evidence that augmentation is a better strategy than becoming a mixalogist. Buspar lithium, T3...

If you run into Wellbutrin + Elavil, you probably have someone who was put on Wellbutrin by a psychiatrist and then Elavil was added by someone else as a non-addicting hypnotic.

Have seen FMs/IMs add on Cymbalta when someone has diabetic neuropathy or some other chronic nerve pain when the patient was already on an SSRI instead of replacing the SSRI. Not saying it's right, but that's the justification I was told.

 

[st2205]

I had an attending at the VA who suggested I try “California rocket fuel” by combining an SSRI and an SNRI. I tried to correct him but he would have none of it. Incredibly concrete and I despised working with him, in addition to the other attending we had in VA clinic. The two worst attendings in all of training.

 

[michaelrack]

I do like adding remeron to SSRI's or SNRI's, and feel that California rocket fuel (remeron + effexor) is a powerful combo

California rocket fuel: And what about being a first line treatment? - ScienceDirect

 

[hamstergang]

I have a patient now on 2 SSRIs as we got stuck in a cross taper. I still plan to taper one off but it will now take a while and possibly won't ever work out.

 

[MacDonaldTriad]

Have seen FMs/IMs add on Cymbalta when someone has diabetic neuropathy or some other chronic nerve pain when the patient was already on an SSRI instead of replacing the SSRI. Not saying it's right, but that's the justification I was told.

Cymbalta has this indication because Lilly did the work to get the data. There is no study that shows Cymbalta is better at diabetic neuropathy than any other antidepressant because no one has done a head to head that I know of.

 

[Stagg737]

Cymbalta has this indication because Lilly did the work to get the data. There is no study that shows Cymbalta is better at diabetic neuropathy than any other antidepressant because no one has done a head to head that I know of.

Cymbalta has a bunch of pain indications though (I think 11 last time I checked), do none of them have head to head studies compared to other SSRIs or SNRIs?

 

[clausewitz2]

Wellbutrin + TCA is a good combo which is underused and there is some data for.

Would you expect this to be more efficacious with Wellbutrin + imipramine/clomipramine or is the data there for the more noradrenergic TCAs as well?

 

[Bad Moose]

I thought California Rocket Fuel was Wellbutrin and Zoloft.

 

[John1513]

Remeron was a part of California rocket fuel. That combo has an actual high risk for seizures

 

[st2205]

Remeron was a part of California rocket fuel. That combo has an actual high risk for seizures

Any links on that?

 

[OldPsychDoc]

Cymbalta has a bunch of pain indications though (I think 11 last time I checked), do none of them have head to head studies compared to other SSRIs or SNRIs?

A quick review: Pain, Pain, Go Away: Antidepressants and Pain Management

Note: "As a caveat, please note that there have been few head-to-head comparisons between TCAs and other types of antidepressants; hence, we have had to rely on some interpretation of these data. "

 

[romanticscience]

Remeron was a part of California rocket fuel. That combo has an actual high risk for seizures

Dr. Stahl mentions a bunch of combos with witty names in his books. Wellbutrin + Zoloft is "Welloft." I tried a quick search for any evidence-base for the combo and I could only find blog postings/discussion boards.

Pharmacodynamically, sertraline actually has a higher affinity for the dopamine transporter (DAT) than bupropion. This could be additive to wellbutrin's seizure risk and reason for high incidence of akathisia when using it.

 

[clausewitz2]

Dr. Stahl mentions a bunch of combos with witty names in his books. Wellbutrin + Zoloft is "Welloft." I tried a quick search for any evidence-base for the combo and I could only find blog postings/discussion boards.

Pharmacodynamically, sertraline actually has a higher affinity for the dopamine transporter (DAT) than bupropion. This could be additive to wellbutrin's seizure risk and reason for high incidence of akathisia when using it.

As certain old school types are wont to point out, sertraline actually has a higher affinity for DAT than Effexor has for NET. So in some sense it is not crazy to call it an SDRI.

 

[MacDonaldTriad]

I have seen sertraline bring back childhood ticks and worsen stuttering so there is probably something to this. Of course when Bupropion first came out we had a limit of 800 mg so this combo isn't probably worse than that. Dr. Stahl does have some theory behind his combination recommendations, but as always, the data is way behind the theory. It is like the old adage:

"What is the difference between theory and practice?"
In theory there isn't any, but in practice there always is.