Treatment resistant depression

Hi

diagnosed with agitated depression with anxiery by psychiatrist. He left, locum came, he left, new psych now.  Tried effexor, prozac,amitriptylene,lofepramine, gabapentin, vortioxetine, sertraline and mirtazapine.   Cannot tolerate any due to vomiting, nausea, massive anxiety, ideation etc.  Only one without side effects is mirtazapine but only at low dose. Not helping depression but can sleep along with 5mg diazapam. Going about daily life is very hard. Have been avoiding a lot of activities as feel awful. Tried cbt over 25 sessions. No mania,no schizophrenia, no bipolar, just anxiety and depression.  Dont like having to use diazepam to ge through day but CPN says just do it.  Im sure thats not right. On top of all have ibs and take warfarin for old pulmonary embolism. Sometimes wonder if that doesnt help. Just dont think psyhc knows what to do next.

I am so sorry for what you are going through. What a horrible situation! It is likely that warfarin is causing issues with the psychotropics. Warfarin is quite moody even on its own and when mixed with psychotropics it can all get very volatile. Is there a way to get you on a different, new-class blood thinner perhaps? Do you have a doctor who you could discuss this with? Frankly, your psychiatrist should be the one consulting other specialists in order to be able to help you. But I guess that is expecting too much from a medical professional nowadays.

Don't worry about diazepam at the moment. Honestly that can be sorted later. The most important thing is to give you any relief possible right now as you have enough to contend with.

Ann, when did your depression/anxiety start? Was it following the pulmonary embolism, as in closely following it or triggered by something else much later? Any grief or anything that may have caused PTSD?

Have blood tests been done to rule out thyroid dysfunction and overall blood situation?

Other than warfarin are you taking any other medication? Any alcohol consumption should be curbed at this time as well.

Agitated depression with anxiety does not necessarily justify the use of drugs that are primarily anti-psychotics. I am guessing he is hoping that they will sit with you better due to the fact that they are atypical agents. It is anyone's guess though.

If possible please do discuss your blood thinners with a specialist. There are options other than warfarin now. I think that may be pertinent before adding yet another psychotropic to the mix.

 

You are very knowledgeable.

 Yes i am in discussion about the change from warfarin to apixaban. Psych said it wouldnt make any difference so it was on back burner meantime, do you think its worth a shot?

all this started immediately after an operation which caused clots to lungs, horrendous time in hospital I think traumatised me. Each change of anti deps for anxiety making me feel i cannot get better. Never liked alcohol so not that.  No other meds. Just overall blood tesrs done, not in depth thyroid ones.

yes, i see you are also questioning anti psychotics, me too.  Unwarranted maybe but psych just buying time i feel.

Just want something to make me feel better and getting nowhere.

thanks

 

Well, similarly to your hunch I do believe it is worth a shot yes, and not sure why the psych is so confident it won't help at all? Unless you are worsening and suffering considerably and he doesn't want to wait? To be fair it may take you 3 months to stabilize on a new blood thinner, right? If so I guess that won't be an immediate enough solution whatever the case.

Questioning yes, however there is merit in his rationale too. If your psych does proceed with antipsychotics for your case, they will likely do so at very low doses, similar to what they do for the elderly. There were some studies on use of antipsychotics at low doses for agitated depression, I will try to find these for you to have a look at. If I remember correctly it was quetiapine, while risperidone was best used along a MAOI, which I guess would not be top choice for someone on warfarine I will check it out over the weekend.

Let's see if anyone crops up here taking them for depression and anxiety too. I wonder if anyone on here is taking ADs while on warfarin too.

How old are you btw?

And how long ago did you have the surgery?  

Meanwhile and more importantly, how much relief do you get from diazepam during the day or is it only taken at night? Is there anything at all that helps you cope meanwhile? I think it is important for you to feel positive and remember that this can and will be fixed one way or another.  Just requires patience.

 

Can you run a separate post to see if anyone on here has been taking ADs alongside warfarin? Not sure if there is a separate forum for warfarin on here somewhere where we could ask for experiences?

Thanks so much, you are a mine of information.  two years since op.lets say i just qualify for bus pass!  Diazepam 2mg in day helps a bit so i can at least get out, walk, shop.you are right- lets see if anyone else on a/ds and warfarin, good starting point.

Hang in there. I know the wait is horrible and it can feel hopeless. I am sure they will figure it out very soon. At least you were not left entirely to fester like some other patients i have met here who can't even get a referral to a psych after years of suffering.

haha ok - bus pass is a fair orientation point! I did not mean to be rude. But it makes a difference. If you were just getting to menopause at this time it would make it much more complicated. This is actually why i asked. Next time I will say what I mean

Well, i have now started different blood thinner apixaban. Had it a week and feel pretty awful. Started with hoarse voice, then cough, now itching skin, together with fatigue and to top it all, nausea for first part of day.  I dont know if these will calm down given time but i think its my body reacting again to a med it doesnt like, , cant believe ve got this now on top of the anx/dep. another month till i see psych to decide what next there.  Just cant understand why they cant get me right.  My normal functioning days are so far away now i can hardly remember what its like to be normal.  Because i dont feel well it makes me not want togo out, do anything etc. Me friends still pop in and i try to take a walk each day, but as for eals out, holidays etc, seems all in the past.

i need to get better as i am missing out so much on my family.

do you think i should try the augmentation from psych, i am really not sure about antipsychotics when there is no bipolarity.  

I value your opinions.

P S 

not sure if i am asking right questions on here but nobody seems to be on anti dep with anticoagulant.  Must be some surely?  Maybe your investigations will throw something up

Dr has increased apixaban to 5mg twice daily, says the 2.5 i was given has been superceded by this dose. Now have to make decision about low dose risperidone.  Have you come across anyone on both anti dep and anticoag, i havent. Your expertise is helpful.

I have come across someone who has tried but the person had to stop ADs due to inability to stop alcohol use. Which is not helpful.

Any change since starting 5gm apixaban? It may take a while to stabilize on it though. Are you still managing to sleep with diazepam? more than 3-4 hour stretches?

Hi, good to hear from you.

yes, the higher dose made me feel very much more depressed and sleep affected too.  I do not have an alcohol issue as i dont like it so i cant understand why i am just unable to tolerate anti deps.

i am seriously thinking of asking to go back on warfarin as i am sure these last few weeks the apixaban has lowered my mood significantly.  Just wish there was someone out there having this difficulty and its not just'all my fault' as this illness seems to be seen.

getting sleep on usual meds but not good quality and wake feeling ive not really been asleep at all.

of course my side effects are not listed on the drug packaging!

Your extreme chemical intolerance makes me think that something else is at play here. I wish your doctors would discuss this together and readjust approach.

What was your last CBC bloodwork like?

I feel you may be right. My dr  did bloods about four months ago, but not in depth.   She said they were within limits.  I would like more in depth ones done i.e thyroid b12 etc but i think shes fed up with me not getting better and having sensitivity to meds.

Do you think i am within rights to insist more in depth bloods, if so, which ones should i be asking for.   I am not sure what CBC stands for.

CBC or FBC (Complete/Full Blood Count) - basic blood test.

In addition to which you could do thyroid, B12, magnesium, vitamin D, CRP (shows if there is any inflammation in the body), iron and iron binding, liver function (should be part of CBC anyway). Take it from there.

Your main symptom when taking psychotropic drugs are vomiting, nausea? Plust increased anxiety and ideation that they tried to keep in check by adding sedatives (benzos) or not?

Yes, you got it.

what do you think, i value your opinion,

i am mainly anxious but that is what is depressing me and the more anti deps i try the worse i feel. Mainly nausea. Ideation was bad when they added seroquel low dose.

i just wonder if i could get rid of my low dose mirtaz and my need for diazepam approx 3mg a day, 5 for sleep, ten i know the old me is still in there, just too anxious to find it.

do you get vomiting/nausea with antibiotics, NSAIDs (ibuprofen, voltaren), chocolate? Any acid reflux or other gastrointestinal issues like IBS?

ah i just read above that you have IBS indeed. How is this being managed and how is it presenting?

I have been seeing a dietitian for ibs and lo and behold her fodmap diet is helping. I eat lots of chocolate, always have and dont have any problems with food, only medications, its as if my body rejects them and i get lots of side effects.

What about reactions to NSAIDs or antibiotics? How do they sit with you? Any issues with any other class of medicine except psychotropics?

Not allowed NSAIDs when on warfarin. Antibiotics ok apart from those contraindicated with warfarin

Back on warfarin.  Very depressed and anxious. Psych wants to give risperidone low dose alongside anti deps.  I feel i am going mad with all this. Cant get appt with gp for two weeks to suggest bloods. What do I do now

Now psych has had change of mind. He wants me to take higher mirtazapine with low dose olanzapine.  I am totally scared of all this drug meddling, and these two meds give massive weight gain.  Not sure i trust him but cant go on isolating and feeling anxious a lot of the time.

Hi ann. The only way to get it right is by experimenting. There is no other way unfortunately. Extreme cases like yours are tricky to navigate. I imagine it feels very frustrating and frightening but eventually some mix will work. There is NO way you can be only sensitive to psychotropics and fine on every other form of medication. I would have thought that the alternative thinner you were put on would require more time to settle before deciding to try another or go back on warfarin? Have your symptoms worsened meanwhile?

Back on warfarin which has steadied out so thats good.

yes you are right, it is tricky to navigate and i feel i have given a decent try to several meds for depression.

just dont know what to do next. Dr said,, do you want to go,off your low dose meds and see how you are - no thought of detox

 

Upped mirtazapine and have woken with horrible feelinga of anger at everything. Felt like i could hurt someone close.  If this is what increase is doing how can i go on and add olanzapine.  I can hear children playing in street and its making me agry, what is this drug doing to me?

You have been very helpful in the recent past.  I am now no better and they doubled the anti dep but it has spiked the anxiety and depression making meuse more diaz which makes me more depressed.   I have had to lower the anti dep to get some respite again.  I am so down about all this chopping and changing meds, the psych is just stabbing in dark i think.  I just dont know if i should stop anti deps completely and try to live without

ok it has been a couple of months since you first posted.

It may be a good idea to take a step back.

Did you ever have ANY depression or anxiety prior to your pulmonary embolism?

Since being diagnosed with your agitated depression and anxiety and before starting medication, were you given and MRI, a spinal tap or any heart workup? I know you said you had no indepth tests ran. Anything else you can remember - please share.

What was the very first psychotropic drug you were given when all this started and how long after starting warfarin was this.

Have you ever taken any antidepressants before your pulmonary embolism. Have you ever had an extreme reaction to any drug before all this?

Have you been losing weight?

Have you been agitated at random moments (noise sensitivity) or upon waking for instance? 

While you were in hospital you mentioned you had a traumatic time. What exactly do you remember? What kind of medication were you given during your stay other than thinners. Diazepam perhaps for the nights?

what exact symptoms drove you to consult a psychiatrist. What happenned.

 

Been feeling bad for a few days, but here are answers

i had one episode of agitated depression twenty years ago, tried prozac for five months,very bad reaction,stopped and onto mirtazapine for a year then absolutely fine living normal life for years.

Had MRI  just prior to spinal surgery, six weeks later p.e.s no spinal tap. No heart tests. Felt anxiety starting after microdiscectomy.

first anti dep was lofepramine, did six months on it but no response. Started just after pe anxiety. Every med given since i.e. Duloxetine,sertraline, all gave either high anxiety or zombie feelings.

no loss of weight, in fact two stone heavier on mirtazapine.

yes, i wake feeling agitated and anxious often. Tends to lessen as day goes but not always.

hospital was cery traumatic, i am very sensitive and the mixed short term ward had patients coming all night some screeching and staff not quiet. Desperate to get home.

GP gave me diazepam for anxiety from start of this. Still take it to sleep 5mg. Dont want it but also some days take 2mg in day.

The anxiety symptoms morphed into depression at times so referred to psychiatrist at start as GP tried antidepressant to no avail.

throughout I have had ibs and cannot settle it completely.

comments would be helpful as i now find from latest psych appt he wants ro try to augment with risperidone or olanzapine.  I have read a lot about these and am wary.  I wonder if Buspirone might suit?