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SSRIs vs. Trycyclics for MDD and Panic Disorder?

Dear Doctor,
I was recently hospitalized for severe depression and panic disorder, and am currently in an outpatient CBT program at the same hospital - the program is terrific and I'm learning a great deal.  The problem is medication - I'm hugely sensitive to drugs and virtually every SSRI or SSNRI I've tried - Cymbalta, LexaPro, and now Zoloft - really exacerbates the anxiety.  The psychiatrist affiliated with the program has been wonderful and understanding, and prescribed .5 mg of Xanax four times a day to address the anxiety.  I'm still anxious and fearful, but also incredibly fatigued, sleeping a great deal, and - here's the worst part - have had severe diarrhea for 3 weeks.  I love food, but cannot tolerate anything.  We've tried tapering the Zoloft from 150 down to 100 mg, but the diarrhea is just as bad.  I so much want to get well;  my doc understands that, and is also emphatic that my depression is severe and that I really need to be on an anti-depressant for a long time.  Is it possible that some people just can't tolerate SSRIs?   My body reacts tho them as if they are "speed."  Even before I got sick, I couldn't even handle drinking a cup of coffee - it was too stimulating.
Are there alternative drugs that work?   Would the older trycyclics be less stimulating?  I'm in my 40s and need to be able to think clearly, and want to accomplish a lot more and get through this.
Thank you for your help.
9 Responses
Avatar universal
I only tried a couple (SSRIs), and both were bad, and when I described the problems I was told by someone very knowledgeable that she, at least, simply couldn't tolerate SSRIs. That's the only part of your questions I have any info on, other than it was recommended that I try those tricyclics (I opted for "none of the above", which seems to be doing quite a decent job so far).
Avatar universal
You may want to try a Tri-cyclic. I take Nortriptilyne which is a Tri-Cyclic antidepressant and I have found it to have a less stimulating effect than SSRI's I used to take like Paxil and Zoloft.

I have also found the Nortriptilyne to be more effective at controling my severe depression and anxiety than SSRI's and SNRI's like Effexor.

The side effects are not near as bad as I had thought they might be. I do get some constipation from the Tri-cyclic, but I find that easier to combat than the Diarrhea I got from Zoloft and Effexor.

About the Xanax your taking for anxiety.... Yes that stuff will make you very sleepy. I really think if you can find an antidepressant that works for you then you will be able to knock that Xanax dosage way down. Nortriptilyne does a pretty good job of controling anxiety too.

Just give it some time because the Nortriptilyne takes a good 3 to 4 weeks to even start working. Start low at like only 25Mgs a day and let your system get a few weeks at that dose before jumping up. I take 75mgs a day and I think the maximum effective dose is 150Mgs a day. If it makes you a bit sleepy just take it a night like I do.

Also make sure you keep up a healty diet. I also take a lot of highly soluable vitamins which seems to help some too.

It can't hurt to try the Nortrip. Stay away from the Amitriptilyne. It has some pretty nasty side effects.
432009 tn?1304749841
I am so sorry to read about your severe depression and anxiety, but I'm glad that your program is providing you with the support that you need.

Re: SSRI's - I couldn't tolerate any of them - they were awful - made me agitated, got horribly anxious, felt very wierd mentally.
My Dr. then put me on a tetracyclic - Remeron - mirtazapine. It's known for its sedating qualities, so quite effective for someone who has a strong anxiety component to their depression. That was me.

Hensley's post offers you a wonderful choice, too, so you can discuss both of these with your pdoc.

The drawback to Remeron - appetite increases, weight gain - you have to climb on the scale constantly to ensure that the lbs. don't pack on, and can sometimes be too sedating. But, very effective in helping with sleep, too.

I currently take 30 mg. - I didn't like a higher dose, as my pdoc tried to increase it. This dosage is about right for most patients. Remeron also has a long track record like Nortrip., although Nortrip. has been around much longer than Remeron.

And keep with the therapy. I did my very best when I combined my AD with psychotherapy. This time around, I'm not in therapy, but I finally made an appt. to meet with one next week...

Good luck to you in finding the right medication...
Avatar universal
Thank you so much for the advice!  It's good to know that I'm not the only person in the world who has struggled with the SSRIs.  I'll talk with the psychiatrist about the two trycyclics suggested - I really appreciate the feedback.  
Avatar universal
As Xanweaner mentioned, Remeron may also be a good choice. I have talked to a lot of people that are getting good results with it too. In fact when and if Nortriptilyne ever poops out on me, I plan to try Remeron.

Remeron is a Tetra-cyclic antidepressant and Nortriptilyne is a Tri-Cyclic. I'm not exactly sure what the difference is between the two in terms of how they work in the body.

I have heard that they produce very simmilar results.

Good luck!
Avatar universal
Hi,  I have had anxiety, depression, and panic since my late teens.  I too find ssris very stimulating (sleeping thru the night is a problem) I am taking Celexa which is not a stimulating as Lexapro or Prozac.  I used to take Zoloft but after awhile it gave me alot of stomach problems.  I too take xanax (.25 once a day) It seems to take the edge off.  I take 30 mg of celexa, but I don't think it is working completely because I am obsessing and feeling abit depressed.  I constantly have to urinate and do have diarreah. I read that Celexa can cause that.  I used to take inipramine (which is a Tricylic) along with the ssri which seemed to help my sleep.  I might be trying the combo again soon.  I do think meds are needed but also I do a program call Midwest Stress Center Attacking Anxiety and Depression which has really helped me.  It is nationwide and is the best program I have done.  It's just a 15 week CD program that really help you feel not alone and is a great way to feel better about yourself.  I would highly reccommend it.  Good luck!
Avatar universal
I took Effexor 1x years ago and I thought I had an LSD trip. Now my doc wants me to get an eval from a psych. I do not ever want to go through this again. I currently have .25 mgs of ativan on an as needed basis. Just thinking of going on an anti depressant is actually giving me anxiety becasue of my experience. What should I do when I go into the psychiatrist?  I am just hoping the ativan will help me get through these days while I go to therapy??  I waas just diagnosed with depression/anaxiety/phobia. sorry for the spelling- I  am rushing....I do not want to be heighthened anymore..Ijust want the edge off.  Anytips? This whole depression is sooo new to me and a recent onset out of nowhere. As if I am having a nervous breakdown.
Avatar universal
I'm so sorry you're experiencing those feelings, and understand how upsetting they are.  I would definitely see both a psychiatrist and a counselor and share your concern about the drugs.  A good psychiatrist wil listen to you and help create a personalized plan - it's still trial and error, as drugs affect people so differently.
The biggest thing I've learned throughout this whole process is patience - everything takes time, and that can be so frustrating.  It takes time for the drugs to work;  it takes time to recognize and accept that we're depressed;  it takes a lot of time and effort to work with a counselor and support groups to get to the root cause of depression and to address the emotions, thoughts, feelings that create or spike it.
All the best to you;  it gets better. Fight for it.
Avatar universal
I'm sorry for all of you, although I see this was in 2008, but it should'nt have happened even that late into the 21st. Panic Attacks and panic disorder are different anaimals. People who have a panic attack on occasion should seek out counseling (CBT) although those with Panic Disorder seem to need some medication. If you suffer from Panic Disorder your chances of having some type of depression is about 65% higher than average. Types and severity of the depressive episodes can very.

Xanax and Klonopin can help with panic attacks, but you need to understand that these drugs are NOT for long term use. They are also should not be used three or four times daily as the first person had them prescribed. Use them only when you have oncoming attack. You only want to take them if you don't REALLY need them. If you are having panic attacks all the time then you need to get nother drug if therapy doesn't help. All benzodiazapines have very serious long term side-afffects. Cognition and memory can be seriously impared if taken over a long period. A lot of people have very good luck with Buspar but keep your xanax, klonopin until it begins to take affect.

It makes a great deal of sense to use another all-in-one drug if possible. Tricyclics, imipramine in particular, works for depression and panic disorder. Men will have sexual side-effects, erection and libido, so if you are young you may want to try another route. Women don't fair as badly, although you need to make sure that your heart is in very good condition and you will need to get an annual EKG. Also, you may NOT take this drug if you have serious or uncontrolled glaucoma. You can take the imipramine at bedtime, which also helps you sleep as well if you are having problems there.

You generally will never have another panic attack and this is as good of an anti-depressant as most others, although you will want to make sure to get your depression under control. Anxiety can scare and annoy you but depression can kill you. If you have mild to moderate depression then this should do fine. Also, people, you really want a psychiatrist involved, particularly if you are depressed. Keep your GP and all other medical doctors in the loop, but get evaluated by a Psychiatrist. A psychologist or some other mental health care provider can generally tell if you are depressed, but there are many, many different reasons for depression and sooner or later you will need a Psychiatrist.

Be well!
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