Brief Answer:
Doctor is doing the right thing, you will get well

Detailed Answer:
Hello,

After reading your symptoms and drug regimen I can say from my clinical experience that your doctor is doing the right thing.

First, he raised the drug which you were already on - Lexapro to 20mg. But, as this was unable to curtail anxiety : he added another drug Effexor to it.

Secondly, Effexor is a better molecule compared to lexapro, both in terms of mechanism of action and efficacy -in managing cases of depression which have heightened anxiety. It has a different and multiple modality of action compared to lexapro -which helps in treating anxiety when simpler molecule fail.

Thirdly, he gave you Ativan. This is fine for now as - there is a need to control the debilitating anxiety and make you feel better till the main drug (Effexor in your case) start acting adequately. You may take it on & off basis for some time and when you get better, just stop taking it. It has addiction potential so, Donot take it unnecessarily when you can mange your anxiety by distraction or by keeping busy.

Fourth, I think your doctor would increase the dose of Effexor to 150mg or so, to achieve full response & later he may taper and stop lexapro altogether. It is done because we must try to keep the patient on single drug when ever and wherever possible.

fifth, please try to identify the cause (or precipitating factor) for this relapse and try to avoid it in future to keep well.

Get blood tests, TSH, Vit. B 12 level and blood pressure readings and see if they are in normal range.

Please feel free to ask more questions for clarifying any doubts.
Wish you a speedy recovery!

Dr. Manisha Gopal
MD Neuropsychiatry

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Brief Answer:
Waiting had it's advantages & increasing risks

Detailed Answer:
Hello,
You are somehow right in saying that lexapro should have been tried alone for some more time, at a higher dosage, before adding Effexor. I can acknowledge this point; the dosage could have gone upto 30mg and we could have waited for two to three weeks before adding Effexor.

But what about the increasing anxiety during all that time?? Would you be comfortable dealing with it, and it would have posed an unnecessary danger of increasing the symptom duration in relapse, making it difficult to curb....Even the relapse should be controlled as early as possible. So, he added Effexor at an early stage.

Moreover, the symptom are severe this time, with more amount of anxiety : an SNRI is more suitable (e.g. Effexor or paroxetine, etc.).

You say that you are not happy with Effexor ? Is there is any specific side effects which is bothering you? then please discuss it freely, as it should be paid an early attention and managed. Effexor is usually a good molecule which if suits some one, is very good for maintaining long and symptom free life.

Please ask if there is anything more which you want to discuss regarding Effexor or the illness itself.
Wish you good health!

Dr. Manisha Gopal
MD. Neuropsychiatry

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Brief Answer:
hike after 5-7days; take more water

Detailed Answer:
Hello,

The dosage of effexor can be hiked by 37.5mg after every 5-7days. You may take 75mg straight at night time or take 37.5mg twice a day (divided doses are preffered by most patients).

Many patients of depressive disorder and anxiety have increase in symptoms in morning hours (as soon as they open their eyes) and report improvement as the evening approaches and they say that they feel better when they know they are going for sleep.
I think it is more because as the day starts, there are new works to be done, more responsibilities, etc. All these things increase the pressure and anxiety.

Donot worry, this all will get well with treatment. You will gradually feel less anxious and would be more comfortable like ever before.

Take more water in form of sips all day long; and you may practice deep breathing in morning time for early recovery.

Wish you good health.
Dr. Manisha Gopal
MD Neuropsychiatry

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Brief Answer:
I think Effexor should be hiked to 75mg, or more

Detailed Answer:
Hello,
Well, according to my clinical experience we can increase (and it is wise to do so) the dosage of venalafaxien (Effexor) by 37.5mg every 5-7 days, or Atleast after 10 days. It is not good to wait for few weeks when symptoms are so disturbing. This will only aggravate the symptoms and unnecessarily prolong the suffering.

If we plan to wait for few weeks to see the response- then we should have waited with lexapro to 20/30mg before adding Effexor...
whenever we add a new molecule, we accept that the earlier was not sufficient enough to control symptoms.....so, in such case we need to atleast build the dosage of Effexor to a reasonable level....

Effexor is a good and early acting molecule. Many research evidence suggest that the dosage can be safely hiked every week or 10 days ( even faster in case of severe symptoms). 37.5 mg is just the beginning...Usually, this drug starts to show effect within few days of adding it & I guess you have been taking it (Effexor) for almost a week now . If there is no good result yet, then, had I been treating you, I would have hiked the dosage to 75mg and wait for another week or 10days and hiked it further.

Get your blood pressure checked, get TSH and serum. B 12 levels if you haven't done so til now ( if they are disturbed, correcting them helps a lot in improving symptoms with lesser drug dosage).

Hope the reply is useful for you.
Wish you good health

Dr. Manisha Gopal
MD Neuropsychiatry

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