Making Effexor more Effective for depression and anxiety

Anne writes in . . . (I) am currently taking effexor. effectiveness marginal. still depressed and still anxious in social circumstances, perhaps, I just need more time with that aspect. what, if any other drug might I combine with the effexor to help with the depression?

The first step, of course, is to make sure that you are taking enough Effexor.  As you may know, Effexor acts as an SSRI at lower doses but does have some norepinephrine action at higher doses.  If you can tolerate it, your dose of Effexor should be pushed up to 300 mg daily (some docs push even higher).  If, after two months or so, that is not being effective for your depression/anxiety, it is not likely to.  As for your anxiety, you should (OF COURSE) be in with a therapist who is working on behavioral management of your anxiety.  What works best for that is a good primer on managing anxiety with relaxation techniques and then exposure to stressful situations where the anxiety techniques can be practiced in real-time.  That is much better than relying on anti-anxiety tranquilizers like the benzodiazepines (Xanax, Klonopin, etc.).  As for your depression . . . YOU SHOULD ALSO BE IN THERAPY FOR THAT . . . needless to say . . .!  Medication-wise, if the dose of the Effexor has been maximized, but not effective, you can either change medications completely (the next choice would depend on what you have been on in the past) or augmentation.  The first agent I typically use to augment an antidepressant trial is Wellbutrin.  Combining Wellbutrin with other antidepressants is well accepted at this point and often quite effective.  It makes sense because of the complementary mechanism of action it has when combined with other antidepressants.  Other augmentation strategies that would make sense in someone with significant anxiety include the addition of lithium or Abilify.  You should also taking appropriate dietary supplements to make sure that your brain is optimized to accept the help that the medication has to offer.  At the very least, I would recommend fish oil, vitamin B12 and vitamin D.  Talk to your doc about those as well.

–Dan Hartman, MD

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