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Dr. K
Dr. K, Psychiatrist
Category: Mental Health
Satisfied Customers: 358
Experience:  15 years clinical experience in all areas of psychiatry. Holistic and practical approach.
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I have been taking mirtazapine since October,2010, and am now

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I have been taking mirtazapine since October,2010, and am now on 45mg
Even though I feel my depression has lifted, I still at times feel low and slightly
agitated. My doctor would like to change my medication, by reducing mirtazapine
to 30 mg and adding venlafaxine 75mg. I am undecided as to what to do, mainly
fear of side effects, and wondering if it will work. Last year I started taking citalopram
and had a very bad reaction, consequently, on fluoxatine and bad reaction continue
even though I had very good results of it in the past.
I would be very grateful for your advice.
This is a great question. Remember, ultimately, you are in charge of what goes in your body (whether it's medications, herbs, alcohol, nicotine, drugs, or food). Doctors are here to give you their best recommendations...it's a team approach...we're not supposed to order you around as if we always know what's best.

It's natural to be worried about side effects...especially since you had recent bad reactions to celexa & fluoxetine. One thing to keep in mind is that at your age & with your h/o being sensitive to side effects, I would go very slowly & conservatively with any med changes.

The 1st decision you half to make is this. You say that even with the 45mg dose you still at times feel low/agitated, but your depression has lifted. If you are content with this level of improvement, you do not have to change your meds.

Remember, depression is best treated holistically. Medications can be helpful for some people. I also recommend 1) psychotherapy with a live therapist, and 2) learning some formal relaxation therapy.

The last 2 treatments I mentioned are proven by sophisticated studies using brain scans (CT, MRI, EEG, pet scans) to improve brain function.
Most studies on depression show the best results are with a combination of medications & psychotherapy.

Also, by formal relaxation therapy I mean yoga, meditation, or similar methods. Having relaxing hobbies is also important, but not quite the same as formal relaxation therapy. More studies are coming out in which people are incorporating relaxation therapy & mindfulness into psychotherapy...and the results look great. And these treatments have no side effects!!

And remember you can't separate emotional health from physical health, so exercise & nutrition are vital.

There are also several self-help books you can read which can help including: 1) The Seven Spiritual Laws of Success by Deepak Chopra, 2) The Feeling Good Handbook by David D. Burns; 3) The Relaxation & Stress Reduction Workbook (New Harbinger Self-Help Workbook) by XXXXX XXXXX, and 4) The Depression Workbook: A Guide for Living with Depression and Manic Depression, Second Edition by Mary Ellen Copeland and Matthew McKay.

Using the above approach can help treat the residual symptoms for you (i.e. the leftover symptoms that the remeron 45mg is not treating).

That being said, if you do decide you want a med change. Here is how I would do it. Stay on the 45mg dose of mirtazapine. I wouldn't start on a 75mg dose for you (I use this dose for younger people, people who aren't sensitive to side effects, or hospitalized patients.).

I would start one of 2 ways: I would get 25mg tablets of venlafaxine (not the extended release version) and take 1/2 tablet in the morning...and then increase (as long as tolerated) to 1/2 tab twice a day. Or, you could start with 37.5mg of the extended release version in the morning.

In theory, the XR (extended release) versions are better b/c they are easier to remember once/day and have smoother blood levels through out the day. The smoother levels often mean less side effects for people. There are some patients, like those who get insomnia or other side effects at nighttime, who do better on the non-XR versions. Despite all the science, there is a trial & error approach.

I hope this helps. Let me know if you need more feedback. Good luck & take care.
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