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Dr. Mark
Dr. Mark, Psychotherapist
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I have a few questions regarding 2 anti-depressant

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Hi I have a few questions regarding 2 anti-depressant medications that have been prescribed to me. First one is Buproprion XL 300mg x1, daily/ Second is Fluoxetine 200mg x1, daily. I had been on Cymbalta but dc'd it due to the cost since I did not have insurance. Unfortunately, I still do not have insurance and have not taken the other 2 antidepressants for about 3 months. Have been doing alright till recently that I felt the need to start them again. Just a quick medical backround. I am 56 yrs old, Female, hx of depression and fibromyalgia. I am being seen by a physican. Got the script yesterday and I started thinking of these questions and if you could answer them I would appreciate it greatly. . . I just started yesterday the 2 mentioned Buproprion and Fluoxetine. How long do you feel it will take me to feel abit more positive emotionally and motivational? I also have been having an increase in feeling fatigued and am associating this with my depression as well. I just want to know the side effects to expect and really when I could start feeling emotionally better. I know it can take time, but I think I waited too long to go back on them and I really know I am depressed and want to take control over it. Thanks for your time, I truely appreciate your availablity!!! P.S. I am not feeling like I want to hurt myself or others. I know this must be a worry for you all that do this. I just was stubborn thinking I could do it, and really the primary one, I had no money to buy the meds! Thanks Again!

Hi! I believe I can be of help with this issue.

First, let me say I can imagine how distressing this situation is for you. You're dealing with a lot of issues it sounds like and you are starting to be overwhelmed by them. I don't think, though, that you should feel that it was a bad idea to stop the medications. You sound as though you don't want to have to rely on medications your whole life and so it's important, if that's the case, to not be too dependent on them. So you did fine with that. You are now taking meds again and that's fine. You may want to discuss with your doctor that you don't want the meds to be a long term part of your life. That's a good discussion to have so that the doctor and you can strategize after a while how to consider when it's time to taper off the medications.

I think, then, it's important to give you some self help tools and some encouragement to have counseling/therapy as an alternative to medications in your thinking process. I also want you to know that at the end of the posting I'll paste in for you a technique you can use to help when you are in that dark hole of depression and anxiety. When you are feeling depressed and in a dark hole, this is something you can use to help with some relief and you can use it over and over.

But let me address your medications issues directly first. I'm assuming you mean 20 mg of the fluoxetine because even 80 mg is the high end of dosage and you've just started. 20 mg is a common starting dosage once a day. As for the bupropion, that high a dosage once a day is usually administered as sustained release or extended release tablets. Otherwise, it would be worthwhile to discuss with your doctor why such a high dosage all at once is being administered and if it would be better to switch to extended release or 2-3 times a day taking a single dose tablet. As for the fluoxetine, if it is indeed 20 mg, that is an initial dosage and probably will be raised after a while.

You need to give 10 days to 2 weeks to feel the full effects of the medications and then to report to the doctor whether there is an improvement to know whether the medications and/or dosages need to be adjusted. Neither of these meds are particularly fast acting so that is the time frame to keep. After a week you should be feeling relief, though.

Common side effects include weight gain (though doctors will deny it), diminishing of sexual desire, some drowsiness or the opposite--sleep difficulty, dry throat, some nausea, etc. These are common. But that only means a few cases. The rest are rare, which means just that, rare. With weight gain, you really will need to increase exercise to counteract it.

Now, if you have any breathing problems, or start throwing up, or you get really seriously depressed and start thinking of hurting yourself, or other serious symptoms, then you need to call your doctor right away or go to the ER. That's for real and please don't skip this if you do start having serious symptoms, okay? But again, these are all very rare.

Okay. So you have some things to watch out for and some things to talk to your doctor about. Now let's turn to what you can do yourself to help yourself. We want to come up with a coherent program for moving forward. The 5 components of a total self help care program are: diet, exercise, motivation, spiritual life, and psychotherapy.

Diet: cut out coffee, sugar, white flour. That may be tough. But you will see results as some of the newer research shows. And lean meats only. No fast food restaurants, no fatty foods.

Vitamins can be useful for moods. A good quality daily vitamin, for example. One of the most important supplements is Omega 3 fatty acids, either in fish oil or capsules or in flax seed oil. Buy good quality. The clinical dosage is 1,6000 mg to 3,000 mg daily. Try the higher end of the range if you can afford it. Omega 3 is the main supplement. The research on it and depression is conclusive. All these things you should get at the biggest and most frequented health food store and ask them for the best brands they trust in terms of quality.

Exercise: 5 days a week moderate exercise, to include 3 days of strength training as you get more used to it. Your doctor will verify the research results showing the benefit.

Motivation: I recommend you apply the principles in the following videos and books. So that you can be yourself with more confidence and share it with others. Coach yourself. Be your own life coach! I want you to get really into motivational videos and books. In other words, accept your past fears, accept your past worries and hurts and traumas. Accept them and focus on becoming who you WANT to be now. Here's a simple YouTube search I put together on "motivational speakers":

Some like Tony Robbins are the classic big guys. Some are newer. There are now wonderful women speakers as well. Watch them all. Get inspired. Buy a book or two. Here are some possibilities, but they are only suggestions as there are so many good ones.

The first book is the father of all these type of books. How to Win Friends and Influence People by Dale Carnegie. There are classes in these books now! It was written in the 1930s and still has something to say to us today that is very worthwhile.

I think very highly of the second book on my list, which is a real classic: The Seven Habits of Highly Effective People by Stephen Covey. It is the book that has helped more people than probably any other.

The third book is by Anthony Robbins. He's one of those speakers who fills up huge auditoriums. For a reason. He's a terrific speaker and writer. The particular book (if you like it, try his others): Awaken the Giant Within.

Spiritual life: the medical literature is now rather overwhelming about the benefits to so many different areas of physical health of regular religious and spiritual practice. Going to church, meditation, etc. are all shown to produce benefits to the physical body. What about our mental health? Well, you will see that meditation is now a regular part of psychotherapy interventions. I don't know if you're a religious person or not. But if not, this may be a good time in your life to tune up your spiritual life. If you do not believe in G-d, that's not a barrier to your own spiritual life. Just thinking about the meaning of your life, of life in general, and studying spiritual texts and practices will help with the depression.

Psychotherapy: this requires to have you orient your thinking about depression and meds and remedies as treating the symptoms of your anxiety and depression and that it is important to treat your situation as a HUMAN problem. This would mean making your focus of your "work" be on exploring your emotional reactions, your history and behavior patterns you've learned from your history, and your negative thinking you've adopted from your history. We have emotions because they are part of how we grow and learn and become more fulfilled. But if we keep trying to get them just to go away without ever exploring what's going on, we NEVER get that chance to get anything important from them.

If your doctor isn't able to refer to anyone, here is the web address for Psychology Today's therapist directory. You can sort by zip codes and when you see someone who seems like they might be helpful (they show you a photo of the therapist!) look at the listing and see if they list CBT therapy along with psychodynamic therapy in their orientations and depression and anxiety disorders as one of the areas they work with.

In your situation, you are seeking someone who isn't as structured as a pure CBT therapist, and that's why the psychodynamic therapy is important to be in their orientation, which is a more insight based therapy. In psychodynamic therapy you are looking at the causes of your behavior, your history, and its effect on you. The idea here isn't that these types of therapy are magic. It's that you may want to find a therapist who will form a strong therapeutic alliance with you and will help you look at the sources of your emotions.

Okay, I wish you the very best!

Now for the technique: here are instructions on a therapeutic protocol called Progressive Muscle Relaxation (PMR). It's really quite easy to do almost anywhere. My patients, when I teach them PMR at first are amazed how simple it is and that it is a psychological protocol. It was first used in the 1920s! Since then, of course, it has been refined and many studies have been done showing its effectiveness. I want you to practice the PMR at least 5-6 times before an attack or feeling acute anxiety. Why? Because when you're in the throes of anxiety, you will only remember to do something you are very familiar with it. So practicing 5-6 times is really a minimum.

I want to stress the importance of breathing as well. Part of the physiology of what is happening to you when the anxiety of depression is present is that your breathing is getting shallower. This reduces the oxygen in your blood to your brain. That increases the anxiety and depression, which strengthens the emotion and you are in a vicious cycle! Not good. So breathing is the primary tool. I have found in my practice that learning breathing techniques can be helpful. But some of my patients are not interested in learning more than one thing at the beginning, so I have found that just reminding you to BREATHE deeply at the same time you are doing PMR is almost as good. If you are willing to take a yoga class and learn breathing techniques, that's the best. But, breathing deeply with your PMR will help.

So, we're ready for learning PMR. I want you to print my instructions below my signature and have a copy in each of the rooms of your home where you may be when you have an attack. And again, you need to practice this easy technique at least 5-6 times as soon as you can. It needs to become as natural to you as breathing. Ah, remember breathing?

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  1. After finding a quiet place and several free minutes to practice progressive muscle relaxation, sit or lie down and make yourself comfortable.
  2. Begin by tensing all the muscles in your face. Make a tight grimace, close your eyes as tightly as possible, clench your teeth, even move your ears up if you can. Hold this for the count of eight as you inhale.
  3. Now exhale and relax completely. Let your face go completely lax, as though you were sleeping. Feel the tension seep from your facial muscles, and enjoy the feeling.
  4. Next, completely tense your neck and shoulders, again inhaling and counting to eight. Then exhale and relax.
  5. Continue down your body, repeating the procedure with the following muscle groups:
    • chest
    • abdomen
    • entire right arm
    • right forearm and hand (making a fist)
    • right hand
    • entire left arm
    • left forearm and hand (again, making a fist)
    • left hand
    • buttocks
    • entire right leg
    • lower right leg and foot
    • right foot
    • entire left leg
    • lower left leg and foot
    • left foot
  6. for the shortened version, which includes just four main muscle groups:
    • face
    • neck, shoulders and arms
    • abdomen and chest
    • buttocks, legs and feet

Quickly focusing on each group one after the other, with practice you can relax your body like ‘liquid relaxation’ poured on your head and it flowed down and completely covered you. You can use progressive muscle relaxation to quickly de-stress any time.

What You Need:

  • A comfortable place.
  • Some privacy.
  • A few minutes.


My goal is for you to feel like you've gotten Great Service from me and the site. If we need to continue the discussion for that to happen, then please feel free to reply and we'll continue working on this. If the answer has given you the help you need, please remember to give a rating of 5 (Great Service) or 4 (Informative and helpful), or even 3 (Got the job done) button. This will make sure that I am credited for the answer and you are not charged anything more than the deposit you already made by pressing any of these buttons. Bonuses are always appreciated! If I can be of further help with any issue now or in the future, just put "For Dr. Mark" in the front of your new question, and I'll be the one to answer it. All the best, ***** *****

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