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Ask Dr. Kaushik Your Own Question
Dr. Kaushik
Dr. Kaushik, Psychiatrist
Category: Mental Health
Satisfied Customers: 4636
Experience:  MD Psychiatry
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Dear Sir, hope you are fine. Sir, could u plz come on chat. Sir,

This answer was rated:

Dear Sir, hope you are fine. Sir, could u plz come on chat.
Sir, Presently, I am on the following meds :

1) Duloxetine 30mg twice daily

2) Aripiprazole 20mg once daily

3) Pregabalin 150 mg at night

4) Clonazepam 1mg - sos

Sir, inspite of taking the above meds I still have severe depression and severe anxiety particularly, Social Anxiety Disorder. Sir, which will be a better option ?

a) Adding Mirtazapine ?

b) Adding Bupropion ?

c) switching Arip to Queitiepin ?

d) Anything other that you deem appropriate.

My doctor does not increase duloxetine beyond 60 mg daily.

Sir, Its my prayer to you to kindly help me.


Greetings !


Welcome to the site.


Well you can add any one of these two drugs -- Bupropion xl at dose of 150 mg in the morning or Mirtazapine at dose of 15 mg at bedtime, however I believe Bupropion xl will be a better choice because of it's favourable side effects and the fact that it will not lead to drowsiness when taken unlike mirtazapine.


So you may first give try to bupropion which is to be taken in the morning and assess your condition after 1 month of it's addition.


If after this change you still have not reached that level of improvement as you would have expected then I reckon that you may replace aripiprazole with quetiapine.


Hopefully this revision of your drug regime finally finds control over your symptoms.


I hope this helps.


Wish you all the best.


Please kindly leave a Positive rating if you are satisfied with the answer.


If there is any furher assistace needed please feel free to ask using the reply button.




Customer: replied 4 years ago.

Dear Sir,


I have heard that Bupropion is not a very good drug for anxiety, is that true ?

Yes it is true but I preferred it over mirtazapine because it will cater to your depression and to some extent to anxiety and will not cause any drowsiness which I am concerned mirtazapine may result in due to it's sedative effect which will combine with the sedative action of all the other drugs present in your current drug regime thereby making you too drowsy to carry out your daily routine.


However if you think anxiety in your case is too overwhelming then you may use mirtazapine instead, starting at 15 mg / day dose to be taken at night time and after 1 week you may up the dose to 30 mg / day and maintain on it.


I hope this helps.



Customer: replied 4 years ago.

Sir, lastly, do u think I can stop Pregabalin and start on mirtazapine...or do u think its not necessary. Sir, Anxiety is my main problem.

Yes you may come off pregabalin now and add mirtazapine at night time , this shall avoid any possibility of an excessive drowsiness.



Dr. Kaushik and other Mental Health Specialists are ready to help you
Customer: replied 4 years ago.

Dear sir, one last question plz.


1) What should be the dose of quetiapine for my extreme anxiety ?


2) Is it a better idea to replace Duloxetine with Escitalopram ?


3) Will it be a better idea to add Mirtazapine at night if u think escitalopram should be introduced and if then , should quetiapine be there ?



Greetings !


Below are the answers.


1) Quetiapine shall be taken in the dose of 25-75 mg / day to be taken as a single dose at night time , starting first at lower dose of 25 mg and raising the dose by 25 mg every 2 weeks until reaching to 75 mg/ day.


2) With the addition of mirtazapine in the drug regime escitalopram use is not adviced as it does not work well with mirtazapine so replacement of duloxetine with escitalopram is not a good idea if you plan to add mirtazapine to the drug regime.


3) I will ask you not to use escitalopram with mirtazapine but instead add mirtazapine to the drug regime along with quetiapine as their combination with duloxetine works



I hope this helps.



Customer: replied 4 years ago.

Thanks a lot Sir.



Take care.



Customer: replied 4 years ago.


sorry to ask you another question which is bothering me.


should i swith to effexor xr instead of duloxetine, sir which is superior particularly for anxiety and depression too ?


Greetings !


Welcome to the site.


Well you see both Effexor xr and Duloxetine belong to the same class of SNRI anti depressants and they are almost equal in efficacy against depression and anxiety, however in your case it may so have happened that after prolonged usage of this drug your body has become less responding to it and therefore the anxiety and depression are not well controlled as expected. So in this situation you can switch over to Effexor xr , but the transition needs to be done after bringing off duloxetine in a systematic gradual manner by reducing 20 mg dose every 10 days until you reach total dose of 20 mg / day and then take this 20 mg / day dose every alternate day for 1 week followed by discontinuation of the drug completely.


After a gap of 2 days you shall get started on Effexor xr at dose 37.5 mg two times a day which can be further raised after 2 weeks to 75 mg two times a day.


Hopefully this will take care of your anxiety and depression.


I hope this helps.


Wish you all the best.





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