Thanks for watching, and for your question! This is a much older video, so be sure to check out some of my newer offerings on this subject ( I just created a separate "Sexual Functioning" playlist that contains them all). First, let me say that each individual is unique, and there is no "one-size-fits-all" answer, but in general, _yes,_ I would say we expect to see the least sexual dysfunction with Lexapro and Celexa, and the worst with Paxil, especially if we are talking about anorgasmia, but it also very much depends on the _dosage._ While most antidepressants can cause ED, it is not commonly reported on bupropion (although yes, norepinephrine would be to blame), and here again, demographics, overall health status and lifestyle variables are extremely important: middle-aged and older men are especially vulnerable, compared to boys and men in their twenties, and co-morbid conditions like diabetes, obesity, hypertension, _et al._ also dramatically lower the threshold for this side effect, especially if they are severe or poorly-controlled. Whether or not an individual is a smoker or uses alcohol are two major lifestyle variables, among many more, including diet and exercise, and then there are potential _psychological_ variables: some men only experience ED with a partner, but never during masturbation. Performance anxiety (or any type of anxiety, or major mood disturbance) can certainly detract from the strength and stamina of the erection. It's hard to say that SNRIs cause more ED across-the-board than SSRIs, although there is a theoretical basis for that speculation. I don't think it has been systematically studied (I could find no head-to-head comparisons...no pun intended...but we would need meta-analyses to make any blanket statements). Thanks for watching and please stay tuned for more great content!

@@notonanemptymind Thank you for the response! I really appreciate it. Ya, I do have elevated cholesterol and borderline high blood pressure, so I know that is a factor, too, which could be why bupropion made it worse with raising my BP a little further. I've dug a lot on this subject, and these are the only two studies or meta-analyses I've found that really have any granularity to the data IMO. You might know about these already, but just incase you don't: ecommons.luc.edu/cgi/viewcontent.cgi?params=/context/luc_diss/article/4341/&path_info=Jacobsen_luc_0112E_11977.pdf pmc.ncbi.nlm.nih.gov/articles/PMC6832699/ Thanks again!

This will depend on the dosage, whether or not a person is already taking a serotonergic medication (and if so, how much, for how long, and how they are doing with any nausea from that medicine), what other medications they may be taking, how sensitive they are to nausea from these types of medications, and a host of other potential variables having to do with body chemistry at the time of ingestion. To minimize nausea, one should begin with a conservative dose, and take with food. If the nausea is severe, consult with your provider! When a medication causes a person to vomit, it is being dosed too aggressively (assuming that there were not other, external and unrelated factors that contributed). In either case, the nausea would be expected to abate in short order.

@@notonanemptymind Nice to meet you, Doc! I took what my psychiatrist prescribed me, just half of 5mg - so 2.5mg and it gave me an instant headache followed by pretty terrible nausea for 30 minutes until I vomited.

Good to meet you as well, and thanks for watching, and for engaging! The psychotropic medication prescribing guide that I use states that the tablets should not be divided, crushed, or chewed; the tablets are not scored, although I couldn’t find any specific reason for not splitting them. Trintellix is an immediate-release preparation and, although the tablets are film-coated, this is apparently for aesthetics only. Still, whenever you break a coated tablet in half, you alter the way that the body absorbs it and so, with such a low dose, my best guess is that that may have ironically worked against you, in terms of tolerability. I assume that, if you kept taking it, the nausea quickly abated? I would have advised my patient to take the whole 5mg pill with food and to give it time. There may have been another factor that affected you, especially if you were used to taking medication that increases serotonin, but some people just respond idiosyncratically to certain medications. If I felt that we really wanted to give the Trintellix an adequate therapeutic trial, but the nausea were not improving, another option would be to pair it with an anti-emetic medication, possibly even another antidepressant, like mirtazepine. Thanks again for watching and please stay tuned for more great content!

Maybe Wellbutrin isnt good for your ocd and make it worse... Do you take high dose ssri in addition?

Noradrenergic/dopaminergic medications like Wellbutrin XL definitely exacerbate OCD in a dose-dependent fashion and should be balanced with serotonergic medications like an SSRI, for sure. The decision to take a given medication, at what dosage, for how long, and in what combination with other medications, is based on individual risk/benefit analyses, which can change over time. In my case, the Wellbutrin XL is a necessary component of my overall regimen, because it helps keep me alert throughout the day, since I have to take high-dose Lyrica for neuropathic pain, but I find that I am not only less sleepy, but also more motivated to get things done, and my overall energy level is better. The problem it gives me is not so much OCD exacerbation as irritability and trouble modulating anger, which is also a lifelong issue, attributable to my temperament, which I inherited. At the end of the day, it's about finding the right balance: a new homeostasis that alleviates symptoms, without causing new ones. Thanks for watching and please stay tuned for more great content!

There is redundancy between Savella and Trintellix, so if the insomnia persists you can discuss whether you need to be taking both with your prescriber. I assume you take Savella for its FDA indication, fibromyalgia? As an SNRI, Savella has antidepressant and anxiolytic actions (that will vary from individual to individual, and which would also be presumed to be dose-dependent). One obvious option is to add a hypnotic agent in the short term; please see my "Insomnia Armamentarium" video for an overview of the major classes of agents that are available, their major advantages and disadvantages, including several non-habit-forming options. Best of luck, and thank you for watching!

Thank you! And thanks for watching. It’s a slippery slope, isn’t it? I think if the hypomania is not obvious, it’s not hypomania, or at least, not clinically-relevant. A response to medication is never appropriate as a basis for a diagnosis, with the exception of seeing frank mania in response to an antidepressant. Please see also my most recent video on “Treating Symptoms and Other Clinical Pearls” for more on that subject. Thanks again for tuning in.

Good luck! If you take it with food and take your time increasing the dosage, the nausea should subside over time.

I’ve heard that from a number of viewers. I’ve only used it for major depression, sometimes with anxious distress, but the best anxiolytic antidepressants in my experience are the SSRIs and the SNRIs. Thanks for your comments.

Thanks so much

Great question. No, with proper mood stabilization (i.e., the coadministration of (a) mood-stabilizing agent(s)), there is no contraindication to using Trintellix for manic dysphoria.

I will place it in the queue, thank you for requesting it, yes, that would make for an interesting talk!

Thank you for the positive feedback, and thanks for watching! Yes, it would be my opinion that your hypo/manic condition (inasmuch as we are talking about your brain chemistry at the time) muted mild-to-moderate pain signals traveling from your extremities up the spinothalamic tracts of the spinal cord at the level of the cord, before they could reach the brain, via the actions of noradrenergic efferent neurons. Great question.

Check out my "Wakefulness Wars" video: kzbin.info/www/bejne/kKuXgZqXnbiNfqs

@@notonanemptymind Will do! Thank you!

Hello, thanks for watching and thanks for your question! Yes, antidepressants, including Lexapro and Remeron, can cause middle or terminal insomnia as a side effect. Sometimes this improves slowly over time, as you develop some tolerance to this effect, but it can be a chronic side effect. I usually prescribe a hypnotic agent (sleeping pill) in those situations, at least in the short term (see my "Insomnia Armamentarium" video for an overview of the various options available to patients). Thanks again for tuning in! Where do you live?

@ Thanks for your answer! I was on lexapro for 7 months until insomnia became unberable. I didn’t see any improvement in that time… Hope it can get better with mirtazapine… but if not, how can i manage it? I really don’t want to take sleeping pills, there are really addictive and the effect were off quickly so you need to increase the dosage. If the chronic insomnia due to the antidepressant doesn’t improve, can it be better to rely only on benzo to manage anxiety? They are addictive but the anti-anxiety effect tend to stay and they don’t cause insomnia… Because i think all antidepressants have the same effect on me… middle night insomnia.. I am from Italy by the way!

Otherwise i was thinking about CBD. Do you think it could help and be safe?

@@bastienberthelot6653 I wish I could say, but I am really not an expert on CBD. I would caution any of my patients about using herbal dietary supplements of any kind, however, because supplements are notoriously unregulated and studies have shown that they often do not contain appropriate amounts of what they claim to contain and adulterants have also frequently been discovered (the FDA does not concern itself with these supplements, and so the industry is self-regulating). I am also skeptical of most CBD applications because there seems to be an unlimited amount of them; i.e., CBD is touted as a panacea that treats _everything,_ and yet, we have no idea how. Since nothing has to be proven to the FDA, or to anyone, herbal supplements can be touted for everything from insomnia to pain to cancer to better skin! Not surprisingly, CBD can be found in an endless array of products. I've seen CBD candles and CBD soap, both of which I would feel safer using than a gummy I have to swallow. CBD is classified as a Schedule I controlled substance by the Drug Enforcement Administration, meaning that, as a derivative of marijuana, it is considered illegal under the Controlled Substances Act, unless it contains less than 0.3% THC; in that case, it is legally permitted under the 2018 Farm Bill. I personally would avoid the supplements market. It is driven primarily by profit-mongering. Most of those "snake-oil" companies are corporations that care about the consumer's wallet, not the consumer. Big Pharma also comprises multinational corporations motivated by the love of money, but at least they are subject to governmental oversight.

@@notonanemptymindYes i share your point of view. I think it’s mostly commercial as you said but i might try once, just to see. Also i was wondering if it is possible to take mirtazapine in the morning even though it’s sedative. It could solve the problem of middle night insomnia as it’s taken far from bed time? I saw your video about seroquel which could be used for treatment resistant anxiety. It’s clear that it’s seems way more « dangerous » than antidepressants but if even a sedative antidepressant causes me insomnia, seroquel could be an option? Do you have an opinion about that? Because when i see my options for a long term treatment of anxiety , as antidepressant seems to give me insmnia, there is only pregabalin and seroquel…

Thanks for watching. You are fortunate to tolerate Remeron without continued weight gain. If your weight has plateaued and this medication is helping your sleep and your mood, there is really no reason to discontinue it. Best of luck!

@notonanemptymind Thank you for your reply. Looking forward to more of your posts.

I have not, and weight gain is not expected with Trintellix. Good luck, please let us know how you do. Thanks for watching, and please stay tuned for more great content!

The dietary concern was probably over-stated, but always better safe than sorry, and if you are taking 2 separate stimulants, I would be very careful about blood pressure monitoring if you started an MAOI, and definitely stay away from charcuterie. I have a video on the MAOIs in which I review the dietary restrictions in detail, explain the pathophysiology underlying that food-drug interaction, and mention the fact that, even in your case, the dietetic perils are no reason not to try this class of very effective medications, especially if you did well in the past. However, the risk of serotonin syndrome in someone taking 2 different amphetamines must be carefully assessed. It is always best to try to nip the source of the problem in the bud, rather than reaching for an antidote, if possible. You can't do anything about your temperament (your genes), and the nurture piece, your childhood and your prior experiences, likewise cannot be altered, but you can do a lot of good work in psychotherapy unpacking that baggage, figuring out your triggers, analyzing your reactions and aiming to modify your future behavior, although it's not easy if the anger is fast and intense (see also my "Controlling Anger: Emotional Analgesia" video for more on that). The easiest thing to do would be to stop pouring gasoline on that fire, so I would encourage you to re-evaluate the risk-benefit analysis of taking not one, but two, different amphetamines, an analysis which can change over time, by the way, as you age and your circumstances change, and the indication for that type of regimen varies. I would especially periodically review the dosages, because this side effect might be dose-dependent in some individuals (for others, I think it is more-or-less all-or-nothing, since very low doses let the genie out of the bottle every time, and lowering the dose doesn't help much). There are also roundabout ways stimulants can make you tense and snappy, such as not sleeping and forgetting to eat. As far as Qelbree, remember that at the end of the day (metaphorically and literally, as I mention in this video), the final common pathway is mediated by the increase in dopamine and norepinephrine, so any stimulating, dopaminergic/noradrenergic agent would be expected to cause the same problem. Qelbree is most like Strattera (atomoxetine), if you have ever had that. Finally, if you were my patient, I would delve deeply into this phenomenon of not being able to tolerate even low doses of a serotonergic agent due to intractable nausea. You only need _a little_ SSRI to help _a lot_ with anger, and nausea dissipates 100% for 99%+ of patients over a fairly short period of time (see my "3 Ways of Avoiding Side Effects" video for added strategies, but your body adapts on its own), such that if you are truly such a rare outlier, you might consider taking an anti-emetic agent like Zofran (or perhaps better yet, Remeron, which also blocks 5HT3 receptors but is a great sleeping pill/antidepressant agent as well, see "Remeron, an Almost Perfect Antidepressant"), at least for a few months. If you continue to experience severe, pervasive nausea on a tiny, starting dose of an SSRI taken with food and ondansetron, something is up. Meaning, that is not medically feasible and the nausea is almost certainly psychosomatic: genuinely experienced, but triggered by, and largely based upon, psychological factors. A directed psychotherapeutic program of desensitization (deconditioning) would then be in order. I can’t say whether this is the case with you, but have you tried combining with anti-emetics? If so, you might also explore this intolerance of serotonergic agents (which it is obvious you need, and from what you say, even if you weren't pouring gasoline) with a therapist. Therapy + medication is almost always better than either alone. (“How to Engage in Meaningful, Successful Psychotherapy”) Those are my thoughts, that is how I would approach a case like yours...and I have seen a patient or two with your issue with intractable, medication-induced nausea. Whatever else is going on with your chemoreceptor trigger zone, by now you must have developed a certain psychological aversion to entire classes of serotonergic medications, such that we can't divorce you from the placebo effect. That is, initially; the whole point of therapy would be to do precisely that. I'm sure you must dread the thought of yet another such trial: "here we go again..." The thought is enough to make you...queasy.

@@notonanemptymind Wow, thx so much for such a comprehensive reply Dr. Silva. So much to think about. For whatever reason, I don't tolerate and/or like taking the adjunct meds and thx to your notes above I may seek via my physician to take only Vyvanse. That is to take my usual morning and try also early afternoon dose too. I didn't know that Vyvanse is considered a different stimulant per se and I have been taking 10mgs of dexedrine around 2pm because it's thought I'm a fast metabolizer, but the slower release of the afternoon Vyvanse could help ease me down at the end of the day and not interfere with sleep. I hv had periods when I was not taking any stimulants for months at a time in the last 20+ years, but unfortunately I hv a very heavy paperwork intense job and I work from home and found I was unable to function without the stims. Thx again Dr. Silva and I look forward to learning more about your out-of-state consult offering.

Both Dexedrine and Vyvanse are amphetamines. Careful with taking Vyvanse in the afternoon, because it is a long-acting agent that could definitely cause insomnia. I wouldn’t dose it after noon. To learn more about my non-medical consult service, you can contact me at [email protected]. Cheers.

You are most welcome, thanks for tuning in! Speaking as a highly neurotic person myself (I suffer from OCD and other interesting maladies of the mind), so-called neuroses have more to do with inadequate serotonergic neurotransmission, but at the end of the day it's really the _balance_ of neurotransmitters, and hormones, and exogenous compounds (like vitamins and caffeine and medicine and recreational drugs, etc.) that determines our mood, and our perspective, and our mental thresholds at any given moment. Hundreds, if not thousands, of molecular species, continuously impinge upon the mind, a vast quantum tide, dictated in large part by our genome, inducing emotion that scripts our thoughts, thoughts that consequently synthesize our subjective realities. Please see my "Primordiality of Mood" videos, parts 1-2 for more on how the chemical environment doesn't just determine how we respond to the outside world; it determines what aspects of it we are capable of sensing. kzbin.info/www/bejne/g36ogYyilpWCd9E

@@notonanemptymind Thanks for referring me to your videos. Quite a brew of factors involved. Maybe AI and bioanalytics could one day be synthesized to an individual level. Really enjoy your videos.

That is a paradoxical reaction and it has nothing to do with bipolar disorder; the _sine qua non_ of manic depression is mania (see my videos in the bipolar playlist, especially "Be Skeptical," "Nowhere Near Mania" and "True Mania" for more information about that). It does mean you need to adjust, but if it was truly brought on by beginning an SSRI with absolutely no other concomitant medication changes, then you need to get to steady state before re-evaluating. That's usually around 5 days, except for Prozac, which can take 2-4 weeks. You may not be a good candidate for the PRN use of an SSRI if you are having this initial reaction.

@@notonanemptymind Thank you for the quick reply.

@@notonanemptymind Shame you are TX only.

Thank you, I do have a non-medical consultation service, where we could meet to discuss symptoms and treatments as they might pertain to you, but really more of a one-on-one, question-and-answer session that would not establish a doctor-patient relationship (since one cannot legally be established outside of Texas), and from which I would not make any formal diagnoses nor provide treatment. I am working on updating my website to reflect this service, and will make a general community announcement soon, but if that is something you might be interested in, you can contact me at [email protected] or text (432) 692-4525 for additional information. Thanks again for watching and please stay tuned for more great content!

@@notonanemptymind Thanks! I'll ponder it! Your videos are fantastic.

Haha, glad you enjoyed that one! When I downloaded that sound byte I renamed it "Scary F@#%! Scream"

Most people can expect to develop tolerance to headaches within a few days to weeks, so yes, I would anticipate that it will get better soon, but that is a high dose for sleep: the FDA approved 3mg and 6mg tablets. You are taking a dose that is considered high for just insomnia, and low for depression, and even lower if we were talking about the treatment of anxiety. If you are not taking it for your mood, or for neuropathic pain or migraines or some other indication, you should ask your provider if you really need to start at 25mg. The headaches are likely dose-dependent; you probably won't experience them on the more standard starting dose of 3mg. If you are also hoping for some antidepressant action, taking it with food or even dividing the dosage (early evening and bedtime) may help in the meantime. Good luck!

Thank you! Unfortunately, chemical dependency is sabotaging treatment.

@ I’m very sorry to hear. Questions for you: do any of your patients ever ask for time off while they start an SSRI? I just started Lexapro and all the side effects you mentioned in your videos are in play.

@@fulcrum16 My patients have certainly requested that I endorse medical leaves of absence, but not tied to starting a medication. All medical leaves have to be justified based on specific symptoms (which could include side effects, certainly, but which usually have more to do with the underlying problem), and the doctor is saying that the patient is temporarily, relatively occupationally disabled: that the patient can't work, because of the severity of the symptoms, whatever is causing them. The only person who would know if that applies in your current situation would be your provider. Best of luck with Lexapro!

@ thank you! Please keep up the great post. Btw, I’m on day 6 of Lexapro and experiencing some increased anxiety, insomnia, sweaty palms/feet, and my nurse practitioner is telling me to stop. After watching your videos, it feels like I should keep going. I have GAD & health anxiety

If you quit now, you’re aborting, and it would definitely _not_ be an adequate therapeutic trial. If you want to complete an adequate therapeutic trial, you would need to push through.

Thanks for watching and for your comments. Not all molecules exhibit chirality; i.e., not all molecules exist as enantiomer pairs...in fact, most do not. When we talk about "superimposing" them, we mean conceptually, as a thought experiment, not literally (you are correct, you can't collide atoms without an incredible force, like a massive amount of gravity: that's nuclear fusion, and it's what lights up the firmament!). But here we are not talking about actually trying to overcome the electromagnetic force that repels individual atoms; the idea of conceptually superimposing mirror images is a thought experiment in which you imagine taking the mirror image of a molecule and rotating it in 3-dimensional space to see if it aligns perfectly with its twin. Most of the time you can do this, because most molecules do not have chiral centers, by which we mean a central atom (usually carbon) bonded to four different atomic species, because when you have such an arrangement, you end up with actual right- and left-handed versions of the molecule (the two mirror images) which are not superimposable, i.e. they are really two different molecules in nature, they are not the same molecule, despite being identical in every other way. The property of chirality is a consequence of the molecule's stereochemistry, the spatial arrangement of the molecule's atoms. Every molecular interaction is governed by the laws of thermodynamics, but here we are not talking about the transformation of energy; we are simply discussing a static, inherent property of individual molecules whose atoms are arranged in such a way that the molecule can "point" in one direction or the opposite direction in actual space, and even if you take one of those two versions and rotate it 180 degrees so that it is now pointing in the other direction, you still can't stack it perfectly on its twin so that they are no longer mirror images. When carbon is surrounded by four atoms we get a tetrahedral molecular structure, like a pyramid with four faces, where carbon is at the center of the pyramid and the four other atoms are situated in the corners. If the four other atoms are four different species, you have a chiral center, and the molecule's stereochemistry dictates the existence of enantiomer pairs. Now imagine the four atoms are the same, such as with methane, CH4. When carbon is surrounded by four hydrogen atoms you still have a tetrahedral structure, but you no longer have a chiral center, because methane's mirror images are superimposable; you don't even have to flip methane around to perfectly align those images. They are the same molecule; all methane molecules are achiral; there are no "right" and "left" versions. The same is true if carbon is surrounded by only three different atoms (meaning two of the four are the same); those molecules are likewise achiral. To force nature to recognize an enantiomer pair, the central atom must be surrounded by four _different_ species. I hope that makes sense. I think it's fascinating how the nature of three-dimensional space evinces these molecular realities, and how that affects biochemistry. It can be the difference between a molecule that helps to lower anxiety (escitalopram) and a seemingly identical twin molecule that is completely inert (R-citalopram).

@@notonanemptymind Thanks for the detailed reply. Oh yeah, I didn't suggest that all molecules are enantiomers. It would be only the properties of particular kinds of molecules given the constraints on them. Yes - stereochemistry is a very interesting area to me. Your explanation does make sense. And, in fact, some theoretical chemistry use an area of mathematics, known as group theory, in order to study the properties of molecules. In particular, you would be looking at the properties of symmetry groups. But what is interesting is essentially all of this is a huge abstraction of what is ultimately going on. When you look at the molecules as wavefunctions, things become much more complex. We have to abstract away this complexity by using Lewis theory or molecular orbital theory. While these theories get us enough to understand the qualitative properties of most molecules, there are still so many mysteries. Nonetheless, I am sure the properties of chirality don't really change even if we were to take the orbitals generated by software. I am very excited about starting this journey and have ordered some books on the foundations of molecular orbital theory and group theory in chemistry, as I do have training in mathematics. You seem to have great knowledge of this subject. I don't think I would have received such a knowledgeable explanation from my psychiatrist... or for about 90% of physicians I encounter!

@@ladyoftheflowers9781 You're very welcome, and my apologies I neglected to say that I really don't have any books I might recommend. To be honest, I am not very well-read or knowledgable about chemistry in general, but this is one particular facet that really captivated my attention when I took organic chemistry, many years ago. I agree that the ultimate reality (if there is such a thing), on the quantum level, is only approximated by our theories. A lot of people equate the term _theory_ with "hypothesis," but in science, a theory is not a speculation; it's a detailed paradigm that guides research and practical applications, and is possibly the highest level of understanding we can achieve in trying to understand reality, as you suggest. Are all things knowable? Are there really any objective realities out there to "know"? Those are the philosophical questions that I find even more fascinating! Thanks again for watching and engaging.

@@notonanemptymind I am glad that, as a beginner in organic and biochemistry, I am fascinated by the exact same concepts you are interested in. Thanks for the comments! Keep up the great content!

The first month you are on a starting, sub-therapeutic dosage to allow your body to get used to the medication. Otherwise, the nausea would be too intense. The dosage more than doubles the second month, from 3mg to 7mg/day. Still, most people experience 5-10 lbs of weight loss that first month (based on my own personal, as well as anecdotal, experience). It is in the second month that the weight really starts to come off. Weight loss is practically guaranteed. It took me about 5 months, give or take. Most people lose that in 3-6, I would estimate. If your BMI is >30, you may continue to lose weight for a year. Around then, a certain tolerance to the anorexia develops, and weigh plateaus for most people, but everyone is different. I "graduated" to Mounjaro, which is definitely much, much stronger and even more effective at curbing the appetite. Those are weekly subcutaneous injections, and I can always tell when I am due if I forget, because I start to obsess about meals and snacks. I tried coming off for a couple of weeks, and the bingeing behavior resurfaced, maybe even with a little rebound vigor; that is, a little stronger than before I started taking the medication, but I wasn't tempted to purge at all. Let me recommend this great primer by Dr. Michael Greger. It is a slim volume that concisely explains the pros and cons of taking this class of medications and in particular, the long-term risks and benefits. amzn.to/4h1nvnj. Good luck!

Where is that, and can you tell us why it was pulled from the market? And you are very welcome! Thanks for watching. Please stay tuned for more great content and please share any information you find useful on social media 🙂

Thanks for sharing your experience!

Thanks for tuning in! Temazepam and lorazepam are, of course, cross-tolerant (please check out my two-part "Benzos" series, if you haven't already!) and so you would not have experienced those withdrawal effects if you were not taking both. You do well to avoid taking a sleeping pill if you don't need it; you will develop less tolerance, it will work better, and you will be in less danger of withdrawal, but you are effectively on a significantly higher daily dosage (if we consider the benzodiazepines as a single entity, which is valid in the context of what it means to your benzodiazepine receptors, the reason you experienced mild withdrawal), so you should think about it in terms of withdrawing from the total daily dosage, and not just your bedtime dose, although yes, that dosage was proximal to the symptoms, and taking it would have avoided them. You would have avoided them had you tapered the Ativan that day instead (for 2 reasons, but mostly because the proximal dose would have protected you from immediate withdrawal 7-9 hours later). You should confer with your prescriber to get a specific tapering schedule, since there are so many variables that are particular to your case and I wouldn't be able to give you a blanket recommendation there (ha, no pun intended!). Is it your intention to completely discontinue the temazepam? Or do you mean, how should you avoid this in the future when you feel you don't need the sleeping pill? I'm surprised you experienced that much withdrawal on those doses, but there again: there are a number of unknown variables, chief among them how much alcohol you drink. If you were my patient, I would start the inquiry there, because even with chronic dosing, I would not expect any physical withdrawal from holding 30mg of temazepam, unless there is cross-tolerance elsewhere that makes you more vulnerable to withdrawal by further tampering with that threshold.

You are very welcome, thanks for watching and Happy New Year! If you are tolerating Paxil well enough, 60mg should definitely be tried for at least 4 weeks for intractable anxiety; I would not consider 40mg an adequate therapeutic trial of paroxetine for anxiety (the dose can be taken as high as 80mg, although this is uncommon). Clomipramine would be my choice for anxiety among the TCAs, and it is certainly worth a try. I often add it at a lower dosage (50, or 75mg, for example) at bedtime _in addition to_ an SSRI or an SNRI, rather than swapping it out entirely, but care must be taken to review all drug-drug interactions and to avoid *serotonin syndrome.* Combining low-dose clomipramine with another serotonergic agent should only be attempted by an expert psychopharmacologist, but it can be very effective for recalcitrant anxiety. If the patient is a good candidate for treatment with benzodiazepines, there is no reason to withhold that class of very effective anxiolytic agents in a combination strategy, as well. Best of luck.

Amphetamines are potent vasoconstrictors, which leads to cold extremities in those individuals who are most vulnerable (e.g., older people, diabetics, smokers, or people with poor circulation for other reasons). This is probably a dose-dependent effect, and a host of other variables likely come into play in explaining why one medication might cause more of that for a given individual than another, having to do with bioavailability, for example; Vyvanse has a significantly different pharmacokinetic profile than Adderall, despite an identical pharmacodynamic one, which is to say, they have identical mechanisms of action, but Vyvanse is taken up and metabolized completely differently. If Adderall was years ago, it may have more to do with changes in your body than differences between the medications, but all of the above are possible. It's ironic you should ask about this in this video, because when I originally released it it was 4 minutes too long, because I went on a tangent about Reynauld's Phenomenon (which is a possibility with any stimulant, not just lisdexamfetamine). I'm not saying that you are experiencing Reynauld's, but if you are interested you can check out the excerpted segment as a separate, "instant replay:" kzbin.info/www/bejne/aoTCZYarotGbqNE

@ thanks for the reply. I was prescribed adderall up until this month, so I've just recently started vyvanse. I'm sure the novelty of vyvanse to my body is contributing to my symptoms, but the vasoconstriction is prevalent enough for me to think there are other contributing factors. I don't believe I'm experiencing Reynauld's since the coldness/vasoconstriction isn't localized to a few fingers and toes, but instead impacts my entire feet/hands and sometimes lower legs. At one point, one foot become tingly , which was concurrent with coldness in both feet/hands. I'll be monitoring these symptoms as I continue through this first month or two, expecting to see them decline as my body adapts. I'll most likely request to be put back on adderall IR though. Vyvanse's extended release keeps me awake long into the night, which is the same issue I had with adderall XR. Thanks again for your reply.

Prozac has no withdrawal/rebound, and fluoxetine was actually approved for PRN use as Sarafem, for PMS/PMDD. See also my "Prozac Family" video for a comparison of the six SSRIs. I also have an "SSRI Overview" video. You can do a channel-wide search for any topic. My library is still building, but I am posting frequently.

Please see my video on Performance Anxiety ("When the Suspense is Killing You...")

Hyperfocusing is a dose-dependent potential side effect, I think even for people with "ADHD," so it is not necessarily a diagnostic litmus (I place ADHD in quotation marks to remind that it is a syndrome, not a single illness with a single etiology or pathophysiology that applies to everyone who actually has it; like most psychiatric diagnoses, it is a _group_ of conditions). In other videos I make it clear that we can never work backwards from the treatment to the diagnosis, especially not using stimulants for attention and concentration, because _everyone_ improves on Adderall, et al., whether they have ADD or not. So many people believe their "diagnosis" was confirmed by their splendid response to all that extra dopamine, and that's just not the case. That would be like saying the euphoria 100% of patients experience, at least, initially, proves that they were depressed. As far as other indicators based on treatment response, I do not believe there are any, not reliable ones that can be generalized to an entire population (perhaps on a case-by-case basis, but only by carefully weighing in a host of other diagnostic variables). If a person with apparent depression does not respond to a series of antidepressants, it doesn't mean they aren't suffering from actual clinical depression, even Major Depression, as their condition could simply be refractory to medication. And if a person with neuropathic pain, migraine headaches and insomnia feels a whole lot better globally with the use of a tricyclic agent, it doesn't mean they were depressed all along, even if their mood improves independently of getting better sleep and having less pain (both of which would obviously greatly improve a person's mood!). Increasing dopamine, norepinephrine and serotonin, as tricyclics do, might improve mood, energy, cognition and other parameters directly, enough for a patient to notice and approve...but it doesn't mean they were clinically depressed to begin with. Take-home message: the response to treatment in psychiatry is _never_ diagnostic. Regardless, I think that those individuals who do not necessarily _need_ (a relative term) more dopamine, like those who are over-dosed, are those most likely to follow rabbit holes. Great question re autism. I am not an autism expert, by any means, and I don't have a definitive answer for you, other than to say the clinical task would be to discern a pre-existing symptom from a side effect due to medication, and to try to measure a _change._ Middle and terminal insomnia can be symptoms of clinical depression, but also side effects of most antidepressants, and so we would look to see if they were present already, and if they improve, that settles it. If they worsen, despite an improved mood and reduced anxiety, that indicates that we are probably dealing mostly with side effects at that point. Another possibility is that insomnia remains more-or-less the same, which might be no effect at all of the medication on those specific parameters, or else the conversion of symptoms into side effects, as the former improve, and we induce the latter with escalating doses of the medicine. It is the clinician's responsibility to tease all of this out.

Thank you! I assume you meant no pun ("super" interesting...haha). I appreciate the specific feedback on my process, because I nearly edited out the part about my Googling and all of the things I did _not_ intend to discuss. I thought, "Viewers aren't going to want to know what I'm _not_ talking about," but I wanted to emphasize that "The Superman Effect" is a phrase I'm proposing, and not necessarily what Medicine officially calls the noradrenergic-fueled fight-or-flight (or freeze!) response. I was finally able to get AI to give me what I meant, given enough inputs (not only were "fight-or-flight" and "The Superman Effect" in quotation marks in the final result, but the word "norepinephrine" was also bracketed by quotes, which I removed, letting me know I was forcing the answer, but still impressive). I had a lot of fun editing this video with all the footage, and I'm especially proud of the soundtrack, which is almost entirely music I selected and mixed. It's probably subliminal for most people who watch, and don't even consciously notice, or else assume that the music belongs to the clips I used, but I think those subtleties are what make videos so watchable. Although my goal is to disseminate interesting and valuable information, video editing is a creative and challenging avocation, and my number-one pastime! I might not be able to monetize this one because of all the copyrighted clips, although I am arguing fair-use, since the video is educational, and I did transform them significantly with the added music and captions...wish me luck!

Thank you so much for the Super Thanks, Dennis! I was wondering where that came from, and just noticed it. I really appreciate your loyal viewership this year. I wouldn’t use the term "addicted" unless you meet at least some of the "use disorder" criteria that used to be found under abuse and dependency categories. Because it is colloquial, the term "addicted" is not useful clinically; this is a perfect example here, because, just as a person might say they are "addicted" to pickle ball, if there is no loss of control, no adverse consequences and no continued use despite those consequences, there is no problem, no matter how much one may rely on pickle ball (or anything else) to feel good. Just because you feel you "need" them doesn't mean you are out of control and hurting yourself, which is what addiction amounts to. Those medications can have deleterious side effects even when used as prescribed, but even in the case of, say, malignant medication-induced hypertension, that wouldn't be an example of a use disorder, either, because the diagnostic criteria are simply not met: a complication of therapy, even a serious one, is not tantamount to what we used to call abuse and dependency. I have another video,"Stimulant Euphoria...Is it a BAD thing?" that you should check out, if you haven't already. Thanks again for watching and engaging, and thanks again so much for the incentive to keep the channel alive!

@@notonanemptymind Excellent reply. Happy new year!

You are so welcome, and I think that Wegovy is the best medicine to curb food obsessions in the long run (once you i’ve been taking it a month or two) because it really goes to the source of the problem: the hypothalamus. I highly recommend that you check out Dr. Michael Greger’s book on Ozempic, which discusses the risks and benefits of long-term treatment with this class of medications; it is excellent, and a quick read.

@ Thank you for the recommendation, Doc! I’ll sure check it out.

Thanks for watching! And for your comment. 🙂

Honestly I have no direct experience with that, and there's no research I could find regarding Trintellix specifically. My general bias (and perhaps it is a bias) on supplementing pharmaceutical-grade antidepressants with dietary supplements such as vitamins, vitamin precursors, amino acids, and other biochemical cosubstrates is that the benefit in a person who otherwise does not have that vitamin or amino acid deficiency would be absent or marginal, at best. A 2009 article in the Journal of Clinical Psychiatry was equivocal: the studies were in patients taking SSRIs, most used folic acid (folate), improvement appeared to be limited to certain aspects of depression (e.g., cognition, somatic symptoms, etc.), depending on the population studied, and those were also special populations: elderly patients with dementia and actual folate deficiency (not surprising their cognition improved with supplementation), and patients with alcoholism, for whom folate deficiency is a common nutritional concern, among other nutritional concerns. 5-MTHF is thought to be safer than folate, but there really is no reliable evidence that it is a safe and effective antidepressant augmentation strategy for the general population; I would favor the use of partial dopamine agonists, like Abilify, Vraylar or Brexulti. Please see my playlist on the Atypical Agents for more information. Thanks for your question! pubmed.ncbi.nlm.nih.gov/19909688/#:~:text=Folic%20acid%20augmentation%20in%20depressed,most%20suited%20to%20folate%20therapy.

I greatly appreciate the time you took to elaborate and write the reply. It's been enlightening. Also thank you for including the link to the study and your playlist

@@gabugmola My pleasure. Thanks for the opportunity to do a little research and enlighten _myself!_ The great thing about these comment sections is that the Q&A is preserved for everyone else who comes along that would benefit from the information. Cheers.

I love that you embrace “weird” and use it with the affection with which it’s intended! Weird is wonderful…we are all a little strange. Thank goodness.

@@notonanemptymind I feel like the more we experience life and are aware of it, the more we react to it. To not get caught up in man made ideas which are deemed to be reality. This way we can distinguish between truth and falsehood. I find that the more I connect to the "ultimate" reality beyond man made words and language, the weirder things become. Life is a miracle, and finding purpose in existence is as paramount as knowing why things came to exist to begin with.

@@notonanemptymind subscribed and look forward to watching future content. ✨🛸

Thank you for watching and I couldn’t agree more! I look forward to doing videos in the not-too-distant future of a more spiritual and philosophical nature. I believe there is far more to reality and existence than we could possibly even comprehend as humans, but I agree that we should aspire to understand.

@@notonanemptymind A second evolution of mind. That is the way humanity is heading. And it will supercede the limitations of our perceptions 🔮