Question. I have been taking 0.1 mg of Synthroid and 200 mg Serzone daily for a little over six months. This seems to have improved my depression and anxiety significantly, however I feel heavily sedated all the time. My physician believes my current dosage of Synthroid is appropriate. If I reduce the Serzone, I feel my depression and anxiety returning. If I were your patient, would you change my antidepressant medication or augment the Serzone with a second agent?
Answer. I would need to know more about your medication regimen; i.e., do you take the 200 mg of Serzone as a single dose or in two or three doses? At what times of day? If you are now taking the Serzone as a daytime dose, I would try shifting most or all of it to bedtime. Splitting up the total dose into 2 small (25 mg) doses and taking the remaining 150 mg at bedtime might work for some patients, without compromising efficacy. If you are already taking the Serzone in this way and are still feeling heavily sedated all the time, there are two equally reasonable options, in my view:
1. Switch to a less sedating agent (e.g., fluoxetine [Prozac] or sertraline [Zoloft]); or
2. Add a small amount of a stimulating agent to the Serzone, such as methylphenidate (Ritalin), bupropion (Wellbutrin) or caffeine. Caffeine, however, may exacerbate anxiety in some patients.
Some patients may tolerate an alternating schedule of, say 200 mg of Serzone one day, 150 mg the next, etc. Have you tried cutting down the Serzone by just 25 mg/day? It may be that if you can cut it down to the point that you no longer feel so drowsy, a small amount of Wellbutrin (e.g., 37.5 mg per day) could be added to augment the Serzone’s antidepressant effect–Wellbutrin does not have very good antianxiety properties. If the first option is used, I would start very low with the Prozac or Zoloft dose, in order to avoid initial worsening of anxiety; e.g., 5 mg per day of Prozac or 12.5-25 mg of Zoloft. You might need to buy a pill-cutter.
Which path to take would depend, in part, on whether you wanted to accept he risk-benefit ratio of a second (augmenting) agent, vs. the risk-benefit ratio of trying a new and hence uncertain, medication. My general rule is “build on strength.” Try to work with and around the first successful agent, if possible. By the way, are you certain that your TSH is now normal? (In most labs, below 4.5-5.0.) Borderline hypothyroidism can certainly contribute to low energy and delay antidepressant response.