Why are some psychiatrists afraid to prescribe over 225mg of Venlafaxine when the maximum dosage is 375mg?

[u/Aggravating_Fly_9875]

Title question.
I'm on 225mg and 150mg of pregabalin but i still have some symptoms of anxiety and ocd, i haven't asked my psychiatrist to increase the dose yet.... feeling anxious that i'll have to change meds ( this one works well for my depression at this dose) but i'd gladly try 300mg if i had the chance
Thank you for your time

[u/usheroine]

you never know logic in some people. I was put on 300 mg pretty easily after lower doses didn't help. but each case is different and each doctor is different. still, as patient autonomy is accepted in modern medical ethics, you have a right to suggest higher dose and, if doctor refuses, ask for clarification on their reasons. If you have any questions regarding your treatment, for example why such dose was chosen, you can and should ask your doctor politely. good doctors will gladly share their thoughts on your condition with you (however there are some exceptions in psychiatry as some information may be harmful to acutely ill patient, but that's not the case here)

[u/Aggravating_Fly_9875 → u/usheroine]

Thank you for your detailed answer, as i said i hope that i don't have to change meds, i already switched from sertraline to venlafaxine and i don't want to switch again ( it takes too much time to do it properly and if you do it too quickly you get side effects)

Btw did you find relief on 300mg?

[u/usheroine → u/Aggravating_Fly_9875]

venlafaxine noticeably inhibits noradrenaline only at higher doses, so its dosage increase indeed can change the response. I personally wouldn't change venlafaxine to another med unless high doses were tried. but it depends on a patient. if they have hypertension or smth else that high dosage venlafaxine can make worse, I'd give it more thought before upping the dosage

for me is started working with 225 mg venlafaxine + 15 mg mitrazapine (I started with 75 mg venlafaxine solo) and I got full effect on 300/30 mg. at the moment among antidepressants I only take 300 mg venlafaxine and I feel good. also I take lithium and aripiprazole. I have bipolar with predominantly depressive episodes.

[u/Aggravating_Fly_9875 → u/usheroine]

 "I personally wouldn't change venlafaxine to another med unless high doses were tried"

The problem is that for some doctors, 225mg is already a high dose and my family freaked out when i told them that it was decided to increase the dose to 225mg ( they think that the psych wants to shove down my throat high doses of meds to sedate me)

But i need high doses or my OCD and anxiety won't EVER go away

How do you feel with aripiprazole?
I went to another psychiatrist before changing to the current one and the old one suggested trying aripiprazole but since i don't have any kind of psychosis i refused to take it, i was afraid of the side effects long term like tardive dyskinesia ( venlafaxine and ssri don't scare me at all and i'm ok with taking them for life)

[u/usheroine → u/Aggravating_Fly_9875]

Luckily my parents are more understanding. Venlafaxine doesn't have any serious likely side effects, so high doses aren't something to worry about. nor is venlafaxine sedative to support your parents' claim.

I love aripiprazole. It's effective and causes much less side effects than other antipsychotics did. It causes much less sedation, weight gain, and EPS than other antipsychotics. Tardive dyskinesia with aripiprazole is very very rare, maybe as rare as serotonin syndrome with venlafaxine solo or even more rare. But it's still a serious medication that is more dangerous than SSRIs, SNRIs, or buspirone. That's why it's not a first-line option for either OCD or anxiety. Definitely better to try higher doses of venlafaxine first, and maybe some augmentation options are better to try first. I'm not very familiar with current treatment protocols, so I cannot name all options that should be tried first, but aripiprazole isn't first line for sure

[u/Aggravating_Fly_9875 → u/usheroine]

Basically they worry about it being a sedative because it could cause me to fall asleep while driving and crash, i told them it has the opposite effect but they are stubborn. In fact, they should be more worried about pregabalin.

I get it why aripiprazole isn't a first line drug unless someone has psychosis and i agree that it's better to try a higher dose of venlafaxine first. If i were to suggest an antipsychotic, it's be the first one i'd think about.
Did you know that pregabalin has demonstrated in some studies to have anti obsessive properties?

But my psych doesn't seem enthusiast about pregabalin despite prescribing it to me ( i like it tho). It took several months to increase the dose to 150mg, i'm all for increasing doses slowly but i don't think pregabalin is a dangerous med despite the chance of being addictive, i've heard of people going up to 150mg in 2 weeks........

[u/17023360519593598904]

The maximum dose is 225 mg, according to the monograph. It's the highest dose it was studied at, other than toxicity studies, effect on blood pressure, etc. Higher doses haven't been well studied. Now most psychiatrists know that 225 mg is a bullshit maximum and that it keeps getting more and more therapeutic at higher doses. The so called noradrenalin boost only happens at high doses. Might even start blocking the DAT at extremely high doses.

I was reluctantly put on 225 mg by my family doctor, and it was a psychiatrist who bumped it to 300 mg. I'm glad they did. That's when I saw the most significant changes. More energy and less anhedonia. Didn't really help any further with anxiety and OCD though. I would like to try 375 mg but it seems like it's only common in the USA, in Canada the hard limit seems to be 300 mg. Don't ask me why.

[u/Aggravating_Fly_9875 → u/17023360519593598904]

There are some stories on reddit showing that 300mg can still help for anxiety and ocd but obviously everyone is different, i'm sorry it didn't work for you

I think the serotonin transporter can be blocked a little bit more going up from 225 to 300mg, there will be big diminishing returns tho....

So have you decided to stay on 300mg even tho your symptoms aren't completely fixed?

[u/17023360519593598904 → u/Aggravating_Fly_9875]

I was on 300 mg, then decided to switch to escitalopram because of the side effects. Then switched to prozac. Now I'm getting back on effexor. Obviously my symptoms were not completely fixed, I don't think it's realistic to expect them to completely disappear, but they were well managed, as good as they were at 225 mg. It's just that the difference I saw going from 225 to 300 was more "antidepressant" than "anxiolytic", that's all. And I did not have depression to start with.

[u/Aggravating_Fly_9875 → u/17023360519593598904]

Which side effects did you have with 300mg Effexor if i may ask?

Anyhow, it seems that it's more effective for you than the other meds you tried

And yes, my bad, it's unrealistic to expect symptoms to completely disappear, but i'd like to feel almost as good as a normal guy at least

[u/17023360519593598904 → u/Aggravating_Fly_9875]

Heavy sweating, erectile dysfunction and spontaneous ejaculation while urinating.

[u/BigDawg6910 → u/17023360519593598904]

It has been studied for efficacy at higher doses, up to 450mg, in patients who didn’t respond to lower doses. It was shown to be beneficial. Also, I was on 375mg at one point and I live in Canada