Frequently Asked Questions by Primary Care Providers

Q: Have you experienced very much hypertension with Pristiq?

• A: All SNRIs can cause hypertension. According to this meta-analysis, “It was established that SSRIs did not affect blood pressure, while SNRIs led to a modest increase in SBP and DBP with statistical significance compared with SSRIs.” In my clinical experience the risk increases with dosing, especially Venlafaxine, which does not start having noradrenergic effects until 150mg. Blood pressure should be monitored routinely when utilizing SNRIs.

Q: Do you recommend Wellbutrin as monotherapy ever? I have only used it in combination, but have several parents who are on it in monotherapy and inquire about it.

• A: Yes, Wellbutrin is a reasonable monotherapy for major depression. However, as this is not an FDA-approved medication for pediatric population, it is typically not a first line therapy, and its use is off-label. It is a reasonable choice after failure of two SSRIs and an SNRI. I have found Wellbutrin to be a good option for those with neurovegetative depression, with anergia, low motivation, and psychomotor slowing. Oftentimes 150mg of Wellbutrin XL will be a therapeutic dose, though I often advance to 300mg if no improvement after four weeks. I often reserve the 450mg dose for those who experience improvement at 300mg, but stops working after a time.
• For augmentation of SSRI or SNRI, I typically start Wellbutrin XL 150mg daily. If you happen to know your patient is a slow metabolizer of Wellbutrin, starting at a lower dose is indicated. I would continue to advance the dose to 300mg daily for augmentation if not benefit after four weeks.

Q: Is dose of Wellbutrin to restore sexual dysfunction the same as normal augmenting dose?

• A: From brief literature review, it appears the benefit of Wellbutrin with SSRI induced sexual dysfunction typically comes fairly quickly (within 2 weeks) at starting doses (100mg of SR or 150mg of XL).

Q: Are there any long term effects for using hydroxyzine long term?

• A: It appears long term use of Benadryl is correlated to development of dementia, so I would assume the same applies to hydroxyzine. The study involved patients >65. Regardless, in child psychiatry we typically use hydroxyzine for a PRN, and use SSRIs and SRNIs as the primary medication for anxiety.

Q: Which benzo do you use for flight anxiety?

• A: Typically Ativan. I always recommend taking a “test dose” before the flight in case of adverse reaction (disinhibition), which is better to see at home than at 30,000 feet. 

 - Dr. Adam Klapperich