u/Flashy_Abrocoma_1271

I suffer from severe, persistent depression that prevents me from doing a great many things—including working and studying—as I simply have no energy for anything. I previously took venlafaxine and titrated the dosage up to 300 mg; however, while on it as a monotherapy, I would sleep 15 hours a day and lost interest in everything. I felt very calm, but I also felt hollow and even stopped sitting at my laptop. Amitriptyline (150 mg) was what truly helped me; yes, it came with a host of side effects and hardships, but it enabled me to gather my documents, complete my medical exams, and enroll in college—something I clearly never would have accomplished in my life without it. However, my psychiatrist switched me to fluoxetine to make things easier for me while studying. It helped me tremendously with my anxiety and didn't cause the same apathy that all the other SSRIs and venlafaxine did; I felt genuinely good. I suffer from quite severe ideas of reference, and these completely disappeared. I was even able to watch a movie on a bus ride with total calm, free of any dread. Overall, I felt much more at ease regarding both my anxiety and my obsessive thoughts. The problem, however, was that while on fluoxetine, I experienced an incredibly intense urge to smoke. Conversely, amitriptyline—even after I had stopped taking it—made any form of nicotine completely intolerable. This effect persists to this day; although nearly a year has passed, the intensity of these symptoms hasn't diminished. Even a single drag from a cigarette triggers tremors and unpleasant physical sensations—such as numbness—and makes it extremely difficult for me to think clearly. Yet, despite all this torment, I still experienced an overwhelming craving to smoke while I was taking fluoxetine. Naturally, this interfered with my studies. But that wasn't even the main issue; the primary problem was that, after two and a half months of treatment, I began to suffer from apathy. This manifested as a complete inability to simply get out of bed and go to class—something I had previously been terrified of being late for. I initially thought I would just take some sick leave to rest, or perhaps skip a few classes and then resume attending as usual. However, this period of absence dragged on. I eventually realized that the only reason I had been able to attend college—and had managed to keep going for as long as I did—was because I was taking amitriptyline; without it, I found myself in a state of utter helplessness. Returning to a dosage of 150 mg would be an incredibly drawn-out process—I had already attempted to do just that between November and April, but I kept either missing doses or being too afraid to take more than 100 mg. Ultimately, I decided that the regimen was simply too arduous and detrimental—partly due to issues with my blood pressure, and partly because the drug's anticholinergic effects severely impaired my cognitive functions. I found this unacceptable, and I remain uncertain about the potential long-term consequences. Amitriptyline has already inflicted a certain amount of damage—or at least it feels that way to me; it genuinely feels as though thinking has become more difficult, and my general sense of well-being has deteriorated. I don't know about "quality of life," but this extreme sensitivity to nicotine really scares me. In short, I decided against taking an academic leave; I simply withdrew from college and admitted that enrolling in the first place had been a mistake. I am currently facing financial difficulties and need to start working, but I don't know what to do—what could I use to replace amitriptyline in my case to ensure I have the energy to work? I went back to a psychiatrist and was prescribed venlafaxine (titrating up to 225± mg) in combination with mirtazapine (30–45 mg). How is this likely to differ from my initial experience with venlafaxine as a monotherapy, and does this approach make sense? I was also prescribed buspirone to treat anxiety associated with venlafaxine—anxiety I don't actually have—so I haven't been taking it. I'm not sure if there is any point in taking it alongside everything else; I worry that it might exacerbate my apathy or trigger serotonin syndrome, which is why I'm avoiding it. Prior to this, I had already tried every SSRI available; I also tried milnacipran, aripiprazole, risperidone, quetiapine, and sulpiride, as well as mood stabilizers used as augmentation agents—none of which provided any relief. Stimulants and bupropion are illegal in my country, and MAO inhibitors are no longer manufactured here. What should I do in my current situation? I am also concerned about my persistent hypersensitivity to nicotine following my course of amitriptyline; I suspect this issue is linked to acetylcholine.