• Edronax (reboxetine)

• Strattera (atomoxetine)

These drugs don't make you produce more norepinephrine, rather they make your neurons soak for a longer period of time in the norepinephrine you already produce.

But is that the same thing?
 
That depends on the person and the sensitivity of your alpha  1 & 2 receptors.  Sometimes it's the same effect, sometimes not.  When not it could be sub-par (to the point of being useless) or too much.

These are a lesser-known form of antidepressant that focuses on a neurotransmitter that had fallen out of fashion, but seems to be making a comeback now. In addition to dealing with depression, norepinephrine is great for dealing with motivation and concentration, which is why the first pure NRI to hit the US market, Strattera, is officially an ADD/ADHD medication and not an antidepressant. While these are not happy pills, for unipolar and bipolar depression they are sometimes quite effective at keeping depression at bay. They are far less likely to trigger mania in the bipolar or seizures in the epileptic.

Either is still possible, and I had to stop taking Strattera after a year because my seizure threshold dropped through the floor and it triggered seizure events.  But in generally such events are less likely, so if no other tests are done to see which neurotransmitter should be attacked first, I think an NRI really should be the first line of attack for bipolar depression and/or any form of depression that accompanies a seizure disorder, just because they are much less likely to trigger unpleasant events like mania or seizures. NRIs typically have a low side effect profile for most people.

You can group most people's experiences into two main categories: ineffectual or the greatest thing ever for someone. In addition to depression, NRIs are occasionally good for panic/anxiety disorders.  And, of course, they are fabulous for moderate ADD/ADHD. They don't work for nearly as many disorders as SSRIs do, but you take what you can get in Bipolarland or Epilespyland.

To help you decide if it's bad enough to require an antidepressant, you should be seeing a talk therapist and you should belong to a support group.  A psychiatrist is basically going to figure out the right meds for you and that's going to be about it.  Sometimes they'll do therapy, but often not.  For more information on, and reasons why you should be seeing a talk therapist and belong to a support group, take a look at my page on support groups.  Both will help you determine if you really do need antidepressants.  And if you do, the services of both therapist and support group are vital to complete what the antidepressants do.  Meds alone are not going to fix your problems!

There are a few things common to all of them that you need to be aware of:

1. Side effects common to all are headache, dry mouth, urinary hesitance, constipation, early awakening. The headache tends to go away and only reappears with a dosage increase for most people. The urinary hesitance (think the Beavis and Butt-Head episode where they forgot how to "go"), constipation, dry mouth and early awakening strike at random throughout the time you take them, but tend to be mild. Unlike with SSRIs, sexual dysfunction and weight gain are rare. NRIs sometimes will regulate your sleep cycle, so except for that bit about waking up at 5:00 a.m. some mornings, you'll sleep more regularly. Personally I like waking up early in the morning, but I am a known freak. Sure, sometimes they'll absolutely mess with your sleep, just like any other psychiatric medication, but for me and many other people they'll see to it that you abide by Benjamin Franklin's maxim of "Early to bed and early to rise." The rest of it is up to you.

 

2. While NRIs are far less likely to trigger mania, they often produce a type of non-manic euphoria that can last for months. I was seriously, weirdly happy for the first few months I was taking Strattera (atomoxetine HCl), and was in a surprisingly good mood for the duration that I was taking the medication. I had to delay increasing the dosage from 25mg to 40mg a day to improve its ADD effects because I was afraid I would get a little too happy. It's little wonder that this site gets hits from people searching Google for information on using Strattera (atomoxetine HCl) to get high. Sorry, kids, it doesn't work that way. You have to take it for at least a week before you feel the euphoria, and there are no guarantees that you will feel it.

 

 

3. NRIs can poop-out just like SSRIs. Unfortunately we don't have as many options for switching meds, let alone rotating. There is one pure NRI on the US market as of 2003, Strattera (atomoxetine HCl), and its use as an antidepressant is purely off label. Another available in most of the rest of the world, is Endorax (reboxetine). Two other meds, Effexor (venlafaxine) and Serzone (nefazodone hydrochloride) reuptake norepinephrine, but they both effect serotonin as well. I had thought that Cymbalta (duloxetine) was to be a pure NRI, but it turns out that it's just another flavor of Serzone (nefazodone hydrochloride), hitting serotonin as well as norepinephrine.  Then there's Wellbutrin (bupropion), which works on norepinephrine and dopamine.  That might work great for your depression, but if you have a seizure disorder you have to avoid it like the plague. 
   
   Worse yet, NRIs tend to poop-out faster than SSRIs. There's no telling how interchangeable Strattera (atomoxetine HCl) and Edronax (reboxetine) are, and I don't have dosage equivalents.  Sure, Strattera is basically a rip-off of Edronax, which is probably why you won't find the two of them in the same country whilst the patents for Edronax are in full force.  So there's very little in the way of anecdotal evidence (i.e. people's stories) on how the two work in place of each other.  What little I have have been acts of pure desperation, and those rarely turn out well.
   
   There are a few TCAs
that are pretty selective in norepinephrine reuptake, and not so much in serotonin, but I'm still researching them (see below).  Unfortunately the TCAs are a lot sloppier than the newer meds, and hit things like the muscarinic and histamine receptors, much like antipsychotics do.  Hence some of both the truly sucky side effects and highly useful off-label applications.

 

7. Booze isn't that big a deal with NRIs. I'll cover that more in the article on booze, tobacco, caffeine and recreational drugs. You shouldn't drink as much as you used to, nor as often. But if you're taking only an NRIs with or without an SSRI and you don't have a problem with booze, you can still have a few drinks now and then. Or your glass of wine or bottle of beer, sake or soju with dinner. Cheers! However, if you're mixing in an antipsychotic with an antidepressant, as is getting very popular, you'll have to cut out the booze all together. Alcohol and antipsychotics don't mix. Also, you can't mix Gin & Tonics with NRIs. It's not the gin, it's the tonic water! The quinine in the tonic water doesn't get along with Strattera (atomoxetine HCl) and Endorax (reboxetine).

8. Mixing l-tyrosine with an NRI isn't anywhere near as dangerous as mixing l-tryptophan/5-HTP with an SSRI. Doing the latter can actually kill you. On the other hand, combining l-tyrosine with an NRI is sometimes a good idea! Then again, sometimes it's a bad idea. When is it a good idea? When you and your doctor work out why and when you should do it. L-tyrosine converts to norepinephrine, the neurotransmitter that NRIs reuptake, and sometimes we don't have enough of it to reuptake in the first place, so we need more.
   
   When do you know you're getting too much norepinephrine? Good question! I wish I had an answer for you. Unlike the potentially fatal serotonin syndrome, I haven't yet found any symptoms for norepinephrine overdose. Even the overdoses on the NRIs hasn't been all that bad in humans. All I can write is, if you're mixing l-tyrosine with an NRI and you start feeling weird, and you can define weird any way you like, then cut back on the l-tyrosine. If the weirdness goes away, you've been getting too much of that neurotransmitter. Simple enough.
   
   Well, it's not so simple if cancer is in your medical history.   Take a look at these articles:
   http://www.mcgill.ca/mog/research/park/
    
   http://www.cbcrp.org/research/PageGrantPrintPage.asp?grant_id=1694
    
   http://cancerres.aacrjournals.org/cgi/content/abstract/49/3/516
    
   It's possible that l- tyrosine or phenylalanine may promote cancer cell division, especially malignant melanoma.  The articles above deal with tyrosine kinase, which are the receptors, not l-tyrosine, the amino acid.  So l-tyrosine does not cause cancer.  If you have cancer already, taking l-tyrosine could make certain tumors take off like you wouldn't believe.  So it's OK to take if you're sure you don't have any tumors laying around.  I can tell you one thing - when new benign moles spring up on me, they are doing it with a speed that harkens back to when I was a kid and my mother would call me "Moleman."  You know, like in The Mole People.  I think she was trying to get me to stop watching classic bad movies and go outside.  Instead it would just make me feel like more of a monster.  Thanks, mom!  Anyway, I digress.  My GP didn't see anything wrong with these moles.  But I can tell the difference since taking l-tyrosine, so there probably is something to oddball cell division.
   
   As always, consult with your doctor first before taking anything as potent as an amino acid.
    

9. If you suddenly get wiped out after an increase in dosage from an NRI or a multiple reuptake inhibitor you don't have enough norepinephrine to reuptake.   Either or both of two things has happened.  The more likely is that it has depleted you of norepinephrine, which will be completely counterproductive to what it's supposed to be doing for you in the first place.  There's also a chance it might make you more vulnerable to the adverse effects of MAO.  As my doctor explained it to me it's like WWI trench warfare - the NRI (be it Strattera (atomoxetine HCl),  Edronax (reboxetine) or even a multiple reuptake inhibitor like Effexor (venlafaxine)) sends its chemical signals after your neurons, but they are repelled.  The sergeant won't have any of that, so it sends them after another set of neurons that are more receptive.  In doing so it allows excess MAO enzymes to do a flanking maneuver and hit those neurons instead.   Either or both of those reasons are why people will feel wiped out when they either start out at too high a dosage or cross the line into taking too much. Then if they go back down to the previous dosage, they still feel crappy and give up.  The thing is, it takes time for the higher dosage to clear out of your system and for your neurons to calm down.  And if it was an MAO attack (to use the trench warfare metaphor), you need to recover from that.  Just chill out and have some patience.  If you're a poor metabolizer (See the Basic Information on Psychiatric Drugs page for more details on how you can find out where you fit in the poor or extensive metabolizer categories.) it can take a few weeks.  As mentioned above, l-tyrosine might be the key to getting you more norepinephrine if the issue is norepinephrine depletion.  If it's an MAO flanking maneuver, then you just need to lower the dosage.
   
   Dr. Stahl also touches upon the connection of MAO, norepinephrine and dopamine in Essential Psychopharmacology of Depression and Bipolar Disorder.  Which helps explain why people who take Strattera and  Wellbutrin concurrently often feel worse instead of better.

10. People are constantly asking me what the equivalents are for different classes of antidepressants.  And it literally is an apples and oranges comparison.  But since apples and oranges are both types of fruits, there are commonalities.  Loren Regier and  Brent Jensen of Queen's University School of Medicine, Kingston Ontario have put together a handy Antidepressant Comparison Chart.  Of course it applies only for meds available in Canada, eh.  But it does cover SSRIs, TCAs, MAOIs, Multiple Reuptake Inhibitors and whatever else they have in the Great White North.
    
    
    You'll also want to check Nom de Plum's Summary of Psychotropic Medications for lots of information on the old-school meds like TCAs and MAOIs.