We reach for duloxetine for comorbid pain, fibromyalgia or a migraine disorder. Otherwise we do not find SNRIs more effective than SSRIs, they have slightly more side effects (even if just the slight blood pressure rise with duloxetine), and when SSRIs have failed and we want more of a kick, we go for venlafaxine over duloxetine.
When we reach for it
We reach for it for comorbid pain, diagnosed fibromyalgia or a migraine disorder; otherwise we do not go for the SNRIs. We do not believe in them for apparent ADHD.
“I'll reach for duloxetine for comorbid pain or patients with fibromyalgia. Those are the patients that I find myself reaching for it”
27:34Anxiety Medications Tier List: The Best and Worst Treatments for GADJul 2026 Also said in 1 more episode
“I don't go for the SNRIs unless, as you say, they have a migraine disorder, a diagnosed fibromyalgia. I don't believe in it, by the way, for apparent ADHD”
41:09Antidepressant Tier List: Psychiatrists Rank Depression Medications for MDDMay 2026
Compared with others
We do not find that SNRIs have any efficacy over the SSRIs, and they have slightly more side effects, even if it is just the slight blood pressure increase with duloxetine.
“I don't find that they have any efficacy over the SSRIs, and I find that they have slightly more side effects. Even if it's just slight blood pressure increase of the duloxetine, slightly more side effects. Another problem is Effexor is just an awful medication in terms of withdrawal syndrome. It's very strong and uncomfortable. So I avoid that entirely”
25:18Treating Depression: Practical Tips & Pearls for Anti-Depressant MedicationsJan 2025 When someone has failed SSRIs and we want a little more of a kick, we go for venlafaxine over duloxetine, though the data show venlafaxine barely outperforms SSRIs (a number needed to treat of about 24).
“I will go for venlafaxine over duloxetine when someone's failed SSRIs and I want a little bit more of a kick. Again, the data shows that it barely outperforms SSRIs. Number needed a treat of like 24 to outperform an SSRI”
27:45Anxiety Medications Tier List: The Best and Worst Treatments for GADJul 2026
From these episodes
- Anxiety Medications Tier List: The Best and Worst Treatments for GADJul 2026 · 2 points
- Antidepressant Tier List: Psychiatrists Rank Depression Medications for MDDMay 2026 · 1 point
- Treating Depression: Practical Tips & Pearls for Anti-Depressant MedicationsJan 2025 · 1 point
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.