Posted by dcruik518 on June 16, 2008, at 18:20:42
In reply to Rocket Fuel Failed; What Magic Combo Is Next?, posted by BGB on June 9, 2008, at 16:40:05
> I have bipolar I and am currently in a horrible depressive state. Honestly, I can't think about anything other than suicide. It's all that goes through my mind.
>
> Anyway, I'm on a ton of meds and none of them are helping. I've tried "California Rocket Fuel" with both Effexor and Cymbalta (separately), to no avail. Here's what I'm on now:
>
> Cymbalta 120mg
> Remeron 60mg
> Wellbutrin SR 600mg
> Trileptal 1200mg
> Lamictal 200mg
> Valium 5-10mg PRN
> Trazodone 150mg (for sleep)
> Cytomel 50mcg (for AD augmentation-my thyroid is normal)
> Propranolol 120mg PRN for tremorsDear BG:
I've taken a lot of the meds you have and I have to say I believe you've somehow gotten off track with your meds. Several of the ones you are taking--such as Wellbutrin and Trileptal--hardly work for ANYONE! Others tend to make you feel lazy, tired and apathetic--Propranolol, especially, but also, Cymbalta, in my opinion, because without any dopaminergic support it tends to induce a state apathetic yet pleasant sit-on-the-couch-all-day-dullness. Also who takes valium anymore? It's one of the least effective benzos.
Here's what I would suggest. You probably have a case of treatment-resistant-depression that may only be responsive to dopaminergic stimulation. That's the one neurotransmitter that none of the drugs you list seem to boost. Unfortunately, not many of the standard psyschiatric drugs do. You may have to order them online. Since you have bipolar one drug you might start with is abilify. At low doses it actually stimulates dopamine release and is a bit activating; just don't go above 10mg or it will turn into a typical anti-psychotic. Here are some other ideas:
A. Dopamine and serotonin stimulating atypical antipsychotics:
1. Abilify
2. AmisulprideB. Dopamine and Serotonin releasing anticonvulsant and mood stabilizer:
1. Zonisamide (like Topamax this one also helps you lose weight!)C. Dopamine agonists used primarily for Parkinson's disease, but recently being tried for bipolar depression, restless leg sydrome, anxiety, sexual side effects of antidepressants and more:
1. Requip this stuff has worked great for me, even though I made the mistake of taking too high a dose. It has a definite anti-depressant effect and for me a definite anti-anxiety effect. I suspect it would also eliminate any movement problems you might have such as hand tremors, hence enabling you to get rid of the deadening propranolol. This would also be a great drug to try out with a good anti-depressant.
2. Mirapex--I haven't tried this yet but it's very similar to Requip, used for both Parkinson's and Restless Leg Syndrom. I believe there have also been promising early trials suggesting it's beneficial use in bipolar disorder.
3. Bromocriptine: this drug works directly on the D2 receptor, which is believed to be the one most responsible for mood and anxiety disorders. I just tried some today and I have to say I think this may work even better than Requip. Makes me feel very calm yet mentally focused. It also has a number of VERY COOL side benefits: in normal subjects in decreases prolactin levels and boost human growth hormone levels naturally. The net effect? You lose weight, gain muscle, your chances of diabetes goes way down, and you live longer!
D. Stimulants boost dopamine and norepinephrine; however, if you're bipolar it's possible they could induce a manic state. If you do try them take a tiny dose!!
1. Adderall--in my opinion this the best stimulant med out there. It has a smooth long last effect and it's potent. It has much better mood lifting effect than ritalin which tends to make people irritable.
1. Dexedrine--this is a little more potent than adderall, and gives a bit more kick, but the pay off is when it wears off you feel crappy, so this is more likely to lead ot addictive type behavior, or pill popping.
E. Anti-depressants: what works for the treatment resistant:
1. most of the SSRI's do not. However, some have promise, especially when they are combined with one or two of the drugs above. Cymbalta, for instance, can be a great anti-depressant, if you add a dopamine agonist; but alone it actually depletes dopamine. Forget Effexor--it causes too much anxiety, even if it does boost dopamine a tiny bit. Another great anti-depressant that boosts both serotonin and dopamine is actually Zoloft, but again, I'd recommend augmenting it with one or more of the above. Probably the greatest antidepressant of all time for atypical or treatment resistant depression is the MAOI, Nardil. It's worked wonders for me and for everyone I know who's given it a fair trial. It's like a using a bomb instead of a guided missile. It affects everything in your brain and you just end up feeling great. However, it has terrible, terrible weight gain, which causes most people to stop after six months or so. The newest MAOI is EMSAM which is a patch and is supposed to have fewer side effects and be less dangerous. It will definitely boost dopamine. Worth a try.
F. Finally the benzodiazepines. Only two option here worth mentioning.
1. Clonazepam: a powerful, long-lasting, non-habit forming very effective anti-anxiety drug that can be tolerated at very high doses. It also used for epilepsy and has a half life of 35 hours or something.2. Xananx XR: the old xanax was a great drug, extremely effective at relieveing anxiety without causing too much drowsiness, but the problem was it was too effective for the five hours it lasted, and it lead to pill popping and addiction among certain people. The new formula, while very expensive, is even better than clonazepam in my opinion; That's partly because it tends to have an anti-depressant effect as well as relieving practically all anxiety. However, the new stuff lasts just as long as the clonazepam, so it doesn't lead to pill popping or addictive withdrawal.
So here's a possible scenario:
1. ZONISAMIDE AND ABILIFY TO STABILIZE YOUR MOOD
2. EMSAM FOR DEPRESSION
3. REQUIP OF BROMOCRIPTINE TO AUGMENT THE EMSAM(FREEDOMPHARMACY) AND HELP WITH TREMOR
4. XANAX XR FOR ANXIETY, DEPRESSION, AND TO HELP WITH TREMOR.
5. IF AFTER A MONTH OR SO, YOU STIL FEEL LETHARTHIC, CONSIDER SLOWLY ADDING A TINY DOSE OF ADDERALL.My humble advice after 25 years of this,
D.C.
poster:dcruik518
thread:833832
URL: http://www.dr-bob.org/babble/20080606/msgs/834956.html