Posted by mtdewcmu on November 26, 2009, at 1:01:23
In reply to calling all armchair psychs, posted by g_g_g_unit on November 8, 2009, at 4:26:41
> i was wondering if anyone could offer any ideas for treatment based not only on my present dx, but also my med history, which i believe has had some effect on things. i would really appreciate any advice. i don't want to take another step, and make more of a mess, until i can meet a competent psychopharmacologist. but until then, if anyone has the time to consider this history i would be so grateful. i apologise for its length, but i feel like i need to be detailed.
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> my last pdoc was not that helpful - he described my depression as a case of depleted neurotransmitters?? from what i can gather through general readings, it sounds like double depression, i.e. major depression superimposed over chronic dysthymia.
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> so, *prior* to treatment - dysthymia, OCD, with a lot of impulsive/addictive tendencies (curious if these are just a coping mechanism, or suggest some other kind of dysfunction), as well as what someone described as emotional lability (i.e. become happy when hopeful or something 'good' happens, angry/frustrated when under stress). i was working as a writer prior to depression, hence the references to writing (this is pulled from a file i'm making up).
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> been on:
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> Moclobemide (300mg) by GP. Stayed on for 6 months.
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> Pros: good anti-anxiety agent
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> Cons: felt more dulled, slight cognitive sfx.
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> Psychiatrist #1:
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> Prozac (10mg) for 4 days
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> Felt more alert and activated, but in a way that precluded pleasure/euphoria. Disturbed sleep, so was advised to discontinue, as due to long half-life, this side-effect supposedly would not go away??
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> Pros: activating
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> Cons: insomnia
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> Mirtazapine (15-30mg) for 3 weeks.
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> Slept well, but felt irritable and sedated the next day. Cognitively fine writing done in this period has a rare lucidity to it but could not stand sedation. Moved dose to 30mg, as heard higher doses were more activating. Terrible exacerbation of OCD symptoms placed in constant state of panic for a week, compounded by fact that family had gone away for Christmas vacation. Eventually pulled myself off drug without taper. Woke up in terrible foggy state suddenly found I was having problems with writing, i.e. paragraphs became much shorter and newspaper-like, could not really think things through in the same way. Complained to psychiatrist, who said it was a symptom of depression?? don't believe so, at that point.
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> Try Prozac (10mg) again.
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> Seems to instantly fix fogginess (don't both this and remeron work on prefrontal cortex?), but again insomnia an issue, so advised to withdraw.
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> ^^^^^^^ it's this is what's bugging me .. whether Remeron just kind of blew out/overloaded some section of my brain which i now need to target??
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> Try Lexapro (10mg) for 8 weeks.
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> Experience unpleasant sense of disconnection ruminations still present, but volume turned down. Worsens ability to think clearly, enhancing earlier fog from Remeron fallout. Socially dulled, exacerbating shyness. Withdraw.
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> Try Luvox (100mg) for 8 weeks.
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> Experience intense, unbearable restless leg syndrome during the day (or is it akathisia?) could literally not sit down for more than 20 minutes at a time due to pressure in legs. Again feeling of disconnection experiences feel less real, when listening to music/watching movie, a lot of it just does not seem to register. Worsened mood crying because I felt so withdrawn. Could not stand restlessness, and finally discontinued.
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> After coming off Luvox, begin to notice problems with executive function:
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> Whereas before, I could maintain an inner monologue amidst all the clutter and obsessive thinking, i.e. think through a certain theoretical point, despite it taking me longer than Id like, now it felt like my thoughts were getting cut off prematurely I could simply not follow them to their conclusions.
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> When writing, I lost my sense of rhythm to an extent, making any sentences that werent completely automatic (i.e. sentences I would construct in the past using my working memory as a kind of placeholder) now completely awkward and clunky.
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> Could not concentrate on tasks at hand would just constantly seek distractions on the internet while trying to write.
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> Completed one last piece in this state, and then finally broke down into a schizoid-like depression complete anhedonia, difficulty communicating with others, difficulty concentrating, but strangely no physical anxiety.
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> Become desperate and try Nardil (3 months):
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> Became (i guess?) hypomanic and far more compulsive, e.g. up exercising everyday at 7/8am after no sleep because i was worried about the weight gain. Seemed to make anxiety and OCD worse at higher doses (guess this might be transient, and due to sleep loss?). could not tolerate hypotension - fainted a couple of times at higher doses. came off.
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> pros: helped depression
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> cons: felt foggy, euphoric, 'not like myself'
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> return of 'schizoid' depression. somewhat pleasant in that i am anxiety-free, but suffer from complete inattentiveness, brain fog, etc.
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> try Memantine (20mg max, 6 weeks).
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> at 5mg, experience slight hypomania (rushing thoughts, far greater mental energy .. almost too much), though this is obviously a relief from depression. drug too inconsistent in effects (long-half life??), and varied day to day, but there were points at higher doses where for the first time i felt completely rational, in command, and certain about my decisions (anti-OCD effect??). memory improves at certain doses. can concentrate and read again. but eventually much noted fogginess/depersonalization sets in.
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> desperate again, so try Parnate with psychiatrist #2
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> Parnate (max dose reached 40mg, 10 weeks)
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> low doses help with attention problems, but increase anxiety, especially at night when stimulation wears off. higher doses cause intractable insomnia which psych offers no longterm plan to treat outside of benzos; will not raise dose either. cannot stand sleep deprivation and taper off.
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> -------------------------------------------------
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> so there you have it. thanks to anyone who read that, and sorry if it's a little messy.
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> i find it interesting that:
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> a) prozac instantly relieved my brain fog at first (so need prefrontal cortex help?)
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> b) that memantine occasionally had me feeling completely calm and rational (mood stabilizer might help?)
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> c) that low dose Parnate helps kind of 'pin' my attention to external things more, which, while increasing ocd/anxiety, also helps me function better. so maybe in my own layman's, drug-naive terms, increasing DA while minimizng NE might help? hence my interest in the atypicals...
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> sorry again this is so rambly. please feel free to ask any questions.Here's what I would do if I were you:
I would go back on Lexapro, increasing to 20mg as tolerated, and I would add Wellbutrin XL, starting at 150 and going to 300.
The detached feeling from Lexapro sounds like something that may subside eventually. The Wellbutrin will counter some of the fogginess as well.
Alternately, you could try Zoloft or Effexor/Pristiq. Each SSRI is qualitatively a little different, and I don't see anything in your history to indicate that you are unable to tolerate SSRIs.
Don't make things too complicated.
poster:mtdewcmu
thread:924919
URL: http://www.dr-bob.org/babble/neuro/20091104/msgs/927006.html