![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 44. This is the beginning of the thread.
Posted by JimD on December 4, 2003, at 8:18:11
I've been struggling with mild depression and am trying to avoid going on meds. I understand that St. John's Wort has been proven in some studies to alleviate symptoms of mild-moderate depression.
Does anyone have any experience with SJW? Has it proven to be effective?
I also understand that it is important to use a 'brand you can trust,' given that it is not regulated by the FDA. Any recommendations?
Thanks!
Posted by woodworks on December 4, 2003, at 9:53:43
In reply to St. John's Wort - Is it worth while?, posted by JimD on December 4, 2003, at 8:18:11
Because of pregnancy, I moved from RX anti-depressants to St. John's Wort. I found it didn't have quite the kick of the RX stuff, but helps keep things manageable for me, and I hope it ultimately will prove to have fewer long term side effects as compared with prescription anti-depressants. I started off on 900 mg/day seven years ago. I'm at a place in my life where I only take it every other day or so now. If things get really stressful for me, I take it every day. I have always used PhytoPharmica, based out of Green Bay, WI, because their quality of ingredients and dosage is supposed to be very consistent. Unfortunately, I think only licensed professionals can order it--I get mine through a chiropractor.
Good luck--
Posted by lotus on December 4, 2003, at 12:17:35
In reply to Re: St. John's Wort - Is it worth while? » JimD, posted by woodworks on December 4, 2003, at 9:53:43
Get a brand standardized for 3% Hyporforin,and Hypercium,otherwise you'll be wasting your time.Perika brand is considered very high quality.
Posted by almondjoy on December 4, 2003, at 22:27:42
In reply to Re: St. John's Wort - Is it worth while?, posted by lotus on December 4, 2003, at 12:17:35
It just made me veeeeeeeeeeeeeery tired...
Posted by Tiger on December 5, 2003, at 19:59:45
In reply to St. John's Wort - Is it worth while?, posted by JimD on December 4, 2003, at 8:18:11
I started taking a combo of St John's Wort (x3/day), 5-HTP (x2/day) and a multi B vitamin (x1/day). I also use a lightbox (Seattle). Even without the lightbox, my overall mood and energy levels are excellent. I'm motivated in ways I haven't felt in 3 years. Not bounding like Tigger all ove the place, but able to *want* to get up and do my job and exercise and make whoopie and laugh at the dog.
Posted by JimD on December 7, 2003, at 1:57:48
In reply to Re: St. John's Wort - Is it worth while?, posted by Tiger on December 5, 2003, at 19:59:45
thanks for the tips. gonna give it a shot. I'm very excited for the possible results! :)
Posted by Larry Hoover on December 7, 2003, at 7:17:11
In reply to St. John's Wort - Is it worth while?, posted by JimD on December 4, 2003, at 8:18:11
> I've been struggling with mild depression and am trying to avoid going on meds. I understand that St. John's Wort has been proven in some studies to alleviate symptoms of mild-moderate depression.
I have pasted in some relevant abstracts below.
> Does anyone have any experience with SJW? Has it proven to be effective?
It was the best antidepressant I've ever used, period.
I am a major advocate of SJW....I'm sorry I came late to this discussion. There are two main active ingredients in SJW extracts, hypericin and hyperforin, but recent work has shown that even if those compounds are removed from SJW extract, the remaining substances still show potent antidepressant activity. Down below is a nice summary of the various effects of SJW extract....virtually every neurotransmitter yet identified is affected directly at receptors, or indirectly at the gene regulatory level....but not with the typical sledge-hammer effect of prescription drugs....broader, and more gentle.
Down below, you'll find a meta-analysis of the research into SJW, done by Cochrane Reviews. The Cochrane people are the absolutely most conservative review group in existence. Studies must meet the strictest methodological standards, or they're simply not considered. The Cochrane people are satisfied that SJW stands up to other antidepressants (the RR of 1.01 statistic means they are identical (1.0 is perfectly equivalent)), but that more research is needed to make the conclusion ironclad. The Cochrane review includes only those studies done before 1998, so I'm sure that they have many more to consider if they revisit the issue now.> I also understand that it is important to use a 'brand you can trust,' given that it is not regulated by the FDA. Any recommendations?
You may want to choose Perika, which is a German product (where herbal products *are* regulated) marketed here by Nature's Way.
> Thanks!Interesting, is it not, how there was so much press given to the heavily flawed American studies published in JAMA, declaring SJW ineffective, while other studies in respected journals which demonstrate efficacy have been ignored? (The Canadian study compared the very same drugs, sertraline and SJW, but came up with a very different result.) Interesting too that the JAMA work was funded by one of the largest pharmaceutical companies in the world...
Am J Psychiatry. 2002 Aug;159(8):1361-6.
Efficacy of St. John's wort extract WS 5570 in major depression: a double-blind, placebo-controlled trial.Lecrubier Y, Clerc G, Didi R, Kieser M.
Unite Institut National de la Sante et de la Recherche Medicale 302, Hopital Pitie Salpetriere, Paris, France. lecru@ext.jussieu.fr
OBJECTIVE: In a double-blind, randomized, placebo-controlled trial with 375 patients the authors investigated the antidepressant efficacy and safety of 300 mg t.i.d. of hydroalcoholic Hypericum perforatum extract WS 5570. METHOD: The study participants were male and female adult outpatients with mild to moderate major depression (single or recurrent episode, DSM-IV criteria). After a single-blind placebo run-in phase, the patients were randomly assigned, 186 to WS 5570 and 189 to placebo, after which they received double-blind treatment for 6 weeks. Follow-up visits were held after 1, 2, 4, and 6 weeks. The primary outcome measure was the change from baseline in the total score on the 17-item Hamilton Depression Rating Scale. In addition, analyses of responders (patients with at least a 50% reduction in Hamilton total score) and patients with remissions (patients with a total score of 6 or less on the Hamilton scale at treatment end) were carried out, and subscale/subgroup analyses were conducted. The design included an adaptive interim analysis performed after random assignment of 169 patients with options for group size adjustment or early termination. RESULTS: Compared to placebo, WS 5570 produced a significantly greater reduction in total score on the Hamilton depression scale and significantly more patients with treatment response or remission. It was more effective in patients with higher baseline Hamilton scores and led to global reduction of depression-related core symptoms, assessed with the melancholia subscale of the Hamilton scale. The placebo and WS 5570 groups had comparable adverse events. CONCLUSIONS: H. perforatum extract WS 5570 was found to be safe and more effective than placebo for the treatment of mild to moderate depression.
Can Fam Physician. 2002 May;48:905-12.St John's wort or sertraline? Randomized controlled trial in primary care.
van Gurp G, Meterissian GB, Haiek LN, McCusker J, Bellavance F.
Emergency Department, St Mary's Hospital Centre, 3830 Lacombe Ave, Montreal, QC. gerald.vangurp@mcgill.ca
OBJECTIVE: To compare the change in severity of depressive symptoms and occurrence of side effects in primary care patients treated with St John's wort (SJW) and sertraline. DESIGN: Double-blind, randomized 12-week trial. SETTING: Community-based offices of 12 family physicians practising in greater Montreal, Que. PARTICIPANTS: Eighty-seven men and women with major depression and an initial score of > or = 16 on the Hamilton Rating Scale for Depression (Ham-D). INTERVENTIONS: Patients were randomized to treatment with either sertraline (50 to 100 mg/d) or SJW (900 to 1800 mg/d) in a double-blind fashion. Assessment of depression was done at entry and at 2, 4, 8, and 12 weeks using the Ham-D, the Beck Depression Inventory (BDI), and a questionnaire asking about compliance and side effects. MAIN OUTCOME MEASURES: Changes from baseline in Ham-D and BDI scores and self-reported side effects. RESULTS: There were no important differences in changes in mean Ham-D and BDI scores (using intention-to-treat analysis), with and without adjustment for baseline demographic characteristics, between the two groups at 12 weeks. Significantly more side effects were reported in the sertraline group than in the SJW group at 2 and 4 weeks' follow up. CONCLUSION: The more benign side effects of SJW make it a good first choice for this patient population.
Pharmacopsychiatry. 2001 Jul;34 Suppl 1:S38-41.
Differential therapy of mild to moderate depressive episodes (ICD-10 F 32.0; F 32.1) with St. John's wort.
Friede M, Henneicke von Zepelin HH, Freudenstein J.
Schaper & Brummer GmbH & Co. KG, Salzgitter, Germany.
The purpose of this report was to evaluate specific depressive symptoms that are most suitable for a therapy with the Ze 117 St. John's wort extract. We examined the antidepressant efficacy and drug safety of Ze 117 and fluoxetine in a multicentric prospective randomized double-blind parallel group comparison according to generally accepted guidelines such as the Declaration of Helsinki and GCP. We treated outpatients (n = 240; Ze 117: 126; fluoxetine: 114) with mild to moderate depressive episodes (ICD-10: F 32.0, F 32.1; HAMD range: 16-24) with either two tablets St John's wort (Ze 117; 500 mg extract/day) or fluoxetine (20 mg/day) for 6 weeks. Antidepressant efficacy was evaluated with the validated HAMD psychometric method. A validated analysis of HAMD subscores was made to verify the efficacy for certain depressive symptoms. The main results were: * The HAMD responder rate was 60% in the Ze 117 group compared to 40% in the fluoxetine group (p = 0.005). * Particularly, there was a marked decrease of depressive agitation (pre-post comparison: 46%) and anxiety symptoms (44%) during the therapy with St. John's wort. Depressive obstruction (44%) and sleep disorders (43%) were reduced during the treatment, too. There were no statistically significant differences between the treatment groups. * Adverse events occurred in 28 patients (25%) in the fluoxetine group and in 18 (14%) of the St. John's wort group (p < 0.07). St. John's wort extract is a clinically effective equivalent to fluoxetine regarding overall depressive symptoms and main symptoms of depressive episodes. An especially interesting overall observation is that Ze 117 is particularly effective in depressive patients suffering from anxiety symptoms. St. John's wort revealed better safety and tolerability data than fluoxetine.
Int Clin Psychopharmacol. 2001 Sep;16(5):239-52.
A systematic review and meta-analysis of Hypericum perforatum in depression: a comprehensive clinical review.Whiskey E, Werneke U, Taylor D.
Pharmacy Department, Maudsley Hospital, London, UK.
The herbal remedy St John's wort is widely used as an antidepressant but its efficacy has not been systematically investigated. Meta-analyses and systematic reviews of published trials strongly suggest St John's wort is more effective than placebo although comparative efficacy to standard antidepressants is less clearly established. We updated and expanded previous meta-analyses of St John's wort, scrutinised the validity of published reports and examined possible mechanisms of action. Twenty-two randomised controlled trials were identified. Meta-analysis showed St John's wort to be significantly more effective than placebo (relative risk (RR) 1.98 (95% CI 1.49-2.62)) but not significantly different in efficacy from active antidepressants (RR 1.0 (0.90-1.11)). A sub-analysis of six placebo-controlled trials and four active comparator trials satisfying stricter methodological criteria also suggested that St John's wort was more effective than placebo (RR 1.77 (1.16-2.70)) and of similar effectiveness to standard antidepressants (RR 1.04 (0.94-1.15)). There was no evidence of publication bias. Adverse effects occurred more frequently with standard antidepressants than with St John's wort. The mechanism of action of St John's wort remains unknown. Future research should include large scale, appropriately powered comparisons of St John's wort and standard antidepressants.
CNS Drugs. 2003;17(8):539-62.
Mechanism of action of St John's wort in depression : what is known?
Butterweck V.
Institute of Pharmacology and Toxicology, Universitatsklinikum Munster, Munster, Germany. butterv@uni-muenster.de
Extracts of Hypericum perforatum L. (St John's wort) are now successfully competing for status as a standard antidepressant therapy. Because of this, great effort has been devoted to identifying the active antidepressant compounds in the extract. From a phytochemical point of view, St John's wort is one of the best-investigated medicinal plants. A series of bioactive compounds has been detected in the crude material, namely flavonol derivatives, biflavones, proanthocyanidines, xanthones, phloroglucinols and naphthodianthrones. Although St John's wort has been subjected to extensive scientific studies in the last decade, there are still many open questions about its pharmacology and mechanism of action. Initial biochemical studies reported that St John's wort is only a weak inhibitor of monoamine oxidase-A and -B activity but that it inhibits the synaptosomal uptake of serotonin, dopamine and noradrenaline (norepinephrine) with approximately equal affinity. However, other in vitro binding assays carried out using St John's wort extract demonstrated significant affinity for adenosine, GABA(A), GABA(B) and glutamate receptors. In vivo St John's wort extract leads to a downregulation of beta-adrenergic receptors and an upregulation of serotonin 5-HT(2) receptors in the rat frontal cortex and causes changes in neurotransmitter concentrations in brain areas that are implicated in depression. In studies using the rat forced swimming test, an animal model of depression, St John's wort extracts induced a significant reduction of immobility. In other experimental models of depression, including acute and chronic forms of escape deficit induced by stressors, St John's wort extract was shown to protect rats from the consequences of unavoidable stress. Recent neuroendocrine studies suggest that St John's wort is involved in the regulation of genes that control hypothalamic-pituitary-adrenal axis function. With regard to the antidepressant effects of St John's wort extract, many of the pharmacological activities appear to be attributable to the naphthodianthrone hypericin, the phloroglucinol derivative hyperforin and several flavonoids. This review integrates new findings of possible mechanisms that may underlie the antidepressant action of St John's wort and its active constituents with a large body of existing literature.
Cochrane Database Syst Rev. 2000;(2):CD000448.
St John's wort for depression.
Linde K, Mulrow CD.
Munchener Modell - Centre for Complementary Medicine Research, Technical University/Ludwig-Maximilians-University, Kaiserstr. 9, Munich, Germany, 80801. Muenchener.Modell@lrz.uni-muenchen.de
BACKGROUND: Extracts of the plant Hypericum perforatum L. (popularly called St. John's wort) have been used in folk medicine for a long time for a range of indications including depressive disorders. OBJECTIVES: To investigate whether extracts of Hypericum are more effective than placebo and as effective as standard antidepressants in the treatment of depressive disorders in adults; and whether they have have less side effects than standard antidepressant drugs. SEARCH STRATEGY: Trials were searched in computerized general (Medline, Embase, Psychlit, Psychindex) and specialized databases (Cochrane Complementary Medicine Field, Cochrane Depression & Neurosis CRG, Phytodok); by checking bibliographies of pertinent articles; and by contacting manufacturers and researchers. SELECTION CRITERIA: Trials were included if they: (1) were randomized; (2) included patients with depressive disorders; (3) compared preparations of St. John's wort (alone or in combination with other plant extracts) with placebo or other antidepressants; and (4) included clinical outcomes such as scales assessing depressive symptoms. DATA COLLECTION AND ANALYSIS: Information on patients, interventions, outcomes and results was extracted by at least two independent reviewers using a standard form. The main outcome measure for comparing the effectiveness of Hypericum with placebo and standard antidepressants was the responder rate ratio (responder rate in treatment group/responder rate in control group). The main outcome measure for side effects was the number of patients reporting side effects. MAIN RESULTS: 27 trials including a total of 2291 patients met inclusion criteria. 17 trials with 1168 patients were placebo-controlled (16 addressed single preparations, one a combination with four other plant extracts). Ten trials (eight single preparations, two combinations of hypericum and valeriana) with 1123 patients compared hypericum with other antidepressant or sedative drugs. Most trials were four to six weeks long. Participants usually had "neurotic depression" or "mild to moderate severe depressive disorders." Hypericum preparations were significantly superior to placebo (rate ratio 2.47; 95% confidence interval 1.69 to 3.61) and similarly effective as standard antidepressants (single preparations 1.01; 0.87 to 1.16, combinations 1.52; 0.78 to 2.94). The proportions of patients reporting side effects were 26.3% for hypericum single preparations vs. 44.7% for standard antidepressants (0.57; 0.47 to 0.69), and 14. 6% for combinations vs. 26.5% with amitriptyline or desipramine (0. 49; 0.23 to 1.04). REVIEWER'S CONCLUSIONS: There is evidence that extracts of hypericum are more effective than placebo for the short-term treatment of mild to moderately severe depressive disorders. The current evidence is inadequate to establish whether hypericum is as effective as other antidepressants. Further studies comparing hypericum with standard antidepressants in well defined groups of patients over longer observations periods, investigating long term side effects, and comparing different extracts and doses are needed.
Posted by Ron Hill on December 8, 2003, at 20:23:21
In reply to Re: St. John's Wort - Is it worth while? » JimD, posted by Larry Hoover on December 7, 2003, at 7:17:11
Lar,
How are you my friend?
> You may want to choose Perika, which is a German product (where herbal products *are* regulated) marketed here by Nature's Way.
Do you recommend Perika over the Kira brand (Lichtwer Pharma)? As you know, the latter has been a past proud recipient of the coveted "Hoover-Seal-of-Approval" in previous PB-alt posts.
As always, many thanks for freely sharing your knowledge and research expertise.
-- Ron
Posted by DSCH on December 10, 2003, at 21:42:11
In reply to Re: St. John's Wort - Is it worth while? » JimD, posted by Larry Hoover on December 7, 2003, at 7:17:11
Thanks especially for the Butterweck abstract.
Posted by Larry Hoover on December 10, 2003, at 22:15:16
In reply to Re: Best St. John's Wort Brand Name » Larry Hoover, posted by Ron Hill on December 8, 2003, at 20:23:21
> Lar,
>
> How are you my friend?Fair to middlin, thanks. My sleep's messed up, and everything goes to heck when my sleep's messed up.
> > You may want to choose Perika, which is a German product (where herbal products *are* regulated) marketed here by Nature's Way.
>
> Do you recommend Perika over the Kira brand (Lichtwer Pharma)? As you know, the latter has been a past proud recipient of the coveted "Hoover-Seal-of-Approval" in previous PB-alt posts.Kira is a quality product, but recent studies have shown that it pretty consistently contains less than the labelled quantity of active ingredients. You need to take more of if (by 1/2 again), to get what you thought you were getting.
It's one of the most consistent products, but consistently weaker than claimed too.
> As always, many thanks for freely sharing your knowledge and research expertise.
>
> -- RonMy pleaure Ron. How's life down in Texas these days?
Lar
Posted by Ron Hill on December 11, 2003, at 11:47:12
In reply to Re: Best St. John's Wort Brand Name » Ron Hill, posted by Larry Hoover on December 10, 2003, at 22:15:16
Larry,
> My sleep's messed up, and everything goes to heck when my sleep's messed up.
Sorry to hear it, Lar. Just curious; what time of day do you take your magnesium and what is your daily dosage? I currently take 800 mg (as Mg) just before bed and, as I think you already know, it puts me right to sleep and keeps me in a deep sleep all night (except for the pee breaks, after which I fall right back to sleep).
Every now and then I will have a bad night. I will have trouble falling asleep and/or I will wake up after about four hours of sleep and have difficulty falling back asleep. For me, this almost always means that I need more moodstabilizer (Lithobid), but your situation is different than my BP II case.
> How's life down in Texas these days?
Phil lives in TX (as does Shar, if I recall correctly). But I live in Idaho (which, as you know, shares a short border section with western Canada).
-- Ron
Posted by Larry Hoover on December 12, 2003, at 8:47:01
In reply to Re: Sleep Problems » Larry Hoover, posted by Ron Hill on December 11, 2003, at 11:47:12
> Larry,
>
> > My sleep's messed up, and everything goes to heck when my sleep's messed up.
>
> Sorry to hear it, Lar. Just curious; what time of day do you take your magnesium and what is your daily dosage? I currently take 800 mg (as Mg) just before bed and, as I think you already know, it puts me right to sleep and keeps me in a deep sleep all night (except for the pee breaks, after which I fall right back to sleep).Part of my problem is my self-care goes out the window when I get sleep-deprived....talk about a vicious circle. The other is I am doing med trial after med trial, and I don't want to confound my observations by taking anything extra. In the last month, I've tried Seroquel, trazadone (for the fourth time....frig, I hate that stuff), and now Zyprexa (olanzapine).
> Every now and then I will have a bad night. I will have trouble falling asleep and/or I will wake up after about four hours of sleep and have difficulty falling back asleep. For me, this almost always means that I need more moodstabilizer (Lithobid), but your situation is different than my BP II case.
I'm going to push to try mood stabilizers next....can't hurt, might help.
> > How's life down in Texas these days?
>
> Phil lives in TX (as does Shar, if I recall correctly). But I live in Idaho (which, as you know, shares a short border section with western Canada).I'm sorry Ron. I can't even keep my people straight (and after you kindly sent me the NADH you didn't need any more). But you didn't answer the question....
> -- RonTake care, buddy.
Lar
Posted by Ron Hill on December 12, 2003, at 16:13:19
In reply to Re: Sleep Problems » Ron Hill, posted by Larry Hoover on December 12, 2003, at 8:47:01
Hi Lar,
> In the last month, I've tried Seroquel, trazadone (for the fourth time....frig, I hate that stuff), and now Zyprexa (olanzapine).
What symptoms are you attempting to treat with these trials; just insomnia, or additional symptoms as well? As an aside, I had no idea you were conducting these heavy-duty med trials. You are so great at helping others on this board, yet sometimes I wonder if it is difficult for you to ask for help so that the support can flow in both directions? In any case, you are a good guy in my book; I just hope you can get the help you need (and deserve).> I'm going to push to try mood stabilizers next....can't hurt, might help.
Which one(s) do you have your eye on? Refresh my memory; please give me a list of all prescription medications that you are currently taking.
> > > How's life down in Texas these days?
> > Phil lives in TX (as does Shar, if I recall correctly). But I live in Idaho (which, as you know, shares a short border section with western Canada).
> I'm sorry Ron. I can't even keep my people straight ... But you didn't answer the question....Answer to the question: Things are good down here in Texas <smile>. I periodically have trouble with anhedonia, low motivation, and anergy which I believe to be attributable to poor dopaminergic pathway functioning. And if I give-in to the symptoms and start staying in bed, I cycle into a deep atypical depression for about five days, after which, I immediately cycle into a highly irritable dysphoric mood state (which perhaps fits into the category of a mixed state).
It is my layman’s opinion that my dopaminergic pathways were damaged by taking Ritalin, Paxil, and other SSRI’s during the years that I was misdiagnosed as ADHD. But I could be wrong about this. As I look back over my life, it is clear to me that I’ve been bipolar II since childhood (starting at about age eight). My anhedonia, low motivation, and anergy symptoms are definitely worse now than they were prior to taking Ritalin and SSRI’s, but maybe that is merely reflective of the fact that the depressive side of bipolar disorder worsens with age. Or it could be an outcome predicted by the “Kindling Theory” (i.e.; the more times the BP patient cycles, the worse the disease becomes).
In any event, I have improved dramatically over the past couples of years by finding various nutrients to feed my brain. I’m still looking for the additional nutrients (or, perhaps, medications) necessary to complete this project of brainchemistry restoration.
Also, I self-medicated (unknowingly) with rigorous exercise most of my adult years prior to getting derailed with Ritalin and Paxil. I’m currently in the process of ramping up my exercise program to therapeutic levels.
Overall, I’m doing well. Thanks for asking!
--Ron
Posted by Larry Hoover on December 13, 2003, at 9:44:24
In reply to Re: Sleep Problems » Larry Hoover, posted by Ron Hill on December 12, 2003, at 16:13:19
> Hi Lar,
>
> > In the last month, I've tried Seroquel, trazadone (for the fourth time....frig, I hate that stuff), and now Zyprexa (olanzapine).
>
> What symptoms are you attempting to treat with these trials; just insomnia, or additional symptoms as well?Just insomnia.
> As an aside, I had no idea you were conducting these heavy-duty med trials.
I'm getting desperate. Some background....
My mood is stable. That's not a problem. I have no other psych symptoms that really cause me any concern.
The insomnia appears to be directly linked to the PTSD/chronic fatigue/fibromyalgia symptom cluster. I see those three disorders as lying on a multi-factorial continuum; diagnostic distinctions between them are arbitrary, IMHO. Insomnia is a problem that likely arises via HPA dysregulation....i.e. a centrally mediated symptom.....very hard to treat. When I don't get restorative sleep, I decline in global function (not surprisingly), but this all began over the summer, when I was doing quite well. I wonder about the "six month effect" of NADH.....but otherwise, I really don't have a clue how to effectively address this symptom.
> You are so great at helping others on this board, yet sometimes I wonder if it is difficult for you to ask for help so that the support can flow in both directions?
I appreciate your raising this question, but I don't know how to answer it. You're probably right.
> In any case, you are a good guy in my book; I just hope you can get the help you need (and deserve).
Yes, thank you.
> > I'm going to push to try mood stabilizers next....can't hurt, might help.
>
> Which one(s) do you have your eye on? Refresh my memory; please give me a list of all prescription medications that you are currently taking.Currently, temazepam, 30 mg at bedtime, and olanzapine 2.5 mg at bedtime. The temazepam effectiveness has diminished over time, so the shrink wants me off it. We're adding in the other meds to see if something will: a) get me back to restorative sleep; b) do so sufficiently well to permit withdrawal of the temazepam (which will very likely cause severe rebound insomnia).
I'm considering mood stabilizers solely because I really haven't been on them yet (save lithium, which so numbed my emotional state that it made me suicidal; if this was to be my state, fuggedaboudit).
I've been trying to tweak with magnesium (gives me drowsiness the next day), melatonin (same), SJW (stimulating), 5-HTP (no effect).....but I'm not tweaking right now, as I need to see the sole effect of the novel meds I'm trying.
> > > > How's life down in Texas these days?
>
> > > Phil lives in TX (as does Shar, if I recall correctly). But I live in Idaho (which, as you know, shares a short border section with western Canada).
>
> > I'm sorry Ron. I can't even keep my people straight ... But you didn't answer the question....
>
> Answer to the question: Things are good down here in Texas <smile>. I periodically have trouble with anhedonia, low motivation, and anergy which I believe to be attributable to poor dopaminergic pathway functioning. And if I give-in to the symptoms and start staying in bed, I cycle into a deep atypical depression for about five days, after which, I immediately cycle into a highly irritable dysphoric mood state (which perhaps fits into the category of a mixed state).You might want to look at Kraepelin's diagnostic concepts....he was way ahead of his time. Sorry, no link....I'll look later.
> It is my layman’s opinion that my dopaminergic pathways were damaged by taking Ritalin, Paxil, and other SSRI’s during the years that I was misdiagnosed as ADHD. But I could be wrong about this.Or you may simply have gotten older....
> As I look back over my life, it is clear to me that I’ve been bipolar II since childhood (starting at about age eight). My anhedonia, low motivation, and anergy symptoms are definitely worse now than they were prior to taking Ritalin and SSRI’s, but maybe that is merely reflective of the fact that the depressive side of bipolar disorder worsens with age.
Or delayed initiation of effective treatment....there's a new concept entering the nutrition literature....long-latency deficiency disease....they're finally catching on.
> Or it could be an outcome predicted by the “Kindling Theory” (i.e.; the more times the BP patient cycles, the worse the disease becomes).
Yes, the brain learns even adverse patterns.
> In any event, I have improved dramatically over the past couples of years by finding various nutrients to feed my brain. I’m still looking for the additional nutrients (or, perhaps, medications) necessary to complete this project of brainchemistry restoration.
Just keep your expectations reasonable, 'kay?
> Also, I self-medicated (unknowingly) with rigorous exercise most of my adult years prior to getting derailed with Ritalin and Paxil. I’m currently in the process of ramping up my exercise program to therapeutic levels.That's a good strategy....I'm pretty much so fatigued that I can't get going on exercise....I'm just going to have to will myself to do so....at the risk of triggering further decline through over-exertion....I walk more than one tightrope.
> Overall, I’m doing well. Thanks for asking!
>
> --RonI'm glad of that. Thanks for drawing me out.
Lar
Posted by Larry Hoover on December 13, 2003, at 12:19:01
In reply to Re: Sleep Problems » Larry Hoover, posted by Ron Hill on December 12, 2003, at 16:13:19
Just because I think Kraepelin got it right a century ago, and we're still trying to get back there:
"As many as one hundred years ago the physician Kraepelin suggested his theory of mixed mood states. He believed that they arose when mood, ideation, and psychomotor activity were incongruent. When all three were decreased, depression occurred; when all three were elevated the result was mania. If one of the domains was contradictory however, (for example, low mood with excitement and acceleration of activity), the diagnosis would be depressive mania. Kraepelin identified six different mixed states, in addition to the two pure states of mania and depression.
Psychiatrists today recognize that there are more variations than Depressive Mania within the spectrum of mixed states, although the characteristics have not been defined, nor are these states official. Clinical experience has identified several different states that could be termed mixed states. These include Depressive Mania, Irritable Mania, Anxious Mania, Excited depression and Agitated Depression and others may exist. "
Neuropsychopharmacology. 2001 Sep;25(3):373-83.
Subtypes of mania determined by grade of membership analysis.Cassidy F, Pieper CF, Carroll BJ.
Duke-Umstead Bipolar Disorders Program, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC 27710, USA. cassi002@mc.duke.edu
Classical descriptions of mania subtypes extend back to Kraepelin; however, in marked contrast to the study of depression subtypes, validation of mania subtypes by multivariate statistical methods has seldom been attempted. We applied Grade of Membership (GOM) analysis to the rated clinical features of 327 inpatients with DSM-III-R mania diagnoses. GOM is a type of latent structure multivariate analysis, which differs from others of this type in making no a priori distributional assumptions about groupings. We obtained 5 GOM Pure Types with good face validity. The major Kraepelinian forms of "hypomania," "acute mania," "delusional mania," and "depressive or anxious mania" were validated. The major new finding is of two mixed mania presentations, each with marked lability of mood. The first of these displayed a dominant mood of severe depression with labile periods of pressured, irritable hostility and paranoia, and the complete absence of euphoria or humor. The second mixed mania Pure Type displayed a true, incongruous mixture of affects: periods of classical manic symptoms with euphoria, elation, humor, grandiosity, psychosis, and psychomotor activation, switching frequently to moderately depressed mood with pressured anxiety and irritability. This multivariate analysis validated classical clinical descriptions of the major subtypes of mania. Two distinct forms of mixed manic episodes were identified. DSM-III-R criteria did not reliably identify either of these two natural groups of mixed bipolar patients. As occurs in depression, this clinical heterogeneity of mania may influence response to drug treatments.
Posted by Ron Hill on December 13, 2003, at 12:29:37
In reply to Re: Sleep Problems » Ron Hill, posted by Larry Hoover on December 13, 2003, at 9:44:24
Larry Hoover,
> When I don't get restorative sleep, I decline in global function (not surprisingly), ...
Yes, I hear you Lar. Very sorry that you are currently struggling. You're smart and I'm believing that you and your pdoc will find an answer.
> Currently, temazepam, 30 mg at bedtime, and olanzapine 2.5 mg at bedtime. The temazepam effectiveness has diminished over time, so the shrink wants me off it. We're adding in the other meds to see if something will: a) get me back to restorative sleep; b) do so sufficiently well to permit withdrawal of the temazepam (which will very likely cause severe rebound insomnia).
Just a couple of thoughts that I feel sure you have already considered. What about replacing the temazpam with a different benzo, say Klonopin? Also, have you ever tried Sonata or Ambien?
> > Also, I self-medicated (unknowingly) with rigorous exercise most of my adult years prior to getting derailed with Ritalin and Paxil. I’m currently in the process of ramping up my exercise program to therapeutic levels.
> That's a good strategy....I'm pretty much so fatigued that I can't get going on exercise....I'm just going to have to will myself to do so....at the risk of triggering further decline through over-exertion....I walk more than one tightrope.Yes, I know you do, Lar. You and johnj.
-- Ron
Posted by Ron Hill on December 13, 2003, at 12:43:37
In reply to Re: about Kraepelin » Ron Hill, posted by Larry Hoover on December 13, 2003, at 12:19:01
Lar,
Looks like Kraepelin was ahead of his day. Thank you for digging up the Kraepelin information and the study.
-- Ron
---------------------> Just because I think Kraepelin got it right a century ago, and we're still trying to get back there:
>
> "As many as one hundred years ago the physician Kraepelin suggested his theory of mixed mood states. He believed that they arose when mood, ideation, and psychomotor activity were incongruent. When all three were decreased, depression occurred; when all three were elevated the result was mania. If one of the domains was contradictory however, (for example, low mood with excitement and acceleration of activity), the diagnosis would be depressive mania. Kraepelin identified six different mixed states, in addition to the two pure states of mania and depression.
>
> Psychiatrists today recognize that there are more variations than Depressive Mania within the spectrum of mixed states, although the characteristics have not been defined, nor are these states official. Clinical experience has identified several different states that could be termed mixed states. These include Depressive Mania, Irritable Mania, Anxious Mania, Excited depression and Agitated Depression and others may exist. "
>
>
> Neuropsychopharmacology. 2001 Sep;25(3):373-83.
>
>
> Subtypes of mania determined by grade of membership analysis.
>
> Cassidy F, Pieper CF, Carroll BJ.
>
> Duke-Umstead Bipolar Disorders Program, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC 27710, USA. cassi002@mc.duke.edu
>
> Classical descriptions of mania subtypes extend back to Kraepelin; however, in marked contrast to the study of depression subtypes, validation of mania subtypes by multivariate statistical methods has seldom been attempted. We applied Grade of Membership (GOM) analysis to the rated clinical features of 327 inpatients with DSM-III-R mania diagnoses. GOM is a type of latent structure multivariate analysis, which differs from others of this type in making no a priori distributional assumptions about groupings. We obtained 5 GOM Pure Types with good face validity. The major Kraepelinian forms of "hypomania," "acute mania," "delusional mania," and "depressive or anxious mania" were validated. The major new finding is of two mixed mania presentations, each with marked lability of mood. The first of these displayed a dominant mood of severe depression with labile periods of pressured, irritable hostility and paranoia, and the complete absence of euphoria or humor. The second mixed mania Pure Type displayed a true, incongruous mixture of affects: periods of classical manic symptoms with euphoria, elation, humor, grandiosity, psychosis, and psychomotor activation, switching frequently to moderately depressed mood with pressured anxiety and irritability. This multivariate analysis validated classical clinical descriptions of the major subtypes of mania. Two distinct forms of mixed manic episodes were identified. DSM-III-R criteria did not reliably identify either of these two natural groups of mixed bipolar patients. As occurs in depression, this clinical heterogeneity of mania may influence response to drug treatments.
>
Posted by Larry Hoover on December 13, 2003, at 14:25:10
In reply to Re: Sleep Problems » Larry Hoover, posted by Ron Hill on December 13, 2003, at 12:29:37
> Larry Hoover,
>
> > When I don't get restorative sleep, I decline in global function (not surprisingly), ...
>
> Yes, I hear you Lar. Very sorry that you are currently struggling. You're smart and I'm believing that you and your pdoc will find an answer.I really hope so.
> > Currently, temazepam, 30 mg at bedtime, and olanzapine 2.5 mg at bedtime. The temazepam effectiveness has diminished over time, so the shrink wants me off it. We're adding in the other meds to see if something will: a) get me back to restorative sleep; b) do so sufficiently well to permit withdrawal of the temazepam (which will very likely cause severe rebound insomnia).
>
> Just a couple of thoughts that I feel sure you have already considered. What about replacing the temazpam with a different benzo, say Klonopin?He wants me off benzos, period. Can you say benzophobe? I've probably asked to try clonazepam 15 different times over the last six years.
> Also, have you ever tried Sonata or Ambien?
They're not covered under my drug benefits, and I'm loathe to pay market price from my meager resources, on a treatment that may not work. I think only one of the two is even available in Canada...
> > > Also, I self-medicated (unknowingly) with rigorous exercise most of my adult years prior to getting derailed with Ritalin and Paxil. I’m currently in the process of ramping up my exercise program to therapeutic levels.
>
> > That's a good strategy....I'm pretty much so fatigued that I can't get going on exercise....I'm just going to have to will myself to do so....at the risk of triggering further decline through over-exertion....I walk more than one tightrope.
>
> Yes, I know you do, Lar. You and johnj.
>
> -- RonSo, given the restraints I've outlined, I don't have too many options, eh?
I've just ordered some horse feed. Maybe that will help.
Lar
Posted by Ron Hill on December 13, 2003, at 15:53:40
In reply to Re: Sleep Problems » Ron Hill, posted by Larry Hoover on December 13, 2003, at 14:25:10
Lar,
> So, given the restraints I've outlined, I don't have too many options, eh?
There are ALWAYS options! Problems are merely solutions waiting to be found. We just have to be smart enough and persistent enough to find one or more of the workable solutions.
> I've just ordered some horse feed. Maybe that will help.You mean tryptophan, right?
I don't know what you think about James South, but he suffered with insomnia for many years. I realize that he is trying to sell stuff, but his writings usually make sense to me. However, you are able to critic his writings better than I. At any rate, here are a couple excerpts from his articles:
<start quote>
Sleep-Aid Program
Chronic insomnia has plagued me since childhood, and so I have gradually perfected a sleep-aid program. I usually take 2-3mg Melatonin, 25mg Dilantin, 1000mg Tryptophan (or 100mg 5-HTP), 1-2 grams GABA, 1-2 grams Glycine, 2-3 grams Inositol, 1 gram Magnesium and 500mg Calcium, I gram Taurine, and various herbs at bedtime. Even with this extensive program I still have my occasional sleepless nights, no doubt due to my intensive nootropic/ neuronutrient intake.
Neuronutrients and nootropic drugs are the core of my supplement program. I routinely take
B1 500-1000mg
B3 500-1000mg
B6 200mg
Biotin 10-15mg and other B’s as well.
Many of the popular neuronutrients, such as ALC, ginkgo, choline and DMAE, simply don’t agree with my system, but I have found NADH, phosphatidyl serine, pregnenolone, CoQ10, Idebenone and Lipoic Acid to be especially helpful.
Since chronic cortisol excess is the "archenemy" of the aging brain, and I have been hypercortisolic since youth, I continually search for cortisol-controlling supplements. I have found Vitamin C, Melatonin, 7-Keto DHEA, Dilantin, Phosphatidyl Serine and GH3 to be useful in minimizing cortisol excess.
<end quote>Above quote taken from: http://www.smartnutrition.info/JamesSouth-program.htm
<start second quote>
Tryptophan and sleep
In recent years, melatonin has gained the reputation as the natural answer to insomnia. Yet the fact that melatonin is made in the pineal gland from serotonin is frequently overlooked.
Thus supplemental tryptophan may induce one’s pineal gland to naturally increase its melatonin production. Also, important sleep regulating nerve circuits in the brainstem (the raphe nuclei) use serotonin as their neurotransmitter, so it is unreasonable to expect melatonin alone to provide optimal insomnia relief.
Low dose melatonin (0.5mg to 1mg) plus tryptophan (500mg to 1500mg) may prove more effective for many people with serious insomnia.
<end quote>Taken from: http://www.smartnutrition.info/JamesSouth-tryptophan.htm
In years past, I had problems with insomnia (due primarily to hypomania). I had some success with low dosage (about 0.5 mg) sublingual melatonin (Source Naturals brand). Melatonin in any form other than sublingual would not even touch my insomnia. I had to take frequent breaks from the sublingual melatonin or else it lost its effectiveness. Also, Sonata worked fairly well for me. YMMV.
-- Ron
Posted by Larry Hoover on December 13, 2003, at 17:25:13
In reply to Re: Sleep Problems » Larry Hoover, posted by Ron Hill on December 13, 2003, at 15:53:40
> Lar,
>
> > So, given the restraints I've outlined, I don't have too many options, eh?
>
> There are ALWAYS options! Problems are merely solutions waiting to be found. We just have to be smart enough and persistent enough to find one or more of the workable solutions.Indeed. The search is ongoing, and still hopeful, despite the tone of my last message.
> > I've just ordered some horse feed. Maybe that will help.
>
> You mean tryptophan, right?Yes. You always were the perceptive one. And, snipping right to the point....
> Thus supplemental tryptophan may induce one’s pineal gland to naturally increase its melatonin production. Also, important sleep regulating nerve circuits in the brainstem (the raphe nuclei) use serotonin as their neurotransmitter, so it is unreasonable to expect melatonin alone to provide optimal insomnia relief.
> Low dose melatonin (0.5mg to 1mg) plus tryptophan (500mg to 1500mg) may prove more effective for many people with serious insomnia.Exactly the point of a discussion with my CBT counsellor just last week....so I decided to see if my horse feed will get past Customs... along with a variety of other supps (great prices!).
> Taken from: http://www.smartnutrition.info/JamesSouth-tryptophan.htm
>
> In years past, I had problems with insomnia (due primarily to hypomania). I had some success with low dosage (about 0.5 mg) sublingual melatonin (Source Naturals brand). Melatonin in any form other than sublingual would not even touch my insomnia.Just in case anybody else is following this thread, most melatonin tablets on the market are substantially more than physiological replacement doses of melatonin (should be 0.3-0.5 mg, not 3 mg like I usually see). So, I chop the tablets into smaller chunks, and take little bits....but it always leaves me "hungover".
> I had to take frequent breaks from the sublingual melatonin or else it lost its effectiveness. Also, Sonata worked fairly well for me. YMMV.
>
> -- RonI'm just trying to do one manipulation at a time (experimental control methodology), but I'll certainly give tryptophan a decent trial.
Thanks,
LarP.S. New supplement and herb regs go into effect in Canada in January, to be phased in over the next three years. Melatonin will be legal right away (as far as I can tell), as will some free aminos. It even looks like tryptophan will be legal again, as an OTC supp, once the approval has been granted. It's hard to tell for sure, but it looks that way.
Posted by joebob on December 14, 2003, at 10:47:47
In reply to Re: Sleep Problems » Larry Hoover, posted by Ron Hill on December 13, 2003, at 15:53:40
best combo i have found for myself....
trazadone 100mg, 45 min before bed
melatonin sr, which i prefer, .5 to 1mg.....which also seems to help with sad this time of year
and occasionally 5mg valium on a hypomanic night, chewed 15 min before sleep while in bedthe meds were what my neurologist, a big time sleep expert here in la prescribed....the doc could care less about supps
you can get both sr and sublingual melatonin in almost any dosages from 'emerson ecologics' on the web....don't know if they ship to canada
regular melatonin at any dose seemed to have a minor effect but i often woke later in the night..hence my switch to sustained release
sleep is the most essential thing for my overall well being
best to all
Posted by johnj on December 14, 2003, at 14:55:50
In reply to Re: Sleep Problems » Ron Hill, posted by Larry Hoover on December 13, 2003, at 17:25:13
HI Larry (and Ron too)
Just got back on and read the thread between you two. I hope you both are doing well and we all find our healing path. Sometimes despair is so great.
larry, well it seems you and I are in the same boat as far as the sleep things goes. I have struggled trying to find something for the last 2.5 years.
I have been away for awhile and for the last 9 weeks have been waiting to do my sleep study. I did it last week and the results, or lack thereof, were almost devastating. I expected something and the only thing I had was a lack of deep sleep,not caused by sleep apnea. I had hoped for some dx and there was none. The only thing that keeps me going is the remeron giving me kind of a "who cares attitude". I seem to have to numb myself to stay functional.
When I added 15mg of remeron last spring and started using a mouth guard since I grind my teeth(I probably mentioned it before). But, I lost the mouth guard and slowly started to feel worse, hence the doc thinking I had apnea. For about two months I was yawning naturally and sleeping through my alarm. Everythin took a dive when I lost my mouth guard. So the dentist made me a new one, different style, and it gave me so much tension in my forehead.
The excercise still makes my insomnia worse, just not that day it happens a day or so later. I think the lack of deep sleep is what hurts me. My body is repairing itself. The one non-drug, supplement thing I long for eludes me still. The fatigue and muscle loss concern me a great deal. All I get from the docs are "excercise will help". Well it used to but not anymore. It is tough to know what to do. I sometimes think maybe paxil could help the anxiety/gad, but ssri's scare me and cymbalta is still a know show.
Larry, is your PTSD causing you anxiety and hence insomnia? I seem to "sleep" 7 hours, but wake up bushed. I also have funny eye twitches, and muscle twitches from lack of sleep. Lack of sleep takes it toll. Have you tried a low dose of remeron? I know you tried it in the past, but at what dose? At least I get to sleep it just isn't as restorative as I need. I also take lithobid and tranzene(which the doc thinks) might mess up my deep sleep.
Take care of yourself and hopefully I will have the energy to keep looking. My wife is not handling things very well and I sometimes wonder if she will leave. I wouldn't blame her as the meds make me intolerable and grumpy and short tempered. Thanks to remeron my sex drive has diminished to almost nothing.
Peace to you both, and may a miracle find us all.
johnj
Posted by Ron Hill on December 14, 2003, at 23:07:12
In reply to Re: Sleep Problems, Ron » Larry Hoover, posted by johnj on December 14, 2003, at 14:55:50
My friend Johnj,
Have you ever tried an AP, say Zyprexa? How about changing to another (better) benzo, say Klonopin?
-- Ron
Posted by johnj on December 15, 2003, at 10:53:29
In reply to Re: Sleep Problems » johnj, posted by Ron Hill on December 14, 2003, at 23:07:12
HI Ron,
No, I haven't tried an AP and really don't want to at this point. I have thought about another benzo such as klonopin, but I don't know how different it would be than tranzene.
I have thought about trying some tryptophan, but since I take nortyptline and remeron I don't know what type of reaction I would have. I would like to go down on the remeron and add trypto, but don't know if that is advisable or not.
I wonder if taking a small amount of tryptophan during the middle morning or middle afternoon would be a good idea for anxiety? I think right now I am having a "hangover" from the med combo so I am out of it in the morning. I may try to go down on some of the tranzene hoping to reduce the hangover effect.
Where did people get their tryptophan? I thought it was illegal?
Have a good one.
johnj
Posted by Ron Hill on December 15, 2003, at 12:34:28
In reply to Re: Sleep Problems » Ron Hill, posted by johnj on December 15, 2003, at 10:53:29
Hey Johnj,
> Where did people get their tryptophan? I thought it was illegal?
I know a couple of overseas sites that sell pharmaceutical tryptophan but, since the sites also sell medications without prescriptions, I can't post the links on Dr. Bob's pbabble. Use your search engines.
Click on the following link to one of Larry's posts. In it he provided information regarding the legal issue and he also provided a link to a site that sells tryptophan supplements for horses at an affordable price. Beware however, McPac's appetite for apples and oats have escalated dramatically since taking the product. Further, McPac now has an incurable urge to gallop at full speed around horse race tracks. His current odds are 7-to-5 for his next event this upcoming weekend.
Here's Larry's post:
http://www.dr-bob.org/babble/alter/20031003/msgs/271979.html
-- Ron
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