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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 34. This is the beginning of the thread.
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.
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.
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).
been on:
Moclobemide (300mg) by GP. Stayed on for 6 months.
Pros: good anti-anxiety agent
Cons: felt more dulled, slight cognitive sfx.
Psychiatrist #1:Prozac (10mg) for 4 days
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??
Pros: activating
Cons: insomnia
Mirtazapine (15-30mg) for 3 weeks.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.
Try Prozac (10mg) again.
Seems to instantly fix fogginess (don't both this and remeron work on prefrontal cortex?), but again insomnia an issue, so advised to withdraw.
^^^^^^^ 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??
Try Lexapro (10mg) for 8 weeks.
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.
Try Luvox (100mg) for 8 weeks.
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.
After coming off Luvox, begin to notice problems with executive function:
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.
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.
Could not concentrate on tasks at hand would just constantly seek distractions on the internet while trying to write.
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.
Become desperate and try Nardil (3 months):
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.
pros: helped depression
cons: felt foggy, euphoric, 'not like myself'
return of 'schizoid' depression. somewhat pleasant in that i am anxiety-free, but suffer from complete inattentiveness, brain fog, etc.
try Memantine (20mg max, 6 weeks).
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.
desperate again, so try Parnate with psychiatrist #2
Parnate (max dose reached 40mg, 10 weeks)
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.
-------------------------------------------------
so there you have it. thanks to anyone who read that, and sorry if it's a little messy.
i find it interesting that:
a) prozac instantly relieved my brain fog at first (so need prefrontal cortex help?)
b) that memantine occasionally had me feeling completely calm and rational (mood stabilizer might help?)
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...
sorry again this is so rambly. please feel free to ask any questions.
Posted by Alexanderfromdenmark on November 14, 2009, at 8:04:08
In reply to calling all armchair psychs, posted by g_g_g_unit on November 8, 2009, at 4:26:41
What about
Agomelatine?
Prozac + sleep medication?
Posted by g_g_g_unit on November 14, 2009, at 16:46:58
In reply to Re: calling all armchair psychs, posted by Alexanderfromdenmark on November 14, 2009, at 8:04:08
thanks Afd; sorry if my post was such a jumble. a psychologist has actually tentatively diagnosed me as having both ADD and OCD, which explains why SSRI's made my situation so much worse. unfortunately, i'm kind of stranded now, because my present psych doesn't want to acknowledge the ADD component (there's sort of a stigma here), and is just pushing to treat the OCD.
i guess Prozac would've helped cos of it's frontal cortex action, but doesn't that soften out eventually?
i was thinking Stablon might be a good compromise.
Posted by Phidippus on November 14, 2009, at 18:49:42
In reply to Re: calling all armchair psychs, posted by g_g_g_unit on November 14, 2009, at 16:46:58
> i guess Prozac would've helped cos of it's frontal cortex action, but doesn't that soften out eventually?
If you've got ADHD and OCD, you're best friend might be dextroamphetamine - it is recommended by the APA as monotherapy for OCD. In other words, you'lll kill two birds with one stone.
If you want an antidepressant that has a lot of dopamine action, you might want to try Wellbutrin, but only as an adjunct to an SSRI.
Wellbutrin + Prozac might be a good combo for the OCD and ADHD
> i was thinking Stablon might be a good compromise.
Stablon will not be as effective Anafranil in your case. Have you ever tried Anafranil?
P
Posted by g_g_g_unit on November 14, 2009, at 22:31:36
In reply to Re: calling all armchair psychs » g_g_g_unit, posted by Phidippus on November 14, 2009, at 18:49:42
> If you've got ADHD and OCD, you're best friend might be dextroamphetamine - it is recommended by the APA as monotherapy for OCD. In other words, you'lll kill two birds with one stone.
the hoops you have to jump through to be prescriped a stim in my country are insane. at my psychologist's behest (i speak to a US psychologist via Skype), i went and saw an ADHD specialist last week. his secretary accidentally booked me in for a 25 minute evaluation (as opposed to the initial 90 minutes usually mandated), during which time he declared unequivocally that i had GAD (because most of my anxiety comes from not being able to concentrate, which i had assumed was more of an ADHD feature), and wanted to place me on antipsychotic therapy. uh .. no thanks.
i am going to see a different ADHD GP next week who uses TOVA testing. even if i didn't have fullblown ADHD to begin with, there's no doubt in my mind i would qualify at this point, given how perpetually cloudy, catatonic and amotivational i feel after AD therapy (and i honestly don't buy the "it's depression" label, because i was working and functioning prior to going on AD's. now i'm not).
the only two stims available where i live are ritalin/concerta and d-amphetamine. i am honestly considering omitting the OCD side of things in an attempt to get dex prescribed (my guess is that he'll otherwise push Effexor or something). i am done with ethical niceties at this point. i really just want to go back to school and/or my job. at this point, most AD's make the situation worse, and what's more, psychiatrists aren't really into the cocktail thing.
>
> If you want an antidepressant that has a lot of dopamine action, you might want to try Wellbutrin, but only as an adjunct to an SSRI.
>
> Wellbutrin + Prozac might be a good combo for the OCD and ADHDi'll consider Prozac + WB, at least if nothing else works out.
>
> > i was thinking Stablon might be a good compromise.
>
> Stablon will not be as effective Anafranil in your case. Have you ever tried Anafranil?
>
> P
>no, i haven't. it sounds too cognitively dirty. the OCD is really not much of an issue at this point - psychs don't really believe me, but i feel so braindead and 'out of it' that i really experience very little physical anxiety or intense ruminations at the moment. the volume on them feels completely dialled down. unfortunately, so does the rest of my brainpower.
so, my aim isn't to eliminate the OCD. i would rather get back to a point where i have enough executive function to work and exist. right now i'm kind of in an exasperating no-man's land.
Posted by Phidippus on November 15, 2009, at 1:50:54
In reply to Re: calling all armchair psychs » Phidippus, posted by g_g_g_unit on November 14, 2009, at 22:31:36
>during which time he declared unequivocally that i had GAD (because most of my anxiety comes from not being able to concentrate, which i had assumed was more of an ADHD feature), and wanted to place me on antipsychotic therapy. uh .. no thanks.
ADHD can present with an awful lot of anxiety-lord knows I'm an anxious mess when I'm off my Dexedrine. Antipsychotics would make you feel yucky.
> the only two stims available where i live are ritalin/concerta and d-amphetamine.
Ritalin can make OCD worse. d-Amphetamine is what you want.
Effexor is recommended by the APA if treatment with SSRIs is ineffective.
>i feel so braindead and 'out of it' that i >really experience very little physical anxiety >or intense ruminations at the moment.This would be the dissociative state OCD can impart on the victim. Give Anafranil a shot and you may find yourself out of that state.
Posted by g_g_g_unit on November 15, 2009, at 4:58:32
In reply to Re: calling all armchair psychs » g_g_g_unit, posted by Phidippus on November 15, 2009, at 1:50:54
> ADHD can present with an awful lot of anxiety-lord knows I'm an anxious mess when I'm off my Dexedrine. Antipsychotics would make you feel yucky.they did. Seroquel made me feel like a chicken with it's head cut off; my inattentive symptoms were amplified x1000. it wasn't akathisia (because there was no physical anxiety/restlessness), but i simply couldn't keep my attention trained on so much as tying my shoes.
>
> > the only two stims available where i live are ritalin/concerta and d-amphetamine.
>
> Ritalin can make OCD worse. d-Amphetamine is what you want.unfortunately, i think Ritalin is usually prescribed as a frontline med, and i don't really want to go ahead and request dex for fear of being denied treatment altogether. do you think Memantine might be able to curb Ritalin/Concerta's effect on OCD? otherwise, i guess i could always just say Ritalin isn't working for me i guess.
>
> Effexor is recommended by the APA if treatment with SSRIs is ineffective.
>
> >i feel so braindead and 'out of it' that i >really experience very little physical anxiety >or intense ruminations at the moment.
>
> This would be the dissociative state OCD can impart on the victim. Give Anafranil a shot and you may find yourself out of that state.i hate to sound picky, but right now a stim (or d-amphetamine, at least) is my first choice as far as treatment goes - and wouldn't they possibly be just as effective in a dissociative state? i've dealt with the worst of the dissociation (mainly the thoughts it conjures) through psychotherapy, but confronting the pain doesn't really bring back my functioning. i imagine that if i could go back to performing the tasks i enjoy regularly (reading, writing, etc.), the dissociation might evaporate. right now it just feels like a blanket that's helping me cope.
it seems like Anafranil might help get me out of this funk, but i really want to get back my pre-med state of functioning (or as close to as possible). i was working as a writer prior to all this, and anticholinergic drugs just seem to wreak havoc on my word-recall, idea generation, etc. but i guess if i'm refused a stim, then i might have no choice. i hope i don't sound bratty, or like i'm investing all my hope in a drug; but it breaks my heart when i see how readily stims are made available in the US. i've had friends fake ADD so they could get them for partying, but when i asked my last psych if i could try Ritalin (not knowing at that point that it might make OCD worse) so i could go back to school, he accused me of drug-seeking and nearly through me out his office. that's why i'm approaching the matter with incredible trepidation this time.
Posted by Phidippus on November 15, 2009, at 16:11:57
In reply to Re: calling all armchair psychs, posted by g_g_g_unit on November 15, 2009, at 4:58:32
>do you think Memantine might be able to curb Ritalin/Concerta's effect on OCD?
Its possible.
P
Posted by g_g_g_unit on November 16, 2009, at 3:44:24
In reply to Re: calling all armchair psychs » g_g_g_unit, posted by Phidippus on November 15, 2009, at 16:11:57
> >do you think Memantine might be able to curb Ritalin/Concerta's effect on OCD?
>
> Its possible.
>
> Ppharmalogically-speaking, is there a basic difference between Dex and methylphenidate which results in one soothing OCD and the other aggravating it?
Posted by conundrum on November 16, 2009, at 7:17:37
In reply to Re: calling all armchair psychs » Phidippus, posted by g_g_g_unit on November 16, 2009, at 3:44:24
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448202/
THis study shows that Methylphenidate has the strongest affinity for the dopamine transporter and then norepinephrine. It barely increases serotonin.
Dextroamphetamine has its strongest effect on norepinephrine and then dopamine. It also releases more serotonin than Methylphenidate.
Posted by Phidippus on November 16, 2009, at 8:49:49
In reply to Re: calling all armchair psychs » Phidippus, posted by g_g_g_unit on November 16, 2009, at 3:44:24
d-amphetamine tends to do most of its work in the PFC where it modulates glutamate-excressive glutamate in the PFC is implicated in OCD. Methylphenidate tends to do its work in the brain stem.
I did find something interesting though:
http://www.ncbi.nlm.nih.gov/pubmed/3429704
P
Posted by conundrum on November 16, 2009, at 9:12:41
In reply to Re: calling all armchair psychs » g_g_g_unit, posted by Phidippus on November 16, 2009, at 8:49:49
When you say it modulates glutamate, does it increase it or decrease it?
Posted by Phidippus on November 17, 2009, at 19:06:50
In reply to Re: calling all armchair psychs » Phidippus, posted by conundrum on November 16, 2009, at 9:12:41
> When you say it modulates glutamate, does it increase it or decrease it?
Dextroamphetamine does not alter glutamate levels in the prefrontal cortex. This may be because dextroamphetamine increases dopamine release in the prefrontal cortex; activation of the dopamine-2 receptors inhibits glutamate release in the prefrontal cortex. However activation of the dopamine-1 receptors in the prefrontal cortex, increases glutamate leves in the nucleus accumbens. An increase of the glutamate levels in the nucleus accumbens may be part of the reason that dextroamphetamine has an ability to increase locomotor activity in rats. Serotonin may also play a role in dextroamphetamines affect on glutamate levels.
Posted by conundrum on November 18, 2009, at 22:40:12
In reply to calling all armchair psychs, posted by g_g_g_unit on November 8, 2009, at 4:26:41
Was there much of a time lapse between when you first took prozac and then Remeron? Its possible you are cognitively responding to the 5 HT2C antagonism of both drugs.
Perhaps you would have felt the same cognitive problems if you had stayed off prozac and not gone on remeron.
Who knows. I found that I had really bad sexual dysfunction on St. John's Wort and then taking lexapro made it somewhat better, and now I'm taking neither and it hasn't gotten worse. A human being is a complex organism.
Posted by g_g_g_unit on November 18, 2009, at 23:31:18
In reply to Re: calling all armchair psychs » g_g_g_unit, posted by conundrum on November 18, 2009, at 22:40:12
> Was there much of a time lapse between when you first took prozac and then Remeron? Its possible you are cognitively responding to the 5 HT2C antagonism of both drugs.
no, i think there was about a week's lapse. the problem is that my cognition was okay prior to the whole Remeron thing. i had never really sought to treat my OCD - i basically just lived on my nerves. i was a lot slower in certain areas - it took me forever to finish books, etc. but i don't feel like my higher thinking abilities were really compromised. the fogginess i experience now (a kind of full-brain sensation - blurry vision, cottonwool head, etc.) is exactly what i had after i came off Remeron. when i took Prozac, i remember everything 'clearing up'. other SSRI's made it worse. i don't think Remeron caused brain damage or anything drastic like that, but i just wondered if like too much stress is placed on the frontal cortex, it can shut down or something? Remeron just felt like the nail in the coffin i guess.
>A human being is a complex organism.
i know. i feel really naive for even trying to find a throughline in this whole mess. but it's not like any doctor i see has proven anymore useful. they just keep trying to treat the 'original disease' (i.e. OCD) which has never really worked out - stamping out the OCD always seems to come at the expense of something else (drive, motivation, etc.).
my head feels like a complete mess now - i still ruminate, but i also feel like i have full-blown ADD, so it's like my OCD thoughts never reach a full crescendo (which is good), but i also can't focus on anything productive to save my life. it's totally depersonalizing, because i can never really finish my thoughts or engage in anything that requires sustained thinking (i was working as a writer, so that's incredibly important). my parents wants me to see a neurologist, but i don't know how much more help they'll be?
i'm not necessarily looking at trying to rid myself completely of my problems, but i want to get to a point where i can go back to work. i would rather treat the executive dysfunction over the OCD now.
like i say, low dose Memantine (where it's primarily a D2 agonist i think?) worked well, but was almost *too much* clarity. so i'm wondering if a little D2 agonism might be useful without pushing it too far... i also wonder if i can really get away without using an SSRI ..
so maybe low-dose Geodon, which i know psychobot is using with some success?
low-dose prozac (5mg?), where at least there's a little SRI action. is this working out okay for you conundrum? also, do you find low-dose buspar at all useful for cognition?
memantine + stimulant - though aside from the difficult of getting this prescribed, i wonder if it might just turn me into a logic-driven robot.
i also have some SAM-e which i might try experimenting with.
Posted by conundrum on November 19, 2009, at 6:49:15
In reply to Re: calling all armchair psychs » conundrum, posted by g_g_g_unit on November 18, 2009, at 23:31:18
I think memantine is a D2 agonist not antagonist. Anyway, what do you mean when you say too much clarity?
I noticed with 2.5 mg prozac it did nothing.
I then added 10mgs buspar. It did not improve cognition but it improved my motivation. I then bumped prozac to 5mgs a day. I've been on 5mgs for almost two weeks and it has reversed the positive effects of buspar and made me lazy. I feel tired on it, and there has been no improvement in cognition. I plan to take 30 mgs of buspar next week and see if I feel motivated again. The highest i'll go with prozac is 10mgs. If i don't start to feel hedonic and a cognitive improvement I'll stop. ACtually I'm very skeptical that will happen and wonder if I should just stop prozac now and stick with buspar in the mean time because I was getting things done on it.
I remember brainbeard said something about low dose prozac only being a 5 HT2C antagonist and not having much SRI but I don't think thats true. I'm not even sure where he found that fact, but perhaps its the opposite. Maybe its not until the higher doses that the 5 HT2C becomes noticable.
Posted by g_g_g_unit on November 19, 2009, at 21:11:33
In reply to Re: calling all armchair psychs » g_g_g_unit, posted by conundrum on November 19, 2009, at 6:49:15
> I think memantine is a D2 agonist not antagonist. Anyway, what do you mean when you say too much clarity?
sorry, i meant agonist. i guess without the NMDA inhibition, my mind just went kind of wild at 5mg - ideas were racing through my head faster than i could harness them, i had boundless intellectual energy, was a social titan etc. i guess it was probably hypomania? though drug-induced, in my opinion .. i don't believe i'm bipolar.
i met with an ADD specialist who has finally confirmed what i suspected for a while, and which problems explains why i never did well on SSRI's alone - namely, that i have comorbid ADD and OCD. i disclosed everything, including the severity of my OCD at times, but he believes ADD is the underlying cause.he's prescribed Ritalin LA 30mg. i don't have a tonne of faith in it not setting me on edge and resurrecting my OCD (which has been dormant lately), though i'll give it a shot. i wonder if i could get away with Memantine + Ritalin or if i'll have to add an SSRI to the equation. anyway, it's a relief to finally have a more rounded diagnosis, and at least if i meet with future psychs it opens up the possibility of trying stuff like Dex, etc.
Posted by g_g_g_unit on November 19, 2009, at 21:29:47
In reply to Re: calling all armchair psychs » g_g_g_unit, posted by Phidippus on November 15, 2009, at 1:50:54
Phidippus, did you ever try Ritalin for OCD?
also, if you don't mind my asking, what stopped you taking Dexedrine as monotherapy for ADHD and OCD? did you find it just wasn't enough relief, hence the addition of an SSRI?
to be honest, i am very scared of Ritalin. low-dose Parnate almost had me in tears w/r/t anxiety. i think i need a competent psych to deal with this.
Posted by conundrum on November 20, 2009, at 6:35:38
In reply to Re: calling all armchair psychs, posted by g_g_g_unit on November 19, 2009, at 21:29:47
Well the nice thing about ritalin is it only lasts about 6 hours and starts to work immediately. So you don't have to taper down if you start to feel bad and you don't have to take it for weeks to know if its helping or exacerbating your OCD. It might be worth a shot to see if it helps.
Posted by Phidippus on November 20, 2009, at 13:34:09
In reply to Re: calling all armchair psychs, posted by g_g_g_unit on November 19, 2009, at 21:29:47
> Phidippus, did you ever try Ritalin for OCD?
I did try Ritalin and it made my OCD severe.
> also, if you don't mind my asking, what stopped you taking Dexedrine as monotherapy for ADHD and OCD?
My ADHD is very mild/not really confirmed and I never did dextroamphetamine monotherapy. I always did dex with an SSRI.
P
Posted by g_g_g_unit on November 20, 2009, at 19:12:59
In reply to Re: calling all armchair psychs » g_g_g_unit, posted by conundrum on November 20, 2009, at 6:35:38
> Well the nice thing about ritalin is it only lasts about 6 hours and starts to work immediately. So you don't have to taper down if you start to feel bad and you don't have to take it for weeks to know if its helping or exacerbating your OCD. It might be worth a shot to see if it helps.
yeah, but does it change in character over time, i.e. become less anxiety-inducing once tolerance sets in?
or if it's having a negative effect on my OCD from the get-go, can i be certain it's not worth sticking with?
i picked up my script today, so will give it a shot tomorrow
Posted by conundrum on November 21, 2009, at 14:58:22
In reply to Re: calling all armchair psychs, posted by g_g_g_unit on November 20, 2009, at 19:12:59
I dunno, but you'll find out ;-)
Posted by g_g_g_unit on November 21, 2009, at 18:32:52
In reply to Re: calling all armchair psychs » g_g_g_unit, posted by conundrum on November 21, 2009, at 14:58:22
today's my first day on ritalin. i just feel foggy and high, which beats just feeling foggy i guess :)
does anyone know if Ritalin or the other amps act on specific dopamine receptors, or do they just broadly inhibit the reuptake of dopamine?
Posted by Phidippus on November 22, 2009, at 13:51:22
In reply to Re: calling all armchair psychs, posted by g_g_g_unit on November 21, 2009, at 18:32:52
its chemical structure is more closely related to cocaine. amphetamine works as a dopamine transport substrate where as methylphenidate works as a dopamine transport blocker.
Methylphenidate has both DAT and NET binding affinity, with the dextromethylphenidate enantiomers displaying a prominent affinity for the norepinephrine transporter. Both the dextro- and levorotary enantiomers displayed receptor affinity for the serotonergic 5HT1A and 5HT2B subtypes, though direct binding to the serotonin transporter was not observed.
Posted by g_g_g_unit on November 22, 2009, at 14:38:20
In reply to Re: calling all armchair psychs, posted by Phidippus on November 22, 2009, at 13:51:22
thanks. first day of Ritalin turned out to be a washout - on the one hand, it gives me the mental energy to break from compulsions and redirect my attention to more rewarding activities. but it also makes me more angsty, and the comedown is hellish. i don't envision myself sticking with it for the long haul. maybe the effect would also be more positive if i weren't depressed.
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