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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 21 of 21. This is the beginning of the thread.
Posted by Noa on March 2, 2000, at 14:17:51
Wellbutrin, for instance?
At what point do I say the effexor isn't doing it for me. I mean, it has been working, but what is it with these new episodes? And if these episodes reflect a cycling a la bipolar family, why isn't the lithium helping. I did feel better initially with the lithium, but not anymore.
So, I wonder if it is time to move on. I never gave Welbutrin a proper trial. It was a few years back, in combo with paxil, and I got diarrhea, which I attributed to the wellbutrin, but it all happened so fast, I realy am not sure. At the time, I also didn't like the Wellbutrin because you had to dose three times a day, and I was still spoiled by the single dose prozac,etc. Needless to say, with all I am on now, dosing three times a day really wouldn't matter.
How do people feel about wellbutrin? Especially for an obviously refractory depression.
I don't think I want to go with an MAOI, and the only time I took a tricyclic I wigged out bad on a small initial dose. The other SSRIs? I don't know if they offer anything new for me. Does Wellbutrin?
Is it worth trying? How would one do this--tapering off effexor? I assume it would be ok to overlap at some point.
Posted by Sherry on March 2, 2000, at 16:48:11
In reply to What do you know about...., posted by Noa on March 2, 2000, at 14:17:51
I can only say from personal experience, that the only thing that ever touched my depression was a MAOI, namely Parnate. It didn't last long though, and I am just curious as to why you are against giving the MAO's a try? I never felt deprived because to the diet. The only thing I truly missed was pizza, and I got around that by pulling all the topping off and eating the crust and sauce ( the best part anyway). It would probably be better to try the Wellbutrin first, but if that doesn't work, then I would seriously reconsider trying the MAO's. They often work when nothing else will.Have a wonderful day, week, year.
>
> At what point do I say the effexor isn't doing it for me. I mean, it has been working, but what is it with these new episodes? And if these episodes reflect a cycling a la bipolar family, why isn't the lithium helping. I did feel better initially with the lithium, but not anymore.
>
> So, I wonder if it is time to move on. I never gave Welbutrin a proper trial. It was a few years back, in combo with paxil, and I got diarrhea, which I attributed to the wellbutrin, but it all happened so fast, I realy am not sure. At the time, I also didn't like the Wellbutrin because you had to dose three times a day, and I was still spoiled by the single dose prozac,etc. Needless to say, with all I am on now, dosing three times a day really wouldn't matter.
>
> How do people feel about wellbutrin? Especially for an obviously refractory depression.
>
> I don't think I want to go with an MAOI, and the only time I took a tricyclic I wigged out bad on a small initial dose. The other SSRIs? I don't know if they offer anything new for me. Does Wellbutrin?
>
> Is it worth trying? How would one do this--tapering off effexor? I assume it would be ok to overlap at some point.
Posted by kelly on March 2, 2000, at 17:09:59
In reply to What do you know about...., posted by Noa on March 2, 2000, at 14:17:51
> Wellbutrin, for instance?
>
> At what point do I say the effexor isn't doing it for me. I mean, it has been working, but what is it with these new episodes? And if these episodes reflect a cycling a la bipolar family, why isn't the lithium helping. I did feel better initially with the lithium, but not anymore.
>
> So, I wonder if it is time to move on. I never gave Welbutrin a proper trial. It was a few years back, in combo with paxil, and I got diarrhea, which I attributed to the wellbutrin, but it all happened so fast, I realy am not sure. At the time, I also didn't like the Wellbutrin because you had to dose three times a day, and I was still spoiled by the single dose prozac,etc. Needless to say, with all I am on now, dosing three times a day really wouldn't matter.
>
> How do people feel about wellbutrin? Especially for an obviously refractory depression.
>
> I don't think I want to go with an MAOI, and the only time I took a tricyclic I wigged out bad on a small initial dose. The other SSRIs? I don't know if they offer anything new for me. Does Wellbutrin?
>
> Is it worth trying? How would one do this--tapering off effexor? I assume it would be ok to overlap at some point.when i first started prozac i had the same problem w/ diarrhea,my Dr. wrote me a prescription for compazine 10mg. & and after a couple of weeks i didn't need it anymore.Maybe if you go back on wellbutrin your dr. could give you something like compazine. I hope you feel better
Posted by JohnL on March 3, 2000, at 1:53:11
In reply to What do you know about...., posted by Noa on March 2, 2000, at 14:17:51
Noa,
Sorry to hear things are not going as well as expected. Having followed your posts for some time, I'm still cheering for you.
You don't have a psychostimulant in your mix, right? Based on your history so far, I would not spend any more time beating around the bushes with antidepressants or lithium. There is clearly some other chemistry involved.
If you don't have a stimulant in the mix, I would bet money either Adderall, Dexedrine, or Ritalin(in that order) would do the trick. And fast. They will target other depression-causing chemical imbalances that your previous medications have not touched. You are so used to these long trials, and I know how dedicated you are at giving things a good trial. You'll be pleasantly relieved to find out that if a stimulant is to work, it will do so in days. Usually 24 to 72 hours.
Some docs object to stimulants. I don't know why, since they don't seem to have any problem medicating millions of children with them. But if your doc is at all hesitant, beg for just a one week's supply of Adderall. Dexdrine and Ritalin one-week trials to follow if needed. Psychostimulants are legitimate for refractory depression.
My history is so similar to yours. My pdoc recently wrote my family doc instructions for me. He specified in writing "John should try Adderall or Dexedrine for refractory major depression". I believe this is probably the most overlooked treatment to correct depression-causing chemical imbalances, especially when other popular approaches have been disappointing. All it will take is a couple weeks to see if this is the right direction for you. Take a break from those long trials. Your frustrating search may well come to a happy end. :) I don't remember if you already have a stimulant in the mix, or if you've tried the three I mentioned. If you do, or have, never mind about this post. But to anyone else reading, stimulants can pleasantly halt those long frustrating searches. Especially when there have been multiple failures on a couple other classes of medications. JohnL
Posted by S. Suggs on March 3, 2000, at 4:53:50
In reply to What do you know about...., posted by Noa on March 2, 2000, at 14:17:51
Hello Noa:
If the effexor is not working and you want to taper off w/less "withdrawl", do what I did. I took prozac 20mg for two weeks as a cushion. If I remember correctly, I just stopped the effexor or tapered quickly. W/ the long half-life of prozac, it really helped. I had no problems getting off effexor. Also, I'd stay with the lithium and add the wellbutrin (long acting). It's in and out of your system pretty fast anyway, so if the dr wanted to add a stimulant it could be done pretty quickly. But as far as I can remember, the lithium worked well for you and it is not really in the "poop out class" like the ssri's etc...
best wishes and blessings,
S. Suggs
Posted by ChrisK on March 3, 2000, at 6:10:10
In reply to What do you know about...., posted by Noa on March 2, 2000, at 14:17:51
Hi Noa,
I was having problems with apathy and lack of energy. When I went to my pdoc I asked him for a stimulant and he put me on Adderal. As we continued to talk I mentioned that I had never given Wellburtin a try so he gave me a low dose of that too. Things couldn't have worked out better. I've been taking the two for two months now and notice a big difference. The only problem remaining is that I have a short attention span. That I can live with.
Maybe if it can be worked out with your doctor this may be a way to go.
Chris
Posted by Noa on March 3, 2000, at 6:31:18
In reply to Re: What do you know about...., posted by ChrisK on March 3, 2000, at 6:10:10
Thanks, everyone.
John, I do have a stimulant in my cocktail--have been taking ritalin for a few years, and it did seem to help when it was added. I switched to SR about six months ago, and I like it better because it seems to eliminate the slumps during the day.
I just wonder about the effexor. I am on a fairly high dose (375 mg xr) and with all of these augmentation strategies (ritalin, syntroid, cytomel, lithium), you'd think I would be getting more out of it. It feels like as I had each episode, I increased the dose and added something else to augment, and even tho orignially it did have a fairly good AD effect, it feels like we are augmenting something that isn't carrying its share of the burden. How much more augmenting or dose-raising is there? I am thinking it is time to make a change.
To whomever asked about the maoi--my resistance is because I wouldnt be able to take a decongestant, and even tho I rarely do, I need to if I have a cold, so I can breathe through my nose, which is required to use the CPAP (continuous positive airway pressure) machine that I rely on because of sleep apnea.
Posted by dove on March 4, 2000, at 11:46:13
In reply to Re: What do you know about...., posted by Noa on March 3, 2000, at 6:31:18
Noa, you're in a tough spot. The Effexor is obviously not carrying its share of the weight. You had a bad reaction to the TCAs, which category of TCAs caused the most problems? You have the CNS Stimulant, which isn't helping all that much right now, possibly due to the Effexor wimping out on you. Okay, Wellbutrin doesn't impress me when compared to the TCAs, but does impress me when compared to some of the SSRIs. I don't see any reason not to give it a go, especially in light of the fact that it's considered a stimulating AD.
I have replaced my Wellbutrin with Serzone almost a month ago, and have been really impressed for once in my life. Wellbutrin made my hands shake, as did Prozac, and I felt a little edgy when the Adderall and Wellbutrin overlapped, but it didn't numb my ability to laugh, or be happy like the prozac did. And it slowed me down, which might do the opposite for you, since I seem to be backwards or something. From what I have read, MAOIs can really work where most ADs fail, I find them an interesting option, though the restrictions make me hesitate.
Let us know how you're doing, I hope you get email access back at home soon :-)
dove
Posted by bob (happy to be back chattin' up Noa ;^) on March 4, 2000, at 21:39:37
In reply to Re: What do you know about...., posted by dove on March 4, 2000, at 11:46:13
hey Noa, here's what I tried to post last night, with no success:
--------------------------Noa, if ANYONE is more OVER-medicated than Deb Richard's Mum used to be, it has GOT to be you.
Have you ever thought that so much is happening inside you, chemically speaking, that your body just doesn't know what to do with the stuff? Yeah, I know, that was very scientific and all, but really?
Maybe it *is* time to head back to (a DIFFERENT) Square One.
In terms of meds:
For a primary AD, which TCA did you try? How many other meds were you on at the time? For me, I started nortriptyline to augment zoloft and tho my pdoc and girlfriend (the clinician/analyst-in-training with the encyclopaedic knowledge of psychopharms ... she used to work on one up near Boston) insisted I was wrong on this, I knew that the nortrip was giving me my "main effect" instead of the zoloft when the combo started improving things for me. When I finally convinced them that I needed to drop the big Z and go solo with nortrip as my AD, things improved even more.Yet another case of "Less is More!"
Anyway, given all the stuff you're on, I can see why switching to an MAOI for your primary AD would be a concern ... what of all that stuff would be contraindicated if you made the switch?
What do you think you could wean yourself from wrt the rest of your cocktail? Maybe you should start picking them off, one at a time. Maybe someone out there can compute from a five-way interaction, given known effects of each individual med with the others one at a time, which might be the likeliest candidate to pull. It might look like a house of cards, ready to topple with the slightest breeze, but maybe just the opposite is happening ... maybe you have some neurochemical congestion worse than any sinus congestion you've ever had.
Just tossing that out for consideration.
If the thought of reducing that cocktail is intimidating, let me toss out another weird idea -- alternative medicine. Does your health plan cover it at all? More HMOs are picking up things like acupuncture, acupressure, massage therapy and the like. Maybe something at a 90-degree angle from everything else you've tried can get you through a transition period between meds.
From my recent foray into the literature, if I had to pick one thing to pull, or one place to start, it'd be the synthroid. From what I remember, the evidence of it having any benefit above and beyond what cytomel does for you is nil, and on its own the evidence is mixed.
Oops! Almost forgot this one, from the "With friends like me, who needs enemas?" file ...
Speaking of alternative medicine, how about checking into a good homeopathy book and looking into some procedures for a liver, kidney, and/or colon cleansing? Some purification fasts, perhaps? Clean out the pipes a little, knowhutimean?
Simplify!
bob[as a ps, in case you still haven't gotten my emails to your malfunctioning ISP ... day 3 of Ritalin, and things are looking optimistic.]
Posted by bob on March 4, 2000, at 22:11:16
In reply to Re: What do you know about...., posted by bob (happy to be back chattin' up Noa ;^) on March 4, 2000, at 21:39:37
A number of recent postings made me think of this, but I wanted to put in on your item, Noa. It's from a song by a social worker/folk singer friend of mine:
"Little miracles will build a cornerstone
Next in line to debts of mine
Little miracles are all I own."=^)
bob
Posted by Elizabeth on March 5, 2000, at 7:58:52
In reply to Re: What do you know about...., posted by Noa on March 3, 2000, at 6:31:18
> To whomever asked about the maoi--my resistance is because I wouldnt be able to take a decongestant, and even tho I rarely do, I need to if I have a cold, so I can breathe through my nose, which is required to use the CPAP (continuous positive airway pressure) machine that I rely on because of sleep apnea.
Oh yeah! I'm sorry that had slipped my mind.
As far as decongestants go, I've found the intranasal solutions (oxymetazoline is the usual active ingredient) to be safe. They don't seem to be absorbed systemically so much.
Posted by Elizabeth on March 5, 2000, at 7:59:08
In reply to What do you know about...., posted by Noa on March 2, 2000, at 14:17:51
> Wellbutrin, for instance?
I think I speak for the entire medical and pharmaceutical professions when I say, "not too much." :-) I don't think it's really clear what sort of depressed patients are more likely to respond to Wellbutrin. I do think that, if you're not sure that it caused particularly bad side effects last time you tried it, it's worth another try. BTW, you might try the SR if you used the immediate-release stuff last time.
> At what point do I say the effexor isn't doing it for me. I mean, it has been working, but what is it with these new episodes?
I think you know the answer to that.
> And if these episodes reflect a cycling a la bipolar family, why isn't the lithium helping. I did feel better initially with the lithium, but not anymore.
Take a look at the current issue of Arch Gen Psychiatry. There's some stuff on lithium efficacy there that might be relevant to you.
> So, I wonder if it is time to move on. I never gave Welbutrin a proper trial. It was a few years back, in combo with paxil, and I got diarrhea, which I attributed to the wellbutrin, but it all happened so fast, I realy am not sure.
Noa, I love how you're so grounded and aware. (You may not believe this...just trust me.) What I mean is, realizing you may have misattributed a side effect is an insight I don't see often, but it comes as no surprise from you.
> How do people feel about wellbutrin? Especially for an obviously refractory depression.
Because it has a novel pharmacological mechanism, I would say yes.
> I don't think I want to go with an MAOI, and the only time I took a tricyclic I wigged out bad on a small initial dose. The other SSRIs? I don't know if they offer anything new for me. Does Wellbutrin?
Which tricyclic? (and what exactly is "wigged out?" :-)
Why not an MAOI?
Which of the newer ADs (including SSRIs) have you tried, exactly?
> Is it worth trying? How would one do this--tapering off effexor? I assume it would be ok to overlap at some point.
Tapering off Effexor: very slowly! But you could certainly start Wellbutrin while you're tapering.
Best of luck, Noa.
Posted by Noa on March 6, 2000, at 17:14:23
In reply to MAOIs and decongestants, posted by Elizabeth on March 5, 2000, at 7:58:52
Elizabeth, do you find these decongestants to be effective enough to breathe completely freely through your nose?
Posted by Noa on March 6, 2000, at 17:25:08
In reply to Re: What do you know about...., posted by bob (happy to be back chattin' up Noa ;^) on March 4, 2000, at 21:39:37
Hi, Bob!
Still at the public library. I kind of like this not having internet at home. Let's see how long it lasts.
Anyway, re: your question, the only TCA I ever tried was amytriptiline, which I can never spell correctly, and of course I could just say, Elavil, but there is something about that brand name I dislike. It was the very first AD I ever tried, so I was not on anything else. Elizabeth, I "wigged out", meaning had a severe reaction, in which the following happened simultaneously: I was so hyped up and agitated, almost climbing the walls. The only thing keeping me from actually climbing the walls was the second thing, which was I was extremely sedated, to the point that my speech was slurred, my muscle coordination minimal, I could barely stand up and walk without holding on to the walls. I looked drunk as a skunk, only on the inside I was speeeeeeeeeeding. And this was from just one 25 mg. dose. I think all of this is the anticholinergic effects, because I used to get a very very mild form of the same reaction from benadryl and other antihistamines.
Posted by Noa on March 6, 2000, at 17:34:15
In reply to Re: What do you know about...., posted by JohnL on March 3, 2000, at 1:53:11
Thanks, Sherry, Kelly, JohnL, Chris, SSuggs, Dove, Bob, and Elizabeth.
I will meet with my pdoc on Wednesday, and will discuss this all with him. I think I would like to try the wellbutrin. I don't know if I should keep going with the lithium. It seemed to work initially, but after about 5 or 6 weeks, I started to feel lousy again. I will ask about trying adderall instead of ritalin at some point. And I will keep MAOIs as a possibility if the wellbutrin path proves to be a dead end. I don't know about the serzone, I guess it is helping with sleep enough for now, but I want to reevaluate that, too. And I await more input from you guys on TCAs.
Posted by bob on March 6, 2000, at 20:19:29
In reply to Re: What do you know about...., posted by Noa on March 6, 2000, at 17:34:15
Hey, you know me -- rah rah rah, gimme an N, gimme an O, gimme an R ... almost as big a fan of nortriptyline as I am of klonopin.
Here's an idea to take to your pdoc: if you're going to make a change, what can you do to (a) provide some immediate plus AND (b) move you towards an easy switch to an MAOI? You know, get you off the stuff that is contraindicated with MAOIs, put you on a trajectory where you can head that way without a huge, sudden change in direction?
So, have you found any 24-hour public libraries down your way? Stay outta the cybercafes, no matter what... =^P
cheers,
bob
Posted by Elizabeth on March 6, 2000, at 21:45:28
In reply to Re: MAOIs and decongestants, posted by Noa on March 6, 2000, at 17:14:23
> Elizabeth, do you find these decongestants to be effective enough to breathe completely freely through your nose?
Yes, although supposedly you're more likely to become tolerant to them after a few days than the standard stuff (Sudafed & generics). So I try to limit my use.
If you do try a nasal spray, be sure it's oxymetazoline and not, say, phenylpropanolamine!
Posted by Elizabeth on March 6, 2000, at 21:53:45
In reply to Re: What do you know about...., posted by Noa on March 6, 2000, at 17:25:08
> Anyway, re: your question, the only TCA I ever tried was amytriptiline, which I can never spell correctly, and of course I could just say, Elavil, but there is something about that brand name I dislike.
It's kind of hokey, isn't it?
> It was the very first AD I ever tried, so I was not on anything else. Elizabeth, I "wigged out", meaning had a severe reaction, in which the following happened simultaneously: I was so hyped up and agitated, almost climbing the walls. The only thing keeping me from actually climbing the walls was the second thing, which was I was extremely sedated, to the point that my speech was slurred, my muscle coordination minimal, I could barely stand up and walk without holding on to the walls. I looked drunk as a skunk, only on the inside I was speeeeeeeeeeding. And this was from just one 25 mg. dose. I think all of this is the anticholinergic effects, because I used to get a very very mild form of the same reaction from benadryl and other antihistamines.
Have you thought about trying one of the other TCAs that have less anticholinergic and antihistaminic activity? Desipramine is the one I'm thinking of, specifically; it's very mild in that regard, and most people seem to tolerate it better than the other ones. Amitriptyline probably has the nastiest side effects of them all, overall.
Posted by Noa on March 7, 2000, at 10:28:44
In reply to Re: What do you know about...., posted by Elizabeth on March 6, 2000, at 21:53:45
How do the different TCAs rate in terms of antidepressant effect?
Posted by Noa on March 7, 2000, at 10:29:56
In reply to Re: What do you know about...., posted by Elizabeth on March 6, 2000, at 21:53:45
And POP (poop out potential) Thanks to whoever coined that, I forget who it was.
Posted by Elizabeth on March 7, 2000, at 21:30:59
In reply to Re: What do you know about...., posted by Noa on March 7, 2000, at 10:28:44
> How do the different TCAs rate in terms of antidepressant effect?
YMMV -- none is particularly better than the others, that anyone knows of. (Some of them work better than others for other conditions like panic disorder and OCD, though.)
This is the end of the thread.
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