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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 10 of 10. This is the beginning of the thread.
Posted by Noa on March 13, 2000, at 17:55:29
Imagine it to the tune of Me and My Shadow.
Those who hate babble ramble and chat, skip to number 2.
Otherwise, begin here:
1. I am going along hour by hour day by day, with most, if not all, of my hope placed ever so doubtingly in the thyroid basket. I am tired, and worn out, but hanging in there, and even trying to face some of the things to be done. Still not fully productive at work, but--how shall I put this?--my nostrils are above water, at least enough of the time. My apartment is once again a mess (Torchgirl, thought you'd like to know about that, and Harry--hey I'm with ya there). I managed to get a tiny bit of laundry done yesterday, enough to have some things to wear to work. It seems like I have a ton of fabric things everywhere--mostly in twisted piles covering my bedroom floor--and they are all dirty or smelly or both. Well, at least I now have a couple of clean things. I have nowhere to put them, by the way, but I have them nonetheless. So, I have been on higher doses of synthroid and cytomel for almost a week, and perhaps my mood is a tad (a microtad?) better, in that I actually made some phone calls to friends over the weekend and actually--get this--made plans with a friend for one evening next week. BUT, I am still exhausted by every little exertion of energy. I am still overwhelmed by the littlest task. Getting out of bed--a major achievement for me at this point. I feel like crying a lot, and I feel lonely, which is actually a sign of improvement, because loneliness indicates an interest in being with someone else.2. Cut to the chase--I am planning to go with the increased thyroid meds (currently at .5 mcg synthroid and .25 mcg cytomel and monitor my TSH, and try to get it down to 1. Then, I'll see how that feels for a while. If it works, I will then reevaluate my other meds. If I still need the other meds, I am still hoping to maybe maybe lower the effexor and serzone a bit, hoping maybe I'll feel a little less medicated.
Indulging my fantasy a bit (I know, I know, it is very unrealistic), let's assume I get to get rid of everything except the two thyroid meds. This is a puzzle for all of you pharmiacs: What sequence would you follow if you were to go off of the following: 1500 mg lithium (split), 375 mg effexor xr, 225 serzone (needed to sleep as long as I am on the effexor), and 20 mg ritalin sr, x2.
Posted by JanetR on March 13, 2000, at 22:41:43
In reply to Me and My Thyroid , posted by Noa on March 13, 2000, at 17:55:29
> Imagine it to the tune of Me and My Shadow.
>
> Those who hate babble ramble and chat, skip to number 2.
>
> Otherwise, begin here:
> 1. I am going along hour by hour day by day, with most, if not all, of my hope placed ever so doubtingly in the thyroid basket. I am tired, and worn out, but hanging in there, and even trying to face some of the things to be done. Still not fully productive at work, but--how shall I put this?--my nostrils are above water, at least enough of the time. My apartment is once again a mess (Torchgirl, thought you'd like to know about that, and Harry--hey I'm with ya there). I managed to get a tiny bit of laundry done yesterday, enough to have some things to wear to work. It seems like I have a ton of fabric things everywhere--mostly in twisted piles covering my bedroom floor--and they are all dirty or smelly or both. Well, at least I now have a couple of clean things. I have nowhere to put them, by the way, but I have them nonetheless. So, I have been on higher doses of synthroid and cytomel for almost a week, and perhaps my mood is a tad (a microtad?) better, in that I actually made some phone calls to friends over the weekend and actually--get this--made plans with a friend for one evening next week. BUT, I am still exhausted by every little exertion of energy. I am still overwhelmed by the littlest task. Getting out of bed--a major achievement for me at this point. I feel like crying a lot, and I feel lonely, which is actually a sign of improvement, because loneliness indicates an interest in being with someone else.
>
> 2. Cut to the chase--I am planning to go with the increased thyroid meds (currently at .5 mcg synthroid and .25 mcg cytomel and monitor my TSH, and try to get it down to 1. Then, I'll see how that feels for a while. If it works, I will then reevaluate my other meds. If I still need the other meds, I am still hoping to maybe maybe lower the effexor and serzone a bit, hoping maybe I'll feel a little less medicated.
>
> Indulging my fantasy a bit (I know, I know, it is very unrealistic), let's assume I get to get rid of everything except the two thyroid meds. This is a puzzle for all of you pharmiacs: What sequence would you follow if you were to go off of the following: 1500 mg lithium (split), 375 mg effexor xr, 225 serzone (needed to sleep as long as I am on the effexor), and 20 mg ritalin sr, x2.Dear Noa, I hope you don't mind me asking but you sound so depressed on all this medication , what were you like before you started taking it? I can't help with the order of withdrawal but I sincerely hope that you get better. My thoughts are with you . Jan
Posted by torchgrl on March 15, 2000, at 0:01:45
In reply to Me and My Thyroid , posted by Noa on March 13, 2000, at 17:55:29
Hey Noa,
Haven't been around much of late, but just dropped in today... My place is a complete disaster as well, if it makes you feel remotely better to have company. I thought I was making headway at one point, but chaos-theory reigns! I won't even go into the kitchen anymore... My mood is better (better than when on any of the meds I've been on in the past 8 months or so, and I'm not on anything right now), but my energy is zilch. If I had insurance, I might be looking into the thyroid thing myself, but it's all just become too annoying/draining to cope with when I have to deal with the ramifications of not having insurance. So I'm trying not to think about it right now. Good luck with paring down on the meds--I wish I could think of a good suggestion to start with. Maybe the Effexor, since it seems to be stimulating (like Ritalin) as well as acting as an AD (like Serzone), but that's just an intuitive guess--I'm sure you'll get a more educated, less guess response!
Posted by bob on March 15, 2000, at 21:37:11
In reply to Re: Me and My Thyroid , posted by torchgrl on March 15, 2000, at 0:01:45
my two cents ...
You're on one helluva lot of lithium. Especially if you're unipolar (thoughts of bipolar were just ruminations, weren't they? or was that confirmed?).
Seems like starting to cut back should begin with augmentors. Seems like a lot of people (including yours truly) have been crowing a bit about stims. Besides, cutting back on the lithium may give you more time between bathroom breaks -- that ought to be uplifting in and of itself.
hang in there, kiddo
bob
Posted by Cam W. on March 15, 2000, at 22:18:49
In reply to Me and My Thyroid , posted by Noa on March 13, 2000, at 17:55:29
Noa - I am really not positive how to lower these. I guess you would start with a slow taper of the antidepressants over a month period with a goal of around 223mg Effexor XR and around 150mg Serzone. Monitor your status and lower slowly every 4-5 days. Have frequent (weekly?) Lithium levels done and adjust accordingly, if necessary. If after the month you are feeling reasonably well, maybe drop the Ritalin SR to 20mg daily, if possible. Still monitor lithium (requirements may or may not drop). If euthymic at this point, you can start all over again with the lower of the antidepressants to half of their new dosages. Really Noa, I am not sure how this will work. Bounce this regimen off of your doctor and see what he thinks. I am not comfortable with doing this unless you are under close supervision. I'd hate to see you decompensate, which could happen when one makes drastic changes like this. I'm sorry, I'm not being much help, but I get nervous when wholesale changes of meds are done on an outpatient basis. You know your body, do what you feel comfortable doing and have someone monitor (or keep an eye on you) on a daily basis to watch for changes in your outward presentation that you may miss. Hopefully John or Scott or one of the other good "clinicians" in this room can critique my comments. I hope you will keep your doctor involved in this process, if you do indeed decide to proceed. Thinking of ya - Cam W.
Posted by JohnL on March 16, 2000, at 2:44:07
In reply to Me and My Thyroid , posted by Noa on March 13, 2000, at 17:55:29
I agree totally with Cam. When combinations work it is terrific. But when they don't it becomes more complicated to make wholesale changes. I think a good place to start is to face the fact that you are still meeting qualifications for major depression. A different approach in medication is warranted.
In your shoes I would drop dosage of all the meds, except in varying degrees with each. I would drop the Lithium to 1200mg and keep it there. I would drop the Effexor in small steps every four days or so. I would drop the Serzone too, but a little less so than the Effexor. If nothing else, you want to retain a good night's sleep through it all.
You might get lucky and find you feel a lot better at a lower dosage schedule. More is not always better.
I would also consider trying a med from a class not yet tried. A top choice would be an antipsychotic. There could very well be a dopamine component in the apathy, and these will address that. Zyprexa is good for sleep. Stelazine for some alterness (this is similar to Amisulpride). Risperdal is somewhere inbetween. I mention this simply because other med classes have been disappointing. It is definitely worth exploring other chemistries at this stage of the game. Usually when an AP is going to work, it is obvious in days. They typically don't require the long wait of antidepressants. If it is to work you'll know without a doubt within two weeks.
Another great choice would be Desipramine or Nortriptyline. There is a test that is sometimes predictive....a positive effect of Ritalin on mood predicts a good response to Desipramine....the absence of a good effect of Ritalin on mood predicts a good response to Nortriptyline. In either case, I think one of these tricyclics should be tried and compared.
In your shoes I wouldn't wait to be totally off the other drugs before adding in a new one. If the antipsychotic is to work, you'll know. Then continue the taper down process while allowing the AP to take the wheel. Same with a tricyclic. There's no easy way here, but these are things I would do myself. I am not suggesting these things directly, but sharing with you what I would do myself in the same situation. I would look at unexplored drug classes. And I would definitely take the ones that aren't getting me better out of the program. They're obviously targeting the wrong chemistry. They aren't the molecules our chemistry agrees with. JohnL
Posted by Chris A. on March 16, 2000, at 18:31:56
In reply to Me and My Thyroid , posted by Noa on March 13, 2000, at 17:55:29
Noa,
Forgive my lousy memory, but I hope you have a top notch pDoc helping you make one med change at a time. Personally I have always been chomping at the bit to make the changes too fast to determine cause/effect. I need the steadying influence of my pDoc who makes one change at a time and does not have one impulsive bone in his body. He has been open to my suggestions, but not so open as to jeopordize my well being.
Remember - one step at a time! Hope you get to feeling better.Chris A.
Posted by bob on March 16, 2000, at 18:39:59
In reply to Re: Me and My Thyroid , posted by JohnL on March 16, 2000, at 2:44:07
> Another great choice would be Desipramine or Nortriptyline. There is a test that is sometimes predictive....a positive effect of Ritalin on mood predicts a good response to Desipramine....the absence of a good effect of Ritalin on mood predicts a good response to Nortriptyline. In either case, I think one of these tricyclics should be tried and compared.
Is this documented anywhere? Just curious, because I've had a pretty good response to nortriptyline (cf. to SSRIs) and in just starting on Ritalin, I've had a very promising response to it as well. Is this "test" sound enough to suggest that I might have a better response to desipramine?
(sorry for butting in on you and your thyroid, Noa ... but you know what a pain in the neck I can be =^P)
Bob
Posted by JohnL on March 17, 2000, at 3:27:05
In reply to Re: Me and My Thyroid -- aside to JohnL, posted by bob on March 16, 2000, at 18:39:59
> > Another great choice would be Desipramine or Nortriptyline. There is a test that is sometimes predictive....a positive effect of Ritalin on mood predicts a good response to Desipramine....the absence of a good effect of Ritalin on mood predicts a good response to Nortriptyline. In either case, I think one of these tricyclics should be tried and compared.
>
> Is this documented anywhere? Just curious, because I've had a pretty good response to nortriptyline (cf. to SSRIs) and in just starting on Ritalin, I've had a very promising response to it as well. Is this "test" sound enough to suggest that I might have a better response to desipramine?
>
> (sorry for butting in on you and your thyroid, Noa ... but you know what a pain in the neck I can be =^P)
>
> Bobvv
Am J Psychiatry 1983 Feb;140(2):212-4
The methylphenidate test for differentiating
desipramine-responsive from nortriptyline-responsive
depression.Sabelli HC, Fawcett J, Javaid JI, Bagri S
Monitoring tricyclic antidepressant concentrations in the plasma of 43 patients with major
depressive disorders indicated that some responded to imipramine or desipramine but not to
amitriptyline or nortriptyline, or vice versa, even though plasma levels were within therapeutic
ranges. Mood elevation by methylphenidate predicted marked improvement from treatment
with imipramine or desipramine but not with amitriptyline or nortriptyline. When
methylphenidate failed to improve mood, patients responded to amitriptyline or nortriptyline
but not to desipramine. These results suggest differential drug responses with different
tricyclic antidepressants, the clinical utility of the methylphenidate test, and the heterogeneity
of depressions. The authors question the mechanism of action of nortriptyline via blockade of
norepinephrine reuptake.
Posted by Scott L. Schofield on March 17, 2000, at 20:37:15
In reply to Re: Me and My Thyroid , posted by JohnL on March 16, 2000, at 2:44:07
> I agree totally with Cam. When combinations work it is terrific. But when they don't it becomes more complicated to make wholesale changes. I think a good place to start is to face the fact that you are still meeting qualifications for major depression. A different approach in medication is warranted.
>
> In your shoes I would drop dosage of all the meds, except in varying degrees with each. I would drop the Lithium to 1200mg and keep it there. I would drop the Effexor in small steps every four days or so. I would drop the Serzone too, but a little less so than the Effexor. If nothing else, you want to retain a good night's sleep through it all.
>
> You might get lucky and find you feel a lot better at a lower dosage schedule. More is not always better.
>
> I would also consider trying a med from a class not yet tried. A top choice would be an antipsychotic. There could very well be a dopamine component in the apathy, and these will address that. Zyprexa is good for sleep. Stelazine for some alterness (this is similar to Amisulpride). Risperdal is somewhere inbetween. I mention this simply because other med classes have been disappointing. It is definitely worth exploring other chemistries at this stage of the game. Usually when an AP is going to work, it is obvious in days. They typically don't require the long wait of antidepressants. If it is to work you'll know without a doubt within two weeks.
>
> Another great choice would be Desipramine or Nortriptyline. There is a test that is sometimes predictive....a positive effect of Ritalin on mood predicts a good response to Desipramine....the absence of a good effect of Ritalin on mood predicts a good response to Nortriptyline. In either case, I think one of these tricyclics should be tried and compared.
>
> In your shoes I wouldn't wait to be totally off the other drugs before adding in a new one. If the antipsychotic is to work, you'll know. Then continue the taper down process while allowing the AP to take the wheel. Same with a tricyclic. There's no easy way here, but these are things I would do myself. I am not suggesting these things directly, but sharing with you what I would do myself in the same situation. I would look at unexplored drug classes. And I would definitely take the ones that aren't getting me better out of the program. They're obviously targeting the wrong chemistry. They aren't the molecules our chemistry agrees with. JohnL
This is wonderful.
- Scott
This is the end of the thread.
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