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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 11 of 11. This is the beginning of the thread.
Posted by Noa on April 22, 2000, at 15:09:55
I am trying to figure what to do next with my med cocktail.
Currently on: 375 effexor xr; synthroid; cytomel; 20 mg ritalin SR, twice daily; and serzone 225 in the the evening.
Serzone does two things: augments the effexor and helps me sleep.
However, all of this is not doing enough, as some of you know, as I have had some very bad months of late.
I tried lithium, but had problems (see above posts) and recently went off.I think my thyroid meds are at where they should be, and will be seeing an endocrinologist next week.
I would like to lower my effexor dose at some point because it causes restless legs at night, and seems to be causing some bladder problems.
I have always thought the serzone was very mediocre in its antidepressant effects, but is doing a pretty good job of countering the jitteriness of the effexor, and helps with sleep. While on lithium, the serzone was faster acting and very very sedating. Now, it has returned to being much slower acting (unlike trazodone, by the way, which made me groggy w/in an hour), so I need to take it earlier. I had thought I wouldn't be able to tolerate a daytime dose of serzone because of the sedation, but now I see that I probably could, without the lithium, of course.
So, I am wondering if I should try raising the serzone and lowering the effexor as my first step in adjusting my cocktail.
Anyone on serzone and effexor care to comment?
Anyone on serzone primarily care to comment?
Posted by Cindy W on April 22, 2000, at 21:10:04
In reply to Serzone--have I overlooked its potential?, posted by Noa on April 22, 2000, at 15:09:55
> I am trying to figure what to do next with my med cocktail.
>
> Currently on: 375 effexor xr; synthroid; cytomel; 20 mg ritalin SR, twice daily; and serzone 225 in the the evening.
>
> Serzone does two things: augments the effexor and helps me sleep.
>
> However, all of this is not doing enough, as some of you know, as I have had some very bad months of late.
>
>
> I tried lithium, but had problems (see above posts) and recently went off.
>
> I think my thyroid meds are at where they should be, and will be seeing an endocrinologist next week.
>
> I would like to lower my effexor dose at some point because it causes restless legs at night, and seems to be causing some bladder problems.
>
> I have always thought the serzone was very mediocre in its antidepressant effects, but is doing a pretty good job of countering the jitteriness of the effexor, and helps with sleep. While on lithium, the serzone was faster acting and very very sedating. Now, it has returned to being much slower acting (unlike trazodone, by the way, which made me groggy w/in an hour), so I need to take it earlier. I had thought I wouldn't be able to tolerate a daytime dose of serzone because of the sedation, but now I see that I probably could, without the lithium, of course.
>
> So, I am wondering if I should try raising the serzone and lowering the effexor as my first step in adjusting my cocktail.
>
> Anyone on serzone and effexor care to comment?
>
> Anyone on serzone primarily care to comment?Noa, I tried Serzone alone, for a while, and found it very helpful with depression and in reducing anxiety, and I slept MUCH better. But I stopped it because it didn't touch the OCD. Now am taking Effexor-XR 375 mg/day and wish I could add back some of the Serzone because I still have trouble sleeping. Hang in there! You're always there for us and I hope you're on the right med cocktail soon!
Posted by JohnL on April 23, 2000, at 4:01:57
In reply to Serzone--have I overlooked its potential?, posted by Noa on April 22, 2000, at 15:09:55
Noa,
Since you have been on both of these meds for quite a while, I question either of them as being appropriate for your chemistry. They may be helping somewhat, but are obviously missing the mark. Any benefit they are giving you is probably through a trickle down process that is not directly targeting the proper chemistry.Trying new replacement drugs at this point though would be a huge project, requiring a difficult and time-consuming weaning of these two drugs which both will cause considerable discomfort when discontinuing. With that in mind, I think tweeking the doses as you have suggested is wiser than complete switches. Increasing the Serzone dose makes sense to me as being a worthy option. The primary drawback is it will take some time to evaluate response. But again, I must admit I am skeptical of the current meds in the cocktail. If they were the correct ones for your chemistry, you would have experienced considerably more success by now.
Following your posts from months ago, I would think comparing all the stimulants and comparing antipsychotics--leaving the Effexor and Serzone right where they are for now--would be the way to go. Temporarily stop the Ritalin. Replace it with Adderall for one week. Then try Cylert for a week. Then Tenuate for a week. Ionamin for a week. Then choose your favorite to continue. You may find one of them works on your chemistry much better than Ritalin. Since they are so fast-acting, no long trials are needed. I get the gut instinct that norepinephrine stimulation (not just reuptake inhibition) may work well with you. I mention this strategy because I think it would be easier and much faster than adjusting doses of the other meds. Those adjustments will take time to evaluate. And again, I'm skeptical of them anyway. I think it makes sense to look elsewhere.
And if you haven't tried the antipsychotics, it would be helpful to compare a few. You might be surprised at the unexpected good result potential. Risperdal, Stelazine, and Zyprexa would be my top choices. And as with the sitmulants, you should know inside a week how they are working. Two weeks each would definitely give a clearer picture. But overall, results would be easy to judge in a short amount of time.
The hard part is trying to get the physician to cooperate. They are so entrenched in long drawn out suffering trials that they fail to see the simple logic of comparing different meds quickly in an effort to isolate superior matches which are then given longer trials.
You'll know a superior match when you stumble onto it. There will be no doubt. You'll know it inside a week. And it will be dramatic. I think it's worth exploring. I think it makes more sense than tweeking doses of Effexor or Serzone, which have not exactly been star performers in more-than-adequate time trials. So--it's just my nonprofessional opinion--but I would suggest the consideration of sampling all the available stimulants and several antipsychotics at this point. We're looking for a superior match, which will be known quickly. I just don't think there will be any magic found in tweeking doses of current meds. Just my thoughts. I hope it helps stimulate some ideas. I would LOVE to see you feeling better. I just don't think either Effexor or Serzone have the potential to accomplish what you want, given your unique chemistry based on clues provided by responses thus far. JohnL
Posted by ChrisK on April 23, 2000, at 6:56:54
In reply to Re: Serzone--have I overlooked its potential?, posted by JohnL on April 23, 2000, at 4:01:57
Noa,
I haven't followed the Whys and Wherefor's of your meds but it does sound like you may be leaving out the option of anti-psychotics as Ad enhancers. I know that I was personally helped by Zyprexa even though I didn't react to Risperdol. (Unfortunately) I have been hospitalized four times and have seen many patients helped by the AP's. It's certainly worth a try. My own cocktail is currently wavering between 4 or 5 meds depending on whether I take my Wellbutrin and Adderall. There isn't anything wrong with finding the "reight" meds for you.
Hope you get through this.
Chris
Posted by Scott L. Schofield on April 23, 2000, at 11:27:36
In reply to Re: Serzone--have I overlooked its potential?, posted by ChrisK on April 23, 2000, at 6:56:54
Noa - Adding mirtazapine (Remeron) to nefazodone (Serzone) is supposed to be a very effective combination. I imagine the Remeron would also help with sleep.
Can the addition of thyroid hormone interfere with sleep?
Cindy - It makes a great deal of sense to combine Serzone with an SSRI. Doing so is a well recognized strategy to treat any residual OCD symptoms that Serzone has missed. Note that in the excerpt below, it is suggested that Serzone be started first, and the SSRI added afterwards. Although two SSRIs are suggested because they tend to interact less with Serzone metabolically, neither may be the one drug that your OCD symptoms will respond to best. If you have already had success with a particular SSRI, it might make sense to try that one first. If you decide on one, post a question to Cam W for his input on how the two drugs interact pharmacokinetically (how the two drugs affect each other's levels in the blood and/or tissues). If he is unavailable, your pharmacist should be able to find out for you. Many such combinations are managed without too much difficulty.
- Scott---------------------------------------------
Excerpts from:
Combining Antidepressants Can Boost Efficacy
Carl Sherman, Contributing Writer
[Clinical Psychiatry News 27(4):20, 1999. © 1999 International Medical News Group.]This article was a summary of a lecture given by Dr. Lauren Marangell. She is a research clinician at New York University.
* Noa - When Dr Marangell was working at the NIMH, she had begun a project in 1993 studying thyroid function in mood-disorders, which included intrathecal TRH challenges. I never looked into what her group came up with.
...Nefazodone is a rational addition to venlafaxine because there is no pharmacokinetic interaction, and it appears to improve sleep and sexual function. Anecdotal reports suggest that mirtazapine can achieve "fantastic results" when combined with venlafaxine, she said.
...
When nefazodone -- a weak serotonin and norepinephrine reuptake inhibitor that blocks 5-HT2 receptors -- is the first drug, an added SSRI is often helpful for residual depressive and obsessive symptoms. This sequence is better tolerated than the reverse order, which promotes the buildup of a nefazodone metabolite (mCPP) that can provoke anxiety, Dr. Marangell said.
Citalopram or low-dose sertraline have the least pharmacokinetic interaction with nefazodone, she said.
---------------------------------------------
Posted by Scott L. Schofield on April 23, 2000, at 22:11:59
In reply to Re: Serzone--have I overlooked its potential?, posted by Scott L. Schofield on April 23, 2000, at 11:27:36
Sorry. I must be getting old in my old age.
I mentioned Remeron specifically because you were already taking Effexor.
Please see the corrected text below. It is amplified by the excerpt cited in the previous post.
Noa - Adding mirtazapine (Remeron) to venlafaxine (Effexor) is supposed to be a very effective combination. I imagine the Remeron would also help with sleep.
- Scott
Posted by saint james on April 25, 2000, at 15:07:51
In reply to Re: Serzone-- Sorry Noa, posted by Scott L. Schofield on April 23, 2000, at 22:11:59
>
> Noa - Adding mirtazapine (Remeron) to venlafaxine (Effexor) is supposed to be a very effective combination. I imagine the Remeron would also help with sleep.
>
>
> - ScottJames here...
I agree. I have been on Effexor + Remeron since Remeron came out 2-3 yrs ago. Very effective. It is called a "big gun" in some of the lituature. This combo, in theory, should cover all the bases
as Remeron targets 5HT sites that Effexor dose not. I take 150-300 mgs Effexor XR and 15 mgs Remeron. If I have another breakthru depression my plan is to raise the Remeron to 30mgs.james
Posted by Noa on April 25, 2000, at 18:26:30
In reply to Re: Serzone-- Sorry Noa, posted by saint james on April 25, 2000, at 15:07:51
Hey, John, what's your opinion on trying another stimulant? ;^)
Thanks for the input, everyone. I am still feeling unsure of my next step about the effexor, etc. but I think I will try adderall for a week or two and see if it feels different than the ritalin. I still don't anticipate that this will get at the heart of the matter, because the bulk of my med cocktail is still at issue. In the meantime, I really do want to try to see what it would be like to lower the effexor and raise the serzone, before eliminating any of the big meds or starting a whole new one, because those would be major projects, unlike the stimulants, which, as John so determinedly told us, are a relative snap to substitute and give a brief trial to.
As for the possibility of Remeron, well, that was one of the primary options recommended by the "new" doc I consulted. My concern about it is increased appetite and weight gain. I am already at a very unhealthy size and weight, having put on about 80 pounds in the past few years.
I have to admit how uneducated I am about all the specific neurotransmitters and the specific actions of the different psych meds. I have a basic understanding but not enough to address the question bob asked about figuring out which ones I want to target. I know this: too much serotonin is more than I can handle. I get edgy and fidgety and twitchy and have sleep problems. This is part of the problem with the effexor, I think. But I don't know if this problem is related to a specific receptor target, or just about having too much serotonin in my system altogether. It was a problem with Paxil, as well. My "old" pdoc, which I still am not sure about staying with him or firing him (an article I read today in the Post used the term "divorcing" to describe the phenomenon of leaving your doctor) says he thinks I need meds to address all three--serotonin, norepinephrine, and dopamine, and my current cocktail supposedly does this. Beyond this, I am ignorant.
Posted by Scott L. Schofield on April 26, 2000, at 16:13:16
In reply to Re: Serzone-- Sorry Noa, posted by Noa on April 25, 2000, at 18:26:30
Hi Noa.
I thought I might add one more suggestion that I feel is worth consideration.You may want to take advantage of this opportunity to add Wellbutrin to the Effexor while you are still taking it, unless you have already tried this combination or have had a bad experience with Wellbutrin. I have seen several cases in which this combination has produced a robust antidepressant response when neither drug by itself was sufficiently effective. This has been particularly true for those people who have previously experienced a partial response to both drugs when taken individually.
Possible benefits of this combination:
1. It might work.
2. Adding Wellbutrin may be activating and counteract any Effexor-induced sedation or fatigue.
3. Wellbutrin may counteract any Effexor-induced sexual side effects.
4. Wellbutrin may counteract any tendency towards weight-gain by exerting an anorectic effect.Will Wellbutrin cause or exacerbate sleep-disturbance? It might. If the combination works, such a side effect can probably be dealt with, and may well be worth the effort. If sleep-disturbance is a symptom of the depression itself, it may actually resolve upon remission.
I am still very interested to know if the administration of thyroid hormones can cause insomnia or other sleep-disturbances.
Thanks.
One additional comment: Learning about receptors is pretty neat, but I don't know of anyone who has yet been able to outwit trial and error. Clinical experience with different drugs along with an understanding of their properties can yield some pretty good guesses, but an empirical approach is still necessary. Even the algorithms of Dr. Jensen as described by JohnL are purely empirical. Why any one drug or drug combination works is, at best, conjecture. I try not to exclude any drug based upon the properties it is currently thought to possess.
JohnL - I think Dr. Jensen's approach is great. I find your caveat regarding his short trial periods for antidepressants (as opposed to such things as stimulants, lithium, hormones or neuroleptics) is appropriate when treating unipolar depression. I have profited greatly from your contributes and may end up getting well because of them. Thanks.
- Scott
Posted by Noa on April 27, 2000, at 16:39:44
In reply to Re: Serzone-- Sorry Noa, posted by Scott L. Schofield on April 26, 2000, at 16:13:16
Thanks, Scott. I did try that combo and it caused tinnitus. Also, for me Effexor is anything but sedating, it is very very activating for me, and causes insomnia.
I guess you are right about the trial and error thing. That seems to be the main methodology in psychopharm, whether via the fast track, a la Jensen, or via the standard track.
Posted by Noa on April 27, 2000, at 16:41:36
In reply to Re: Serzone-- Sorry Noa--Thanks, Scott, posted by Noa on April 27, 2000, at 16:39:44
> That seems to be the main methodology in psychopharm----CLINICAL psychopharm, that is. I would hope the researchers are not relying as much on trial and error!
This is the end of the thread.
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