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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 7 of 7. This is the beginning of the thread.
Posted by Londonboy on May 14, 2008, at 4:32:34
Hello everyone, I'm new to this board and have a few questions that I hope people may be able to give me some insight into...
I am now 29 and have suffered episodes of depression since my early twenties which have been treated by various SSRIs and Effexor. From these drugs I have experienced poopout, sexual dysfunction, hypomania (mainly from paroxetine), lack of effectiveness and emotional flattening, and as a result have tended to come off them frequently, only for another depressive episode to kick in later, again requiring treatment.
As a child (aged 8/9 onwards) I suffered panic attacks, tended towards disruptive behaviour and social withdrawal, and my overriding memories of childhood are ones of exclusion and a feeling of inadequacy. My teens were characterised by academic under achievement, school expulsions due to absence and disruptive behaviour, drug use (but not dependency) and nicotine dependency which, despite several earnest attempts, I still have not shaken off.
In my adult life I have been through a series of jobs, almost all of which I have done well in up to a point at which things fall apart emotionally and I quit.
In February I had another major episode after coming off paroxetine at the end of last year. During January I was rather manic, working long days and accomplishing quite a lot in my life that needed doing (more of that later), but by February I hit rock bottom again.
I saw my (new) Pdoc in March and he started me on Cymbalta (duloxetine) 60mg which, within a week, had me up and doing again. We were both rather surprised by its rapid onset.
My Pdoc has diagnosed me with a "biological tendency towards depression" as opposed to suffering from reactive episodes, and I think he is probably correct in this - in light of this, he has also prescribed me Depakote 500mg which I have been taking for the last few days. I am told not to expect much in the way of noticeable effects, but that he will maintain me on this indefinitely and in a couple of months taper me off the Cymbalta.
All well and good, except I think I suffer a further problem which we may have missed up to now....
From reading , I have learned that although AD(H)D is now diagnosed frequently in children (possibly over diagnosed), many adults suffering from the condition may be misdiagnosed with other conditions such as bipolar disorder (biological depression?). Indeed, after taking this quiz - http://psychcentral.com/addquiz.htm - I get "moderate adult ADD" as the result. In almost all my reading on the subject, the symptoms of adult ADD seem to fit better than other symptom lists.
One further event may prove enlightening: Last year I was prescribed bupropion (Wellbutrin) for smoking cessation. I was already taking sertraline for depression, and my doc was happy to prescribe the bupropion on top after reading that it is sometimes used as an SSRI adjunct in the USA.
During that time, I noticed that my drive was superb - I was consistently able to focus on tasks better than I'd ever been able to before, my productivity was superb with no distractedness and full completion. I felt like a "whole person" for the first time in my life. Sadly, in the UK, bupropion is only licensed for smoking cessation, and not for depression, so after 3 months, I had to come off it.
Now, here's the thing. I mentioned that I had a productive (possibly hypomanic) January. Well, in that time I somehow managed to get myself a place at a very prestigious university to read psychology as a mature student.
Obviously this is a HUGE opportunity for me, and I am very excited, but my excitement is tempered by my self-knowledge. I must, over a three year period, apply myself to the course, much of which I know will be dull and routine. If I could get myself back in that place I was at last year, I know I would have no problems, but as things stand, I am very worried about returning to the miserable days of my teens with uncompleted assignments and mounting stress levels.
So, I would be very grateful if anyone has any observations, in particular about my current medication and if there is anything I might try beyond what I have already had. I am seeing my Pdoc next week and would love to have some ideas to discus with him.
Thanks in advance!
Posted by undopaminergic on May 16, 2008, at 7:32:29
In reply to In need of answers! ADD/Bipolar/MDD?, posted by Londonboy on May 14, 2008, at 4:32:34
It's quite likely that you have a degree of ADD/ADHD, but that doesn't account for your depressive-hypomanic symptoms, so it's probable that you also have bipolar II or unipolar depression, if the hypomanic episodes were always drug-induced as opposed to spontaneous.
The most effective drugs for ADHD are the stimulants, of which at least methylphenidate (Ritalin, Concerta), dextroamphetamine (Dexedrine) and modafinil (Provigil) are available in the UK.
Selegiline is also of some use in ADHD, and in conjunction with phenyalalanine or phenylethylamine, it is also effective in depression.
Posted by Londonboy on May 16, 2008, at 11:27:33
In reply to Re: In need of answers! ADD/Bipolar/MDD?, posted by undopaminergic on May 16, 2008, at 7:32:29
Hi Undopaminergic,
Interesting points, thank you.
A couple of questions,
Firstly, what sort of dosage would you be talking about with Selegiline and PEA? Would I be suitable for the EMSAM patch (if available in the UK)?
Secondly, I read that stimulants are often used as an adjunct to other meds in cases of depression. Would this apply to Cymbalta, or does the NRI aspect preclude this due to the action on the circulatory system?
Thirdly, what are your thoughts on Wellbutrin. Do you think this could be an avenue worth pursuing if my Pdoc were to prescribe off-label?
By the way, my hypomanic symptoms were never present in the levels at which they occurred when taking SSRIs/coming off them, although I certainly did have days when my mind would race prior to my medication days.
Many thanks again.
Posted by garylee on May 16, 2008, at 16:54:45
In reply to In need of answers! ADD/Bipolar/MDD?, posted by Londonboy on May 14, 2008, at 4:32:34
Londonboy
Wow, your life seems a doppelganger of mine! Except you are a year older than me...
The very fact you become hypomanic after taking antidepressants, particularly SSRI's pretty much say you are Bipolar, probably type II or NOS as you haven't had any psychotic/manic episodes.
As a Bipolar, STAY AWAY FROM ANTIDEPRESSANTS! Search on Google, there is lots of evidence for this. I'd recommend that you look into 'Mood Stabilizers' I highly recommend Lamictal as a general mood stabilizer (work up to around 200mg a day), Sulpiride for any anxiety and social phobia (also helps as a mild antidepressant) and if you have trouble with sleep, Seroquel 25mg - 50mg and around 0.5mg - 1mg of Clonazepam, it's a very good sleep combo.
Also if you have been a substance abuser in the past or even the present, I'd say you probably feel 'normal' on them? If you don't mind me asking, what was/is you drug of choice? Mine's always been MDMA (but serotonin drugs are a no no) and especially Cocaine. Anything Dopamine has a great effect on me and I have done some of my best work whilst being 'high'. Therefore Dopaminergics such as Pramipexole and Ropinerole are a good choice. Pramipexole almost brought me into remission, I'd say around a 70% improvement all round. Though I came off it to try another one and it didn't work second time round, so IF you did try it and it worked, DON'T come off it!
I am also trying opiates right now, Tramadol to be precise and I feel ever so slightly hypo, which I like as things get done and I feel good, hence this long reply, lol. Omega fish oils in high does are also a must...
Anyway, I'll leave it that for now... Feel free to ask more questions. Always like to help! :O)
Gary
P.S. I started an Architecture course last September but dropped out due to this f**king disease. Have to plod on though.
Posted by Londonboy on May 17, 2008, at 9:57:39
In reply to Re: In need of answers! ADD/Bipolar/MDD?, posted by garylee on May 16, 2008, at 16:54:45
Hi Gary and thanks for your reply!
You've certainly been through quite a journey in terms of working out which meds are effective for your condition. You must have a very experimental Pdoc!
In terms of my prior drug use, I've found that the stimulating drugs such as cocaine and amphetamine have always produced the best, "normalising" response. MDMA was never a favourite, purely due to the after effects - left me feeling practically suicidal with anxious depression.
I have just started taking depakote in addition to the Cymbalta, which is just kicking in now after a month - it does feel as if the depakote is holding back the hypomania somehow.
Did you have any thoughts on the ADD type symptoms? I think I will ask my Pdoc on Monday about trying out a stimulant of some description.
Thanks for all your info, it has certainly given me some more talking points! I'll be sure to let you know what he says.
Sorry to hear about the architecture course. Have you decided what you are going to do now?
LondonBoy
Posted by Londonboy on May 19, 2008, at 15:40:01
In reply to Re: In need of answers! ADD/Bipolar/MDD?, posted by Londonboy on May 17, 2008, at 9:57:39
....And no stimulants for me right now! However we did talk about ADD, and he seemed to agree that I have some level of attention deficit.
So, for now he wants me to stabilise on the Cymbalta at which point he will review the meds and we will think about bupropion or stimulant medication for when I start university.
He seemed quite reticent about stimulants saying that they are only recommended for the under 20s as they can result in addiction in adults.
I had thought that the therapeutic doses were too low to reach the addictive potential?
Posted by undopaminergic on May 21, 2008, at 6:03:48
In reply to Just got back from Pdoc......., posted by Londonboy on May 19, 2008, at 15:40:01
>
> He seemed quite reticent about stimulants saying that they are only recommended for the under 20s as they can result in addiction in adults.
>
> I had thought that the therapeutic doses were too low to reach the addictive potential?
>No, especially in the case of methylphenidate, it may be necessary to use very high doses. I often use up to 216 mg in a 24 hour period (followed by prolonged sleep). However, a prerequisite for becoming addicted is to experience some kind of euphoric high, and I've never come close to that.
It isn't true that stimulants are less addictive in younger people. It really depends on whether one gets high on them, and there are many teenagers who abuse cocaine, which is very similar in its pharmacological effects to methylphenidate.
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