![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 9 of 9. This is the beginning of the thread.
Posted by Roslynn on September 16, 2022, at 15:11:48
Dear Scott,
Thank you for your replies to my question. I think my depression may be changing a little. I definitely have all those movement/freezing issues that you mentioned as well as the slowness/lethargy. Does this mean my depression is getting worse? Can it change from atypical to endogenous?
I unfortunately can't take lithium anymore due to my kidneys. I'm also hyperthyroid (not hypo) so I have to see a specialist about it. I have just restarted ritalin.
Thank you for all your thoughts and suggestions. I hope you are still doing well.
~Roslynn
Posted by SLS on September 16, 2022, at 21:16:59
In reply to To SLS, posted by Roslynn on September 16, 2022, at 15:11:48
Hi, Roslynn.
It is hard to find the right words to describe a feeling.
> Thank you for your replies to my question. I think my depression may be changing a little. I definitely have all those movement/freezing issues that you mentioned as well as the slowness/lethargy. Does this mean my depression is getting worse? Can it change from atypical to endogenous?There is nothing I have encountered that would give evidence that a switch between atypical and endogenous depression occurs.
Yes, biogenic depression can get worse as the decades pass. I think the quality of depression changes, too. As one ages, depression often produces greater cognitive and memory impairments.
> I unfortunately can't take lithium anymore due to my kidneys.
That's another reason why I think lithium should be taken at low dosages when mania is absent. Adverse effects to kidney and thyroid functions are dosage-dependent. I have been taking lithium at 300 mg/day for probably 10 years or so. My blood tests don't show even a hint of abnormal kidney or thyroid functions in blood tests.
> I'm also hyperthyroid (not hypo) so I have to see a specialist about it. I have just restarted ritalin.
What is the explanation for the elevated thyroid function? Lithium usually lowers it. Is your renal insufficiency irreversible? Did lithium produce any improvement in your depression at all? If so, how would you describe the improvement it gives you?
https://www.webmd.com/depression/melancholic-depression
Melancholic depression seems to be more treatable when using tricyclics + lithium. Also, ECT is probably more effective for melancholic depression than for atypical depression.
Melancholic depression is almost invariably worse in the morning than in the evening, often with early morning awakenings. Feelings of dread or doom occur more often in the morning, and melancholic depression in general. Melancholic depression produces weight-loss. Atypical depression causes weight-gain. Melancholic depression is more often accompanied by body aches and pain.
Is there any family history of bipolar disorder?
> Thank you for all your thoughts and suggestions. I hope you are still doing well.
I am still improved. Thank you for asking.
If a drug treatment is going to bring you to remission, it will likely not be a rapid nor steady improvement. With more severe or long-lasting depression, it can take a year to reach. Also, improvement isn't a nice straight line slanting upwards. It's not even like a staircase. It is a saw-tooth pattern. Two steps up, then one step down.
1. Which tricyclics have you tried? What dosages?
2. Which drugs have you used in combination with tricyclics? What were the dosages of each drug?
3. Have you ever tried an anticonvulsant "mood stabilizer"?
Two other things about melancholic depression, it is more likely to end in suicide. It is mentally very painful - psychic pain. It actually hurts to be conscious.
I wouldn't know if you fit the profile for melancholic depression. If some of this sounds familiar OR your depression results from a bipolar diathesis (root pathology), you might be more apt to respond to a treatment that includes a tricyclic antidepressant. I have bipolar depression wherein manias occur, but only as a reaction to drug treatment. Without drug treatment, I appear as having unipolar depression. (This was my initial diagnosis). Even though the *presentation* of my disorder is that of unipolar depression, the *diatheses* of that depression is actually a bipolar. This is why I asked you about your family history. If any of your first-degree relatives were diagnosed as having bipolar disorder, it might be worth treating your depression as bipolar rather than unipolar. One of my ideas is that the features of bipolar depression looks like a hybrid of melancholic and atypical depressions. However, I think the depression might look more melancholic than atypical. I think Ritalin might be better for melancholic and bipolar depression than for unipolar atypical depression. I wouldn't neglect amphetamine. Consider stimulants as augmenters rather than the core treatment.
- Scott
Posted by Roslynn on September 17, 2022, at 16:08:56
In reply to Re: To SLS » Roslynn, posted by SLS on September 16, 2022, at 21:16:59
>
> There is nothing I have encountered that would give evidence that a switch between atypical and endogenous depression occurs.I am still not sure what type I have because I have always had the oversleeping/overeating pattern.
>
> Yes, biogenic depression can get worse as the decades pass. I think the quality of depression changes, too. As one ages, depression often produces greater cognitive and memory impairments.Yikes!
>
>
> What is the explanation for the elevated thyroid function? Lithium usually lowers it. Is your renal insufficiency irreversible?
They still don't know why my TSH is low. Not sure if my kidney issues are reversible.>Did lithium produce any improvement in your depression at all? If so, how would you describe the improvement it gives you?
>Lithium definitely helped me with overall stability and less dissociation. I have much more anxiety off of the lithium.
>
>
> Melancholic depression produces weight-loss.
I have lost a bit of weight due to loss of appetite/dry mouth.
> Is there any family history of bipolar disorder?Yes, I have a first-degree relative with bipolar.
>>
> 1. Which tricyclics have you tried? What dosages?
>
> 2. Which drugs have you used in combination with tricyclics? What were the dosages of each drug?This would take me several months to put together this info :( Sorry!
>> 3. Have you ever tried an anticonvulsant "mood stabilizer"?
I took lamictal which made me extremely tired. Are there others?
>
>
>Even though the *presentation* of my disorder is that of unipolar depression, the *diatheses* of that depression is actually a bipolar. This is why I asked you about your family history. If any of your first-degree relatives were diagnosed as having bipolar disorder, it might be worth treating your depression as bipolar rather than unipolar.I am already taking latuda and seroquel, would that be treating the depression as bipolar?
Thank you for your time and the information you provided.
Roslynn
Posted by SLS on September 18, 2022, at 20:25:24
In reply to Re: To SLS, posted by Roslynn on September 17, 2022, at 16:08:56
Caplyta (lumateperone) has recently been approved for bipolar type I depression and bipolar type II depression. Its original indication was for schizophrenia. In addition to the 5-HT2a and D2 receptor antagonism that other antipsychotics demonstrate, lumateperone acts as a modulator of glutamate activity. There is some thought that low glutamate activity contributes to depression. The conundrum is always the same. Is low glutamate the cause of depression or is depression the cause of low glutamate.
If it had been available 5 years ago, I would have liked to have tried lumateperone. Latuda (lurasidone) is supposed to be for bipolar depression, too. However, I haven't come across any success stories that lead to remission.
I am curious if you have tried Abilify (aripiprazole).
- Scott
Posted by undopaminergic on September 19, 2022, at 7:48:00
In reply to Re: To SLS » Roslynn, posted by SLS on September 18, 2022, at 20:25:24
> There is some thought that low glutamate activity contributes to depression.
>Or the opposite, given that ketamine works to mitigate depression. Likewise memantine. Both of them block NMDA-subtype glutamate receptors.
It's always possible, and even likely, that glutamatergic neurotransmission is too high and and too low, but in different areas of the brain.
-undopaminergic
Posted by SLS on September 19, 2022, at 11:23:32
In reply to Re: To SLS » SLS, posted by undopaminergic on September 19, 2022, at 7:48:00
> > There is some thought that low glutamate activity contributes to depression.
> >
>
> Or the opposite, given that ketamine works to mitigate depression. Likewise memantine. Both of them block NMDA-subtype glutamate receptors.
>
> It's always possible, and even likely, that glutamatergic neurotransmission is too high and and too low, but in different areas of the brain.
>
> -undopaminergic
>
You only quoted part of my post.This is the whole passage:
"There is some thought that low glutamate activity contributes to depression. The conundrum is always the same. Is low glutamate the cause of depression or is depression the cause of low glutamate."
I guess you missed the second sentence when you quoted the first.
As far as describing the seemingly contradictory associations between glutamate activity and clinical mood state, I don't think there is a consensus to account for it. Your hypothesis is very reasonable. However, there is a trend on the part of researchers towards describing a positive association between glutamate levels and clinical mood state.
Low glutamate activity = Depression
High glutamate activity = ManiaThere are (at least) three types of glutamate receptors.
NMDA receptors
AMPA receptors
Kainate receptorsYour idea of location being important might be explainable by opposite effects among the receptor subtypes.
One very important, but not yet verified by a consensus of researchers, is that the effects of lithium are bimodal. Low dosages of lithium yield an increase in glutamate activity and an improvement of depression. However, low dosages are ineffective to improve or prevent mania. Only the traditional high dosages of lithium decrease glutamate activity and improves mania, and perhaps rapid cycling.
- Scott
Posted by Roslynn on September 19, 2022, at 14:36:34
In reply to Re: To SLS » Roslynn, posted by SLS on September 18, 2022, at 20:25:24
> Caplyta (lumateperone) has recently been approved for bipolar type I depression
>
> If it had been available 5 years ago, I would have liked to have tried lumateperone. Latuda (lurasidone) is supposed to be for bipolar depression, too.
I wish I could take Caplyta but I'm on SSDI/Medicare and it would be super-expensive.
>
> I am curious if you have tried Abilify (aripiprazole).
>
I tried it once but it made me extremely irritable.Thank you for all your suggestions :)
Roslynn
Posted by SLS on September 19, 2022, at 19:35:17
In reply to Re: To SLS, posted by Roslynn on September 19, 2022, at 14:36:34
> > Caplyta (lumateperone) has recently been approved for bipolar type I depression
> >
> > If it had been available 5 years ago, I would have liked to have tried lumateperone. Latuda (lurasidone) is supposed to be for bipolar depression, too.
>
>
> I wish I could take Caplyta but I'm on SSDI/Medicare and it would be super-expensive.
> >
> > I am curious if you have tried Abilify (aripiprazole).
> >
> I tried it once but it made me extremely irritable.
>
> Thank you for all your suggestions :)
>
Okay. One more. Since lithium helps you, I think you should approach your doctor and ask him if you can take 300 mg/day of lithium safely. Kidney effects are dosage-dependent.I have a form of bipolar disorder that looks exactly like unipolar depression in that mania never emerged spontaneously. Mania occurs in me only in association with taking certain medications. There is another type of bipolar depression listed in the DSM-5 wherein mania never occurs. You can think of this mood condition as being a normal bipolar disorder that got "stuck" in the depressive phase.
It turns out that my remission is dependent on a small dosage of lithium (300 mg/day). Attempting to discontinue it caused me to relapse. Trying to increase the dosage to 450 mg/day caused me to relapse as well. The brain can be very finicky.
This is what I'm currently taking:Nardil 90 mg/day
Nortriptyline 150 mg/day
Lamictal 300 mg/day
Lithium 300 mg/day
- Scott
Posted by Roslynn on September 20, 2022, at 14:45:06
In reply to Re: To SLS » Roslynn, posted by SLS on September 19, 2022, at 19:35:17
>
> Okay. One more. Since lithium helps you, I think you should approach your doctor and ask him if you can take 300 mg/day of lithium safely. Kidney effects are dosage-dependent.
>
I wish I could still take lithium but the kidney doctor advised against it.
I am very glad you found a combo that works for you. Thanks for all your thoughts :)Roslynn
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.