![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 26 to 50 of 133. Go back in thread:
Posted by phillybob on March 10, 2001, at 19:33:04
In reply to Re: treatment resistant depression » phillybob, posted by sweetmarie on March 10, 2001, at 17:40:48
Anna, sounds like a plan. Also, click on this link to another thread I posted in today for some good lamictal links in addition to the Dr. Ivan Goldberg one I posted earlier in this very thread (click on the one by the doctor as he has familiarity with lamictal):
http://www.dr-bob.org/babble/20010310/msgs/56133.html
Your sister should be able to find out what's up, though. The information is out there. It does sound better that the rash has not gotten worse since you started ... but, again, with the increase in dosage now, you should really have it monitored by someone (somehow!?) who knows what they are looking at it.
[I'm a big Wilco fan, particularly Jeff Tweedy, the lead singer, who's recently done some great solo shows ... I liken him to a future Bob Dylan ... he even sings a song about Bob Dylan's beard. :) ]
Posted by sweetmarie on March 11, 2001, at 6:18:34
In reply to Re: treatment resistant depression » sweetmarie, posted by phillybob on March 10, 2001, at 19:33:04
> Anna, sounds like a plan. Also, click on this link to another thread I posted in today for some good lamictal links in addition to the Dr. Ivan Goldberg one I posted earlier in this very thread (click on the one by the doctor as he has familiarity with lamictal):
>
> http://www.dr-bob.org/babble/20010310/msgs/56133.html
>
> Your sister should be able to find out what's up, though. The information is out there. It does sound better that the rash has not gotten worse since you started ... but, again, with the increase in dosage now, you should really have it monitored by someone (somehow!?) who knows what they are looking at it.
>
> [I'm a big Wilco fan, particularly Jeff Tweedy, the lead singer, who's recently done some great solo shows ... I liken him to a future Bob Dylan ... he even sings a song about Bob Dylan's beard. :) ]phillybob - I checked out the thing you sent. Jah seems only to be on a small dosage of Lamotragine, and doesn`t say whether this will be increased. I wonder if it will (Jah, if you are reading this, could you let me know - cheers). I`m actually quite concerned about this huge increase; the only reason I can think of, is that they are concerned that I be kept on a high level of something whilst I undergo the transition. I am really quite ill already (immobilised by the severity of the depression much of the time) The last time I came off meds altogether, I was very nearly catatonic. This may be a factor, I don`t know. Anyway, I`ll still check it out.
Never heard of `Wilco` (presumably an American band - we don`t get to hear much U.S. stuff over here). As for Bob Dylan`s beard, I always thought it was a poor excuse of a beard! (mind you I was only about 2 when he first grew it, so I didn`t have an opinion one way or the other. I prefer him without, although perhaps he should grow one now; I reckon he looks a lot like an old lady (mind you, I think he`s 60 this year).
Anna.
Posted by JahL on March 11, 2001, at 9:58:20
In reply to Re: treatment resistant depression » phillybob, posted by sweetmarie on March 11, 2001, at 6:18:34
> > phillybob - I checked out the thing you sent. Jah seems only to be on a small dosage of Lamotragine, and doesn`t say whether this will be increased. I wonder if it will (Jah, if you are reading this, could you let me know - cheers). I`m actually quite concerned about this huge increase; the only reason I can think of, is that they are concerned that I be kept on a high level of something whilst I undergo the transition. I am really quite ill already (immobilised by the severity of the depression much of the time) The last time I came off meds altogether, I was very nearly catatonic. This may be a factor, I don`t know. Anyway, I`ll still check it out.Hi Anna.
Valproate more than doubles Lamotrigine blood levels. The increase you described previously was effectively a jump from 50mg-400mg/day in just over a week! Phillybob & I wld take *8 months* to reach 400mg on our current dosing schedule! IMO (FWIW) Lamotrigine has been recklessly prescribed to you.
Phillybob is spot on when he says you must get this checked out, & dropping the dose back to say 100mg is probably good advice too.
To answer your Q, I'm now on 37.5mg/day & intend titrating upwards (weekly) in 12.5mg increments to btwn 100 & 200 mg, based on response/side-effects. If yr depression is severe, the proposed (4 you) dose of 250mg sounds reasonable.
This slowly-slowly approach shld enable me to pin-point the optimal point of benefits against side-effects, whilst reducing drastically my chances of developing the rash.
Jah.
Posted by sweetmarie on March 11, 2001, at 11:35:32
In reply to Re: treatment resistant depression » sweetmarie, posted by JahL on March 11, 2001, at 9:58:20
>
> > > phillybob - I checked out the thing you sent. Jah seems only to be on a small dosage of Lamotragine, and doesn`t say whether this will be increased. I wonder if it will (Jah, if you are reading this, could you let me know - cheers). I`m actually quite concerned about this huge increase; the only reason I can think of, is that they are concerned that I be kept on a high level of something whilst I undergo the transition. I am really quite ill already (immobilised by the severity of the depression much of the time) The last time I came off meds altogether, I was very nearly catatonic. This may be a factor, I don`t know. Anyway, I`ll still check it out.
>
> Hi Anna.
>
> Valproate more than doubles Lamotrigine blood levels. The increase you described previously was effectively a jump from 50mg-400mg/day in just over a week! Phillybob & I wld take *8 months* to reach 400mg on our current dosing schedule! IMO (FWIW) Lamotrigine has been recklessly prescribed to you.
>
> Phillybob is spot on when he says you must get this checked out, & dropping the dose back to say 100mg is probably good advice too.
>
> To answer your Q, I'm now on 37.5mg/day & intend titrating upwards (weekly) in 12.5mg increments to btwn 100 & 200 mg, based on response/side-effects. If yr depression is severe, the proposed (4 you) dose of 250mg sounds reasonable.>
> This slowly-slowly approach shld enable me to pin-point the optimal point of benefits against side-effects, whilst reducing drastically my chances of developing the rash.
>
> Jah.Now I`m really worried. I suppose that I`m reluctant to speak to my psychiatrist about this, as I don`t want hoer to think that I`m questioning her judgement. I guess that the other thing I could do is to take it into my own hands, and drop back to 100 mg myself. As I am seeing her in 4 weeks, this should be easy to do. In other words, I could go back to 100 mg for the next couple of weeks, and then up to 200 mg. I don`t want to take it further than that myself. The other thing is that I am juggling this increase with decreasing the Valproate. So, I`m coming off the Valproate at a rate of 200 mg per 5/6 days (I was on 1000 mg). It`s really bloody complicated I can tell you. I don`t like this set-up at all; I thought that the whole reason for my going into hospital was that this could all be managed there. Frankly, I feel too ill to be doing it myself. Still, that`s the way it is - and I`m perfectly capable of ringing my psychiatrist and asking her to spell it out more clearly for me. Or at least double check the report sent to her by the professor, and see what he actually says. I`m really confused.
Anna.
Posted by JahL on March 11, 2001, at 13:51:24
In reply to Re: treatment resistant depression » JahL, posted by sweetmarie on March 11, 2001, at 11:35:32
> > Now I`m really worried. I suppose that I`m reluctant to speak to my psychiatrist about this, as I don`t want hoer to think that I`m questioning her judgement.I know UK pdocs don't take kindly to patients questioning their judgement but what if you printed out a few of these posts & presented them to yr pdoc, expressing yr concern? The other thing to do is visit the GlaxoWellcome site & download the Lamotrigine PDF. This gives clear dosing guidelines (which you can print out), which do not concur with those of yr pdoc. Yr pdoc cannot argue with the manufacturer's recommendations.
If you're concurrently on VPA, Lamotrigine shld be increased by 12.5mg/week. Mine & phillybob's regimes are conservative bearing in mind neither of us takes VPA.
> >I guess that the other thing I could do is to take it into my own hands, and drop back to 100 mg myself. As I am seeing her in 4 weeks, this should be easy to do. In other words, I could go back to 100 mg for the next couple of weeks, and then up to 200 mg. I don`t want to take it further than that myself. The other thing is that I am juggling this increase with decreasing the Valproate. So, I`m coming off the Valproate at a rate of 200 mg per 5/6 days (I was on 1000 mg). It`s really bloody complicated I can tell you. I don`t like this set-up at all; I thought that the whole reason for my going into hospital was that this could all be managed there. Frankly, I feel too ill to be doing it myself. Still, that`s the way it is - and I`m perfectly capable of ringing my psychiatrist and asking her to spell it out more clearly for me. Or at least double check the report sent to her by the professor, and see what he actually says. I`m really confused.
>
> Anna.I don't feel comfortable actually recommending you independently change yr dose, however the rash is more of a concern. I can't see what damage reducing the dose wld do (except possibly inducing epileptics fits in those susceptible), whereas exacerbating the rash, which higher doses are more likely to do, wld be dangerous.
This is a toughie, Anna. Perhaps yr Lamotrigine trial is best left until you are under the close supervision of the hospital prof. As you say, you shld'nt be expected to deal with this yourself.
J.
Posted by sweetmarie on March 11, 2001, at 15:05:20
In reply to Re: treatment resistant depression » sweetmarie, posted by JahL on March 11, 2001, at 13:51:24
>
> > > Now I`m really worried. I suppose that I`m reluctant to speak to my psychiatrist about this, as I don`t want hoer to think that I`m questioning her judgement.
>
> I know UK pdocs don't take kindly to patients questioning their judgement but what if you printed out a few of these posts & presented them to yr pdoc, expressing yr concern? The other thing to do is visit the GlaxoWellcome site & download the Lamotrigine PDF. This gives clear dosing guidelines (which you can print out), which do not concur with those of yr pdoc. Yr pdoc cannot argue with the manufacturer's recommendations.
>
> If you're concurrently on VPA, Lamotrigine shld be increased by 12.5mg/week. Mine & phillybob's regimes are conservative bearing in mind neither of us takes VPA.
>
> > >I guess that the other thing I could do is to take it into my own hands, and drop back to 100 mg myself. As I am seeing her in 4 weeks, this should be easy to do. In other words, I could go back to 100 mg for the next couple of weeks, and then up to 200 mg. I don`t want to take it further than that myself. The other thing is that I am juggling this increase with decreasing the Valproate. So, I`m coming off the Valproate at a rate of 200 mg per 5/6 days (I was on 1000 mg). It`s really bloody complicated I can tell you. I don`t like this set-up at all; I thought that the whole reason for my going into hospital was that this could all be managed there. Frankly, I feel too ill to be doing it myself. Still, that`s the way it is - and I`m perfectly capable of ringing my psychiatrist and asking her to spell it out more clearly for me. Or at least double check the report sent to her by the professor, and see what he actually says. I`m really confused.
> >
> > Anna.
>
> I don't feel comfortable actually recommending you independently change yr dose, however the rash is more of a concern. I can't see what damage reducing the dose wld do (except possibly inducing epileptics fits in those susceptible), whereas exacerbating the rash, which higher doses are more likely to do, wld be dangerous.
>
> This is a toughie, Anna. Perhaps yr Lamotrigine trial is best left until you are under the close supervision of the hospital prof. As you say, you shld'nt be expected to deal with this yourself.
>
> J.I was kind of thinking along those lines myself. After I posted that last post, I spoke to my sister (a psych nurse), who basically said that I should do whatever feels O.K. for me within the framework given to me by my consultant and the professor. She suggested that I say on 100 mg for another week, and instead of going right up to 200 mg, go up to 150 mg for a couple of weeks. Then 200 mg. By that point, I should be going to go into hospital (I was given a waiting time of 5/6 weeks on Monday, which is now 4/5 weeks, which should tie in with this arrangement. As for the Valproate; I`m not entirely sure. My consultant has told me to decrease from 1000 mg to nothing in weekly 200 mg intervals. In the light of the new arrangement I`ve made with the Lamotragine, I think I`ll slow this down (maybe 200 mg decrease over a week and a half instead of a week). There is something here called `the medication helpline`, who deal exclusively with psychiatric medication questions. I`m going to give them a ring. If Im still confused, I am going to have to `bite the bullet`, and get in touch with my psychiatrist. After all, that`s what she`s there for (and gets very well paid for it, I`m quite sure).
I`ll let you know how I get on.
Anna.
Posted by JahL on March 11, 2001, at 15:42:48
In reply to Re: treatment resistant depression » JahL, posted by sweetmarie on March 11, 2001, at 15:05:20
>
> > I spoke to my sister (a psych nurse), who basically said that I should do whatever feels O.K. for me within the framework given to me by my consultant and the professor. She suggested that I say on 100 mg for another week, and instead of going right up to 200 mg, go up to 150 mg for a couple of weeks.How about staying on 100mg til you see the prof? 50mg (to 150mg) is still quite a big leap, which is in effect doubled whilst you remain on VPA.
> > Then 200 mg. By that point, I should be going to go into hospital (I was given a waiting time of 5/6 weeks on Monday, which is now 4/5 weeks, which should tie in with this arrangement. As for the Valproate; I`m not entirely sure. My consultant has told me to decrease from 1000 mg to nothing in weekly 200 mg intervals. In the light of the new arrangement I`ve made with the Lamotragine, I think I`ll slow this down (maybe 200 mg decrease over a week and a half instead of a week).
Unless Valproate is significantly helping you, it makes sense to decrease it *more quickly* since the sooner it is out of your system, the sooner Lamotrigine blood levels will drop to within safer limits.
Good luck,
J.
Posted by sweetmarie on March 11, 2001, at 16:36:26
In reply to Re: treatment resistant depression » sweetmarie, posted by JahL on March 11, 2001, at 15:42:48
> >
> > > I spoke to my sister (a psych nurse), who basically said that I should do whatever feels O.K. for me within the framework given to me by my consultant and the professor. She suggested that I say on 100 mg for another week, and instead of going right up to 200 mg, go up to 150 mg for a couple of weeks.
>
> How about staying on 100mg til you see the prof? 50mg (to 150mg) is still quite a big leap, which is in effect doubled whilst you remain on VPA.
>
> > > Then 200 mg. By that point, I should be going to go into hospital (I was given a waiting time of 5/6 weeks on Monday, which is now 4/5 weeks, which should tie in with this arrangement. As for the Valproate; I`m not entirely sure. My consultant has told me to decrease from 1000 mg to nothing in weekly 200 mg intervals. In the light of the new arrangement I`ve made with the Lamotragine, I think I`ll slow this down (maybe 200 mg decrease over a week and a half instead of a week).
>
> Unless Valproate is significantly helping you, it makes sense to decrease it *more quickly* since the sooner it is out of your system, the sooner Lamotrigine blood levels will drop to within safer limits.
>
> Good luck,
> J.Valproate is doing absolutely sod-all (and never did), so I will. I was playing it cautious; my consultant advised me to come down by 100 mg every 5 - 7 days. I decided on the 7, which I have now changed to a week and a half. I reckon I`ll stick to her original suggestion.
As to the Lamotragine, I think I`ll do what you suggest. The main thing I guess is to make a plan and stick to it. I`m not going to `fiddle` with it any more.
By the way, was it you that told me that a combination of Valproate and Lamotragine can cause a rash? If it wasn`t you, then someone said it at some point. I hope that this is true because it might mean that the rash coud clear up once I`m off the Valroate. It`s not a serious rash, and caused no physical discomfort, but it`s noticeable and I`m self-concious about it. If it gets worse, I will be ringing my consultant right away. The other thing that I thought of is that they (the team at Newcastle hospital where I will be going), may be able to get a dermatologist to look at it.
Thanks for your help,
Anna.
Posted by sarai on March 12, 2001, at 14:51:36
In reply to Re: treatment resistant depression » JahL, posted by sweetmarie on March 11, 2001, at 16:36:26
Hi,
I work in a research clinic in NYC and we are doing a clinical trial for treatment resistant depression. If you live within travel (weekly) distance of lower Manhattan and would like more information, please call Sarai...
Posted by sweetmarie on March 12, 2001, at 16:43:16
In reply to Re: treatment resistant depression , posted by sarai on March 12, 2001, at 14:51:36
> Hi,
>
> I work in a research clinic in NYC and we are doing a clinical trial for treatment resistant depression. If you live within travel (weekly) distance of lower Manhattan and would like more information, please call Sarai...Sarai - sounds perfect for me. Unfortunately, I live at the other side of the Atlantic. I wish they did that kind of thing here (they don`t).
Anna.
Posted by Dr. Bob on March 12, 2001, at 18:17:10
In reply to Re: treatment resistant depression , posted by sarai on March 12, 2001, at 14:51:36
> I work in a research clinic in NYC and we are doing a clinical trial for treatment resistant depression. If you live within travel (weekly) distance of lower Manhattan and would like more information, please call Sarai at...
It's great to spread the word about studies, but please if you do so include who the principal investigator is, which institution, if any, it's being conducted at, and whether it's been approved by an Institutional Review Board or other human subjects committee. Posts without this information will be removed. Thanks,
Bob
PS: Follow-ups, if any, regarding this should be redirected to Psycho-Babble Administration.
Posted by steve on March 12, 2001, at 18:29:07
In reply to Re: treatment resistant depression , posted by sarai on March 12, 2001, at 14:51:36
> Hi,
>
> I work in a research clinic in NYC and we are doing a clinical trial for treatment resistant depression. If you live within travel (weekly) distance of lower Manhattan and would like more information, please call Sarai...How much money do you stand to make per guinea pig you find?
Are estimates of a $200 bounty accurate?
Do you think you have an ethical obligation to disclose how much money is involved so as to create truely informed consent, or do you advocate the mushroom treatment (feed them manure and keep them in the dark) for your charges?
TIA
Posted by SLS on March 13, 2001, at 17:19:59
In reply to treatment resistant depression, posted by sweetmarie on March 7, 2001, at 14:29:45
> I suffer from (severe chronic `double`) depression, which has proved VERY difficult to treat (I`ve had Tricyclics, SSRIs, an MAOI (Nardil), ECT, Maclobomide, Reboxetine, L-Tryptophan, Venlafaxine, and different permutations. I am currently on Nardil, Trimipramine, Lamotragine and Epilim to no effect).
> I`ve been referred to a specialist in `difficult to treat depression`, who plans to put me onto Venlafaxine, Mirtazapine and increase the dose of Lamotragine.
I hope this helps:Your new doctor has chosen a treatment that demonstrates his expertise. You found a good one.
I have a question for you. What side effects does trimipramine cause? My main concern is that it is too sedating. What do you think?
Good luck with your new doctor. It may still take some time, but it sounds like you have a good chance with this person. Patience is required. It is a requirement that I have lots of trouble with, but I know my chances of getting well are much greater if I exercise it. I too am treatment resistant. I'm still looking.
- Scott
Posted by sweetmarie on March 13, 2001, at 19:31:14
In reply to Re: treatment resistant depression » sweetmarie, posted by SLS on March 13, 2001, at 17:19:59
> > I suffer from (severe chronic `double`) depression, which has proved VERY difficult to treat (I`ve had Tricyclics, SSRIs, an MAOI (Nardil), ECT, Maclobomide, Reboxetine, L-Tryptophan, Venlafaxine, and different permutations. I am currently on Nardil, Trimipramine, Lamotragine and Epilim to no effect).
>
> > I`ve been referred to a specialist in `difficult to treat depression`, who plans to put me onto Venlafaxine, Mirtazapine and increase the dose of Lamotragine.
>
>
> I hope this helps:
>
> Your new doctor has chosen a treatment that demonstrates his expertise. You found a good one.
>
> I have a question for you. What side effects does trimipramine cause? My main concern is that it is too sedating. What do you think?
>
> Good luck with your new doctor. It may still take some time, but it sounds like you have a good chance with this person. Patience is required. It is a requirement that I have lots of trouble with, but I know my chances of getting well are much greater if I exercise it. I too am treatment resistant. I'm still looking.
>
>
> - ScottScott,
Thanks for the encouragement.
Trimipramine has had no side effects on me (as far as i know). It`s difficult to tell, though, as I am taking 4 different medications. I don`t feel `sedated` in any way, or at least not by Trimipramine. I am lethargic, but I think that`s to do with depression in general. In other words, my lethargy has not increased since I started taking Trimipramine. The side effects of the drug are basically the same as those of other Tricyclics (none of which spring to mind except the usual dry mouth, constipation, dizziness, possible weight gain etc.) Are you thinking of taking Trimipramine? I don`t know how effective it is on it`s own (for `resistant` people); As I said, it`s one of four medications I am taking (Lamotragine, Valproate, Trimipramine and Phenelzine). I will be coming off the Trimipramine in order to try out this new combination.
Sorry to not to have been of much use.
Good luck to you too - it`s a long haul and as you say, patience is not easy when you`re suffering.
Anna.
Posted by SLS on March 13, 2001, at 21:21:21
In reply to Re: treatment resistant depression » SLS, posted by sweetmarie on March 13, 2001, at 19:31:14
Dear Anna,
Thank you for replying to my question.
> Trimipramine has had no side effects on me (as far as i know). It`s difficult to tell, though, as I am taking 4 different medications. I don`t feel `sedated` in any way, or at least not by Trimipramine. I am lethargic, but I think that`s to do with depression in general. In other words, my lethargy has not increased since I started taking Trimipramine. The side effects of the drug are basically the same as those of other Tricyclics (none of which spring to mind except the usual dry mouth, constipation, dizziness, possible weight gain etc.)
> Are you thinking of taking Trimipramine?
Yes.
> I don`t know how effective it is on it`s own (for `resistant` people)
I cannot affort to declare inelligible any medication at this point. I am interested in trimipramine (Surmontil) because it is the "black sheep" of the tricyclic family. It doesn't appear to do the things that were considered important for a tricyclic to do, namely the inhibition of the reuptake of norepinephrine, and to a lesser extent, serotonin. That the drug works at all speaks to how little we understand about how antidepressants work and what are the psychobiological abnormalities that cause depression and bipolar disorder.
> As I said, it`s one of four medications I am taking (Lamotragine, Valproate, Trimipramine and Phenelzine).
Have you or any member of your family been diagnosed as having bipolar disorder?
> I will be coming off the Trimipramine in order to try out this new combination.
Don't you also have to discontinue Nardil before beginning Effexor?
> Sorry to not to have been of much use.
Don't be silly. Consider yourself well used. :-)
Thanks.
- Scott
Posted by Dr. Bob on March 14, 2001, at 1:59:39
In reply to Re: treatment resistant depression » sarai, posted by steve on March 12, 2001, at 18:29:07
> or do you advocate the mushroom treatment (feed them manure and keep them in the dark) for your charges?
What I posted above to you applies here, too.
Bob
Posted by sweetmarie on March 14, 2001, at 12:21:28
In reply to Re: treatment resistant depression » sweetmarie, posted by SLS on March 13, 2001, at 21:21:21
> Dear Anna,
>
> Thank you for replying to my question.
>
> > Trimipramine has had no side effects on me (as far as i know). It`s difficult to tell, though, as I am taking 4 different medications. I don`t feel `sedated` in any way, or at least not by Trimipramine. I am lethargic, but I think that`s to do with depression in general. In other words, my lethargy has not increased since I started taking Trimipramine. The side effects of the drug are basically the same as those of other Tricyclics (none of which spring to mind except the usual dry mouth, constipation, dizziness, possible weight gain etc.)
>
> > Are you thinking of taking Trimipramine?
>
> Yes.
>
> > I don`t know how effective it is on it`s own (for `resistant` people)
>
> I cannot affort to declare inelligible any medication at this point. I am interested in trimipramine (Surmontil) because it is the "black sheep" of the tricyclic family. It doesn't appear to do the things that were considered important for a tricyclic to do, namely the inhibition of the reuptake of norepinephrine, and to a lesser extent, serotonin. That the drug works at all speaks to how little we understand about how antidepressants work and what are the psychobiological abnormalities that cause depression and bipolar disorder.
>
> > As I said, it`s one of four medications I am taking (Lamotragine, Valproate, Trimipramine and Phenelzine).
>
> Have you or any member of your family been diagnosed as having bipolar disorder?
>
> > I will be coming off the Trimipramine in order to try out this new combination.
>
> Don't you also have to discontinue Nardil before beginning Effexor?
>
> > Sorry to not to have been of much use.
>
> Don't be silly. Consider yourself well used. :-)
>
> Thanks.
>
>
> - ScottScott,
I`m glad to have been of some use. Like you, I can`t afford to rule anything out (if that`s what you were saying). I`ve been very severely depressed for about 3 years, with all the stuff that goes with that (inability to work, have a social life, carry on any meaningful relationships with friends, etc.)
Nobody in my family has ever been diagnosed with Bipolar Disorder, and it has certainly never been suggested to me that I may have it. The only other person I know of who suffers at all from depression is my sister, who gets mild depression for short periods, and are adequately treated with a short course of anti-depressants. Her low moods are `reactive` though, unlike my illness which is genetically based, and I`ve suffered to differing degrees (from moderate to severe) most of my life. She has a very stressful job - she`s a psychiatric nurse (enough said, probably).
Re. discontinuing Nardil in order to start on Venlafaxine, you`re right - there should be a certain gap (about a week, I believe) before Venlafaxine can be commenced. Having said that, a friend of mine has just cganged from Nardil to Vanlafaxine, and her psychiatrist has overlapped the two. I don`t think that she`s suffered any side effects from this - apart from the severe depression she has been experiencing for slightly longer than me (we are quite a comfort to each other). This isn`t the `correct` way to do it, I`m sure though.
Good luck with the Trimpramine (if you choose to take it). How long have you been depressed? Is it moderate/severe? Whatever, you have all my sympathy - it is truly a hideous illness.
Anna.
Posted by SLS on March 14, 2001, at 22:44:38
In reply to Re: treatment resistant depression - Scott » SLS, posted by sweetmarie on March 14, 2001, at 12:21:28
Hi Anna.
> I`m glad to have been of some use. Like you, I can`t afford to rule anything out (if that`s what you were saying).Yup. That's the story.
> I`ve been very severely depressed for about 3 years, with all the stuff that goes with that (inability to work, have a social life, carry on any meaningful relationships with friends, etc.)
Yup. I know this story too. I am sorry that you had to tell it.
> Nobody in my family has ever been diagnosed with Bipolar Disorder, and it has certainly never been suggested to me that I may have it.
The reason I asked is because you having been taking two "mood-stabilizers", Lamictal (lamotrigine) and Epilim (valproate). This is a strategy that is generally associated with bipolar disorder rather than unipolar major depression. I am very interested to know how critical a role both play in getting you well.
> The only other person I know of who suffers at all from depression is my sister, who gets mild depression for short periods, and are adequately treated with a short course of anti-depressants. Her low moods are `reactive` though, unlike my illness which is genetically based,
Just for the sake of extending understanding, and not as an attempt at diagnosis, all of the features you described above can be symptoms of a "soft" bipolar presentation. My sister has followed exactly the same scenario, her bipolarity being evidenced by a hypomania induced by Nardil, an MAO-inhibitor antidepressant. Bipolar disorders are extremely heritable (genetic) and very often appear among siblings, although not necessarily to the same degree.
> and I`ve suffered to differing degrees (from moderate to severe) most of my life.
I get pissed whenever I have to read a story like yours. Damn it.
> She has a very stressful job - she`s a psychiatric nurse (enough said, probably).
Again, for the sake of understanding, stress can precipitate an episode of an otherwise dormant bipolar illness. This also true of many other mental illnesses. A mild episode can remit spontaneously if the stress is removed or mitigated. I have seen this happen with my sister over the last six months. Thus, episodic mild depressions are no less facilitated via a genetic terrain than are chronic and severe presentations.
> Re. discontinuing Nardil in order to start on Venlafaxine, you`re right - there should be a certain gap (about a week, I believe) before Venlafaxine can be commenced. Having said that, a friend of mine has just cganged from Nardil to Vanlafaxine, and her psychiatrist has overlapped the two. I don`t think that she`s suffered any side effects from this - apart from the severe depression she has been experiencing for slightly longer than me (we are quite a comfort to each other). This isn`t the `correct` way to do it, I`m sure though.
All I can say is that I know of no way to confidently predict which people will experience a life-threatening reaction to such a combination and which will not. Once upon a time, in an act of desperation, I decided to take a nibble off a small piece of venlafaxine (Effexor) to see how it would react with the Parnate I was taking. Within ten or fifteen minutes, I experienced vertigo and I had to lay down. I couldn't get myself to sit up in bed. I became incoherent and hardly knew where I was. I made no sense at all when speaking to my parents. I told them not to worry about me, that I understood what I did wrong, and that I simply had to reboot the system. No problem.
I can't emphasize enough what a tiny amount of Effexor I bit off. Because of its short half-life, I chose Effexor purposely to test for the potential of developing serotonin syndrome when combining a serotonin reuptake inhibitor with an MAOI. If something went wrong, it should dissipate relatively quickly. It did. So did my notions of trying it ever again.
> Good luck with the Trimpramine (if you choose to take it).
> How long have you been depressed?
With the exception of a 6-month remission brought about by a combination of antidepressants, 24 years.
> Is it moderate/severe?
Severe. (I have been accused of being overly proud of this).
It was an honor to be assessed as being the most severely depressed research patient enrolled at the NIH during my nine-month stay there. Although there was this one guy who was an ultra rapid-cycler whose depressed state during the first three to six hours following a switch into his depressive phase seemed worse than mine. I envied him, though. After three days of depression, he would swing into a controllable hypomania that would last for eight. Gosh, what I could accomplish in eight days out of every eleven...
> Whatever, you have all my sympathy - it is truly a hideous illness.
Yup.
Thanks, Anna.
- Scott
Posted by Lorraine on March 15, 2001, at 9:45:54
In reply to Re: treatment resistant depression - Scott » sweetmarie, posted by SLS on March 14, 2001, at 22:44:38
I've been enjoying your dialog. I'm sure it's a flea on an elephant's ass, but I just finished reading a really good book on depression, actually two. The first is "The Brain Wellness Plan" by Lombard and the second is "The Antidepressant Survival Guide by Edaya. Both books are by physicians and both are well researched with extensive footnotes. The are about the nutritional weaknesses that may be contributing to our illness. They don't seek to replace the drugs that we need, they want to augment them with good dietary protocol and suggest various tests to tease out conditions that mimic depression. These books are great. I highly recommend them. (So you get the background I too have treatment resistant major depression and I have read roughly 40 books on my condition--these are the two I recommend.)
Scott, shouldn't you be in the world book of records or something?
Posted by sweetmarie on March 15, 2001, at 12:44:29
In reply to Re: treatment resistant depression - Scott » sweetmarie, posted by SLS on March 14, 2001, at 22:44:38
Scott,
>
>
> > I`m glad to have been of some use. Like you, I can`t afford to rule anything out (if that`s what you were saying).
>
> Yup. That's the story.>
> > I`ve been very severely depressed for about 3 years, with all the stuff that goes with that (inability to work, have a social life, carry on any meaningful relationships with friends, etc.)>
> Yup. I know this story too. I am sorry that you had to tell it.
>> > Nobody in my family has ever been diagnosed with Bipolar Disorder, and it has certainly never been suggested to me that I may have it.
>
> The reason I asked is because you having been taking two "mood-stabilizers", Lamictal (lamotrigine) and Epilim (valproate). This is a strategy that is generally associated with bipolar disorder rather than unipolar major depression. I am very interested to know how critical a role both play in getting you well.I know that both Epilim and Lamotragine are mood stabilisers, and to be quite honest, I`m not entirely sure why I am taking both. As I said, there has never been a hint from any doctor that my condition might be Bipolar. The Epilim replaced Lithium as an `augmentation`, and the Lamotragine was prescribed about 6 months later. The ony reason that I was prescribed Lamotragine was that another of my psychiatrist`s patients had read of it on the Net. She had tried it, and it had worked miracles. So, this is the only basis for me going onto Lamotragine (this previous patient was the first person that my psychiatrist had ever used Lamotragine with). Although my consultant psychiatrist is very good at her job (and I both like and trust her), she only has limited knowledge of resistant depression, and I have proved to be a very difficult case. I think basically, she was clutching at straws, and this combination (Epilim, Lamotragine, Trimipramine and Phenelzine) was more of a `mish-mash` than anything else. It was when this failed to work that she referred me to the specialist (who has subsequently assessed me, given me a diagnosis, and I will be under his care when I go into his hospital - not my local one - in about a months time. I guess that this answers your question about the Epilim/Lactimal combination (i.e. it didn`t help me at all, but a) I was on a very small dose of Lactimal (25 mg, which will now be going up to 250 mg), and b) these treatments are very individual (what didn`t work for me, may work for you).
>
> > The only other person I know of who suffers at all from depression is my sister, who gets mild depression for short periods, and are adequately treated with a short course of anti-depressants. Her low moods are `reactive` though, unlike my illness which is genetically based,
>
> Just for the sake of extending understanding, and not as an attempt at diagnosis, all of the features you described above can be symptoms of a "soft" bipolar presentation. My sister has followed exactly the same scenario, her bipolarity being evidenced by a hypomania induced by Nardil, an MAO-inhibitor antidepressant. Bipolar disorders are extremely heritable (genetic) and very often appear among siblings, although not necessarily to the same degree.
>
> > and I`ve suffered to differing degrees (from moderate to severe) most of my life.
>
> I get pissed whenever I have to read a story like yours. Damn it.Is that because you`ve had a similar experience? From what you`ve said, it sounds like it.
>
> > She has a very stressful job - she`s a psychiatric nurse (enough said, probably).
>
> Again, for the sake of understanding, stress can precipitate an episode of an otherwise dormant bipolar illness. This also true of many other mental illnesses. A mild episode can remit spontaneously if the stress is removed or mitigated. I have seen this happen with my sister over the last six months. Thus, episodic mild depressions are no less facilitated via a genetic terrain than are chronic and severe presentations.The problem here is that I know for a fact that my sister would in no way welcome any queries as to her mental health. I have asked in the past, but she keeps this kind of thing very much to herself. >
> > Re. discontinuing Nardil in order to start on Venlafaxine, you`re right - there should be a certain gap (about a week, I believe) before Venlafaxine can be commenced. Having said that, a friend of mine has just cganged from Nardil to Vanlafaxine, and her psychiatrist has overlapped the two. I don`t think that she`s suffered any side effects from this - apart from the severe depression she has been experiencing for slightly longer than me (we are quite a comfort to each other). This isn`t the `correct` way to do it, I`m sure though.
>
> All I can say is that I know of no way to confidently predict which people will experience a life-threatening reaction to such a combination and which will not. Once upon a time, in an act of desperation, I decided to take a nibble off a small piece of venlafaxine (Effexor) to see how it would react with the Parnate I was taking. Within ten or fifteen minutes, I experienced vertigo and I had to lay down. I couldn't get myself to sit up in bed. I became incoherent and hardly knew where I was. I made no sense at all when speaking to my parents. I told them not to worry about me, that I understood what I did wrong, and that I simply had to reboot the system. No problem.> > I can't emphasize enough what a tiny amount of Effexor I bit off. Because of its short half-life, I chose Effexor purposely to test for the potential of developing serotonin syndrome when combining a serotonin reuptake inhibitor with an MAOI. If something went wrong, it should dissipate relatively quickly. It did. So did my notions of trying it ever again.
>
> > Good luck with the Trimpramine (if you choose to take it).
>
> > How long have you been depressed?
>
> With the exception of a 6-month remission brought about by a combination of antidepressants, 24 years.What happened after the 6 month remission - did you discontinue the treatment, or did the effect simply wear off? 24 years is a long time - has it been severe ALL that time? How old are you? Mind you, I don`t really remember a time when I wasn`t depressed, and I`m 34 now.
>
> > Is it moderate/severe?
>
> Severe. (I have been accused of being overly proud of this).
>
> It was an honor to be assessed as being the most severely depressed research patient enrolled at the NIH during my nine-month stay there. Although there was this one guy who was an ultra rapid-cycler whose depressed state during the first three to six hours following a switch into his depressive phase seemed worse than mine. I envied him, though. After three days of depression, he would swing into a controllable hypomania that would last for eight. Gosh, what I could accomplish in eight days out of every eleven...What do your psych doctors say about your situation? Do they encourage you and say that there will be a `right medication` or `right` combination? Are they sympathetic? How long have you been on medication treatment? (I have been on different things for the past 10 years now. Only the very first anti-depressant I ever had worked; that was Dothiepin, which I took for a year and I was 100% well. So well in fact that I stopped taking it, and when the symptoms returned I went back onto it. It didn`t work 2nd time around, and I have been kicking myself ever since for coming off it in the first place). Have you tried ECT? I had 20 sessions during one hospital stay, and it did sod-all to improve my mood. What it did do though, was to totally wipe out my memory of the previous 18 months. Terrific. And what about a specialist - have you ever been referred? Have you asked?
>
> > Whatever, you have all my sympathy - it is truly a hideous illness.
>
> Yup.
>
Well, keep on keeping on (as they say),
>
Anna.
Posted by SLS on March 17, 2001, at 10:32:56
In reply to Re: treatment resistant depression » SLS, posted by sweetmarie on March 15, 2001, at 12:44:29
Hi Anna.
> I know that both Epilim and Lamotragine are mood stabilisers, and to be quite honest, I`m not entirely sure why I am taking both. As I said, there has never been a hint from any doctor that my condition might be Bipolar. The Epilim replaced Lithium as an `augmentation`, and the Lamotragine was prescribed about 6 months later. The ony reason that I was prescribed Lamotragine was that another of my psychiatrist`s patients had read of it on the Net. She had tried it, and it had worked miracles. So, this is the only basis for me going onto Lamotragine
I am really interested to know to what extent doctors are having success using lamotrigine in true unipolar depression. I would also like to know if there are differences in the success rate among some of the depressive subtypes: melancholic, atypical, dysthymic, anergic, agitated, and psychotic.
> I think basically, she was clutching at straws, and this combination (Epilim, Lamotragine, Trimipramine and Phenelzine) was more of a `mish-mash` than anything else. It was when this failed to work that she referred me to the specialist (who has subsequently assessed me, given me a diagnosis, and I will be under his care when I go into his hospital - not my local one - in about a months time. I guess that this answers your question about the Epilim/Lactimal combination (i.e. it didn`t help me at all, but a) I was on a very small dose of Lactimal (25 mg, which will now be going up to 250 mg), and b) these treatments are very individual (what didn`t work for me, may work for you).
It is good that your doctors are willing to go to 200mg and higher with lamotrigine right away. Personally, I need 300mg to glean the mild improvement it gives me. Lamotrigine can produce an initial improvement with dosages as low as 25mg, but higher dosages are usually needed to make it stick.
> > > and I`ve suffered to differing degrees (from moderate to severe) most of my life.
> > I get pissed whenever I have to read a story like yours. Damn it.
> Is that because you`ve had a similar experience? From what you`ve said, it sounds like it.
Yes. I get upset whenever I see that someone has to suffer so much depression for so long as to completely destroy their lives in the manner it has destroyed mine. Your description of life with depression is so much like my own. I think I get more pissed reading of someone else's misery that I do for my own.
> > > How long have you been depressed?> > With the exception of a 6-month remission brought about by a combination of antidepressants, 24 years.
> What happened after the 6 month remission - did you discontinue the treatment, or did the effect simply wear off?
I was made well using a combination of antidepressents comprised of Parnate and desipramine (Norpramin). After six months or so of euthymia (good mood), I began to develop a hypomania that continued to develop into a mixed-state or dysphoric psychotic mania. As seems to be common sense, my doctor discontinued the antidepressants and gave me lithium and eventually Klonopin (clonazepam) to relieve the mania. After two months of continued remission without antidepressants, I relapsed. Unfortunately, Prozac had just been approved. I guess my doctor wanted to play with a new toy. It didn't work, although I doubt he would have exceeded a dosage of 20mg. After discontinuing Prozac, my doctor decided to return to Parnate, only without the desipramine. He had some notion that the "terrain" of the brain had changed, and that a combination was not necessary. I imagine he was also reluctant to restart the drug regiment that caused mania. He was too stubborn. He spent almost three months trying to force Parnate to work by changing the dosage up and down. To make a long story short, the original combination never worked again. And thus the continued odyssey...
> 24 years is a long time - has it been severe ALL that time?
Yes. I was a junior in highschool at age 17 when the severe depression swallowed me up. It came over me within an hour. It was as paroxsymal as the mood switches that occur with ultra rapid-cycling presentations. Actually, I displayed a robust ultra rapid cycle that comprised of 8 days of depression followed by 3 days of euthymia, followed by 8 days of depression, etc. The switch from one state to the other occurred over the course of 30 to 45 minutes. So too was my initial switch into severe depression. It is important to note that I experienced episodic mild to moderate depressive episodes beginning at age 10 or 11.
> How old are you?
41 years young.
> Mind you, I don`t really remember a time when I wasn`t depressed,
:-(
> and I`m 34 now.
All the more reason to persevere. You are plenty young enough to have a wonderful life once you find an effective treatment. I remember being told the same thing when I was 34. I thought this was nothing but placating crap. They were right, though. You might feel like you have tried every drug in every possible combination. However, I think you would be surprised at how many different drug combinations and treatment strategies you have left to try. I believe it is logical for you to have real hope. I wish I were able to always believe it for myself. You are not alone, Anna.
> > > Is it moderate/severe?
> > Severe. (I have been accused of being overly proud of this).
> What do your psych doctors say about your situation? Do they encourage you and say that there will be a `right medication` or `right` combination?
After investing 10 years with the same doctor with little success, he helped me find a doctor with more expertise in treatment resistant cases. This new doctor seems optimistic that a we will find combination drug treatment that will work. Unfortunately, he impressed upon me that it might still take quite a bit of time. He didn't characterize what he meant by "quite a bit", and I didn't want to ask. However, I think I have a good chance with this doctor, so long as I don't sabotage his algorithm by making drug changes on my own.
> Are they sympathetic?
My previous doctor was very sympathetic. My new doctor is very empathetic. I feel as if he genuinely understands the painful non-existence that is the depressed state. He called my condition horrendous and unacceptable. He described how I experience life as being sub-human. It feels like a huge weight lifted off my shoulders to not have to convince a doctor just how bad things are for me. When he used the word "horrendous", I couldn't help but let out a huge sigh of relief and then cry.
> How long have you been on medication treatment?
I was first diagnosed in 1982 by a study team at Columbia-Presbyterian in New York. The three doctors with whom I dealt with directly were Michael Liebowitz, Wilma Harrison, and Frederick Quitkin. As they proceeded through different treatments, I responded for a few weeks to imipramine (a tricyclic like dothiepin) and a few days to Parnate. They were a bit surprised that amphetamine put me to sleep. After nine months, they pretty much gave up on me and told me that I should not look forward to getting well, as they believed that I had exhausted their treatment resources. They felt that my best hope was for psychotherapy, two years of which had already proved useless. Since I was a rapid-cycler at the time, and I experienced such amazing, although short lived, response to a few medications. Their conclusions did not make sense to me. I wish that I had knocked on Ronald Fieve's door on the same floor I was being treated to see what he had to say. After all, it was his book "Mood Swing" that allowed me to recognize my disorder in the first place.
****************
> I have been on different things for the past 10 years now. Only the very first anti-depressant I ever had worked; that was Dothiepin, which I took for a year and I was 100% well. So well in fact that I stopped taking it, and when the symptoms returned I went back onto it. It didn`t work 2nd time around, and I have been kicking myself ever since for coming off it in the first place.
You will find the Psycho-Babble board littered with this same scenario. Anyone thinking of discontinuing a successful treatment may want to take the time to evaluate to what degree the details of their case allow for discontinuation with a low risk for relapse. It is a difficult judgment to make, and 20/20 hindsight is enlightening, but not terribly helpful. Some of the factors that enter into making a decision toward long-term treatment are:
1. Early age of onset
2. Chronicity - an extended period of depression.
3. Recurrent - recurrent or multiple episodes of depression.
4. Bipolar disorder
5. Treatment resistance****************
> Have you tried ECT?
Yes. 6 unilateral left treatments followed by 6 to 8 of bilateral treatments. I experienced some relief after the sixth treatment, but that was about it. This was performed in 1991. I have been advised that there have been significant advances in the application of ECT since then, and that my lack of response cannot be extrapolated to the treatments currently used. I once wrote a letter to Dr. Max Fink, a doctor who has devoted much of his career to ECT. This was his opinion as well.
> I had 20 sessions during one hospital stay, and it did not-all to improve my mood. What it did do though, was to totally wipe out my memory of the previous 18 months. Terrific.
Sigh...
I'm sorry.
Sometimes I just don't know what to think about this whole ECT and memory thing.
> And what about a specialist - have you ever been referred? Have you asked?
If you are referring to a specialist in ECT, the answer is no. My current doctor says that he will bring up the issue from time to time, but will not apply any pressure in that direction.
If you are referring to treatment-resistant specialists, I have seen and have been referred to quite a few. I have seen people in New York, Princeton, Boston, and the NIH in Washington D.C. (Bethesda, Maryland). My doctors have also conferred with many of their colleagues along the way. I think I have been pretty lucky to have had my case considered by so many people. Hopefully, there will not be a need for any more. One thing I have been surprised at on Psycho-Babble is to learn just how many good psychiatrist-psychopharmacologists can be found everywhere. New York does not have a lock on expertise. Some really good doctors can be found just around the corner from McDonald's.
> - it is truly a hideous illness.
I figured it was worth printing your quote one more time.
Dear Anna,
I hope you have hope. Like I said before, it is logical that you should. There is so much to be had by just reading about all of the success stories here and the details of what treatments worked. For me, this is the most important function of Psycho-Babble because it shows me just how many possibilities I have not yet encountered or have given serious considration to. There are many, many bright and creative people here who care enough to be willing to share information and personal experiences. Thank you for being one of them.
- Scott
Posted by Lorraine on March 17, 2001, at 11:30:12
In reply to Re: treatment resistant depression (long) » sweetmarie, posted by SLS on March 17, 2001, at 10:32:56
I can't tell you how much the message from SLS to sweetmarie touched me. I thank you both. I almost am tempted to print it out and give it to my sister in law who believes that this is all self-indulgence and with a new attitude anything is possible. Something about this exchange really captures what is going on with this disease.
Posted by phillybob on March 17, 2001, at 17:44:10
In reply to Re: treatment resistant depre Scot, Sweetmarie, posted by Lorraine on March 17, 2001, at 11:30:12
I agree with Lorraine. Thanks so much for the history, Scott.
How is the rash, Anna (Sweetmarie)?
[The only thing that I'm in disagreement with SLS on is this statement: "It is good that your doctors are willing to go to 200mg and higher with lamotrigine right away." I think considering the information available, as discussed above in this thread, taking such an increase slowly, especially when valproate is also in the body, is prudent.]
Posted by sweetmarie on March 17, 2001, at 18:59:30
In reply to Re: treatment resistant depre Scot, Sweetmarie, posted by phillybob on March 17, 2001, at 17:44:10
> I agree with Lorraine. Thanks so much for the history, Scott.
>
> How is the rash, Anna (Sweetmarie)?
>
> [The only thing that I'm in disagreement with SLS on is this statement: "It is good that your doctors are willing to go to 200mg and higher with lamotrigine right away." I think considering the information available, as discussed above in this thread, taking such an increase slowly, especially when valproate is also in the body, is prudent.]Scott,
I feel very deeply about what you said re. your history. Frankly, it`s a load of crap - I can`t say more than that. I know how indescribably awful it is, and you have done very well to have got through in one piece. It`s clear to me that you still have hope - something that is virtually impossible, as I well know.
I have `been there` as they say, and well ... it`s no joke. Thank you for sharing your experience, and also thanks to Lorraine. There are far too many people that see depression as some kind of self-indulgence. Would we be going through it by choice? The notion is absurd. I`ve had people suggest things like `have a holiday`, `have a change of scenery`, or `get out more`. Put me on a tropical island with Robbie Williams, and I`d still feel like s**t. I would really like some of these people to walk in my shoes; just for a short time. `Nightmare` is not a strong enough description.
Anna.
Posted by sweetmarie on March 17, 2001, at 19:02:36
In reply to Re: treatment resistant depre Scot, Sweetmarie, posted by phillybob on March 17, 2001, at 17:44:10
> I agree with Lorraine. Thanks so much for the history, Scott.
>
> How is the rash, Anna (Sweetmarie)?Phillybob,
The rash is still the same - no better and no worse. I have since found out that developing a rash can also be a side effect of Nardil (and not a dangerous one). It could be that; I guess I`ll find out when I`m finally off it (Nardil, that is).
Anna >
> [The only thing that I'm in disagreement with SLS on is this statement: "It is good that your doctors are willing to go to 200mg and higher with lamotrigine right away." I think considering the information available, as discussed above in this thread, taking such an increase slowly, especially when valproate is also in the body, is prudent.]
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