![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 236 to 260 of 434. Go back in thread:
Posted by Lorraine on August 16, 2001, at 23:58:55
In reply to Re: Update » Lorraine, posted by shelliR on August 11, 2001, at 19:57:12
>
> What did my comment [re Cam} make you rethink?
>
> ShelliHow broad the board is in terms of posters and how we have to just trust that people can sort things out for themselves rather than trying to curtail the posting of messages that may be harmful for the good of the community.
Posted by Lorraine on August 17, 2001, at 0:17:03
In reply to Re: Stuff -- Elizabeth et al, posted by may_b on August 12, 2001, at 13:10:53
may_b
> > > Well, sorry to intrude
Welcome--come on in, grab a cup of coffee....
> > > For example, I refer to the exchanges on CBT and other therapies, and their limited impact on depression. I have found the talking interventions useful in dealing with behavioural side effects (so to speak) of long term depression, such as self-criticism, self-isolating behaviours, catastrophizing, etc.This is what I believe as well. I'm thinking that I need to find a way to get on with my life in spite of all the uncertainty day-to-day of my moods--I'm thinking CBT might be helpful here.
Lorraine
Posted by Elizabeth on August 17, 2001, at 2:54:10
In reply to Re: that other thread » Elizabeth, posted by Cam W. on August 15, 2001, at 19:24:14
> Elizabeth - • I believe that a lot of my tirade against Sal is just me refocusing the anger (fear?) that I have been experiencing, lately. I have said my piece (peace?) and will leave Sal alone, from now on (except to correct obvious mistakes, or to add more information). I'm sure he is a nice, compassionate guy, who just wants to help people. Hey, you can't knock a guy for that!
I think he is just trying to help, and his heart is in the right place. But I also think that many of the points you made were legitimate ones and should not be simply written off as misdirected anger (although the manner in which they were *expressed* could be :) ).
> > As I'm sure we all realise, "access" doesn't imply reading and understanding.
> >
> •I am not sure that all of the posters and lurkers would understand the implications.How so? (I'm afraid your explanation here has only served to make me more confused! :) )
> • The Beatles went to India(?) to learn from a yogi about life and beyond when they were heavy into LSD. They thought that taking LSD would be a shortcut to nirvana. They found out it wasn't, especially when the yogi tried to sleep with one of the girls that were brought along. In the same light, just having access to all the medical journals in the world does not make one an expert in the field. I was trying to use an analogy, but I still suck when it comes to writing clearly.
Ahh. I think that analogies often suck anyway. < g > Too often I see poor analogies used in attempts to argue a point that degenerate into irrelevant discussion of the analogy rather than the (only tangentially related) point that was being made. But yours wasn't so bad (I do think analogies certainly have their place in discourse; people just misuse them a lot).
> > I think you're stretching it here. :-)
> >
> • Yeah, I'll give you that one; it was off the top of my head. ;^/< g >
> > > Switching meds is by far not the first step in modifying most medication regimens.
> >
> > I think it depends on the situation.
> >
> • I guess that I should have added, "when a psychotropic medication has shown some efficacy", but as a rule, their are no rules, as you state.But you state it more clearly. :) I tend to agree that if there is a partial response and the side effects are tolerated, augmentation is often preferable to substitution.
> • Subjective experience leads to the objective theory which can be studied using scientific method. I think that you need, as a good base, the objective theory (with it's corresponding studies showing proof), but that base needs to be malleable, so that subjective experience from post-marketing surveillance can be integrated into the theory, when the subjective experience is proven to exist.
Goodness. This is getting intense. My main point was that the RCTs required to get a drug approved and used in the writing of the prescribing information are impoverished when it comes to actual patient experience, which I do think should count for something. People here have often spoken of doctors insisting that their subjective experience on a medication (often, an experience confirmed by other posters!) can't possibly be an effect of the medication, or even that the experience isn't "real!" Your comments and offering of specific examples are helpful.
> The delayed weight gain with Paxil or the increase in non-insulin-dependent diabetes with Clozaril or Zyprexa users are examples of subjective experiences that were pooh-poohed because there was no objective information in the literature.
I think that phenelzine can also contribute to type 2 diabetes, no?
> The posts we answer here are of the subjective nature, where we have to be careful not to read into the case, something that isn't there (hard to do sometimes).
Exactly. And that's one reason why I think that it's important not to generalise personal experience to other people. At the same time, we may discover by reading this board that other people have had similar experiences to our own, which suggests that the experience may be caused by the medication (or whatever) in question.
> > I understand. Your knowledge includes knowledge of your limitations; a person without such knowledge might be unaware of his limitations.
> >
> • I shouldn't take his advice as a personal affront, though.That's reasonable too, but I don't recall your reply to him containing any content that I would expect to be offensive to him or others. So I don't think that the taking-it-personally thing really caused any harm: you made your point, which was a legitimate one, and you've also posted that you realise you were taking Sal's postings as a personal affront.
> I guess the best bet is to monitor his posts.
I guess so, although that's quite a task, as he's a frequent poster.
> He will learn what to say, and not to say, as time goes by.
I hope so.
> • I was alluding to the analogy of the Beatles, where knowledge and insight come only from hard work, and a lot of reading for understanding.
Yeah, I think I get it now.
> • Thanks for your comments, Elizabeth.
And you for yours. (What's with the dots, BTW?)
-elizabeth
Posted by Elizabeth on August 17, 2001, at 3:24:22
In reply to Re: I was gone but now I'm back, posted by Lorraine on August 16, 2001, at 23:25:22
> I was in North Carolina for a couple of days with my daughter.
Hey, I lived in NC (Winston-Salem) for 8 years. Where were you (what part of NC, that is)?
> I can't really say how I'm doing exactly. It's not completely clear to me.
That's understandable. Sometimes it can take time for moods and such to cement.
> For one thing, I am pretty much done with hyperventilating.
The Parnate might be responsible; it sounds like you're growing tolerant to the initial stimulant-like effects, which is probably a good thing.
I don't know anything about estrogen dominance so I can hardly form an opinion there. < g >
> Correct and the last one I attended impressed upon me the importance of the participants in the group on its value (little value in that last one).
That's often said of 12-step groups, certainly: "find a meeting you like."
> ... I suspect it's like a lot of the non-med models, it works for some of the people some of the time.
I think it just isn't that effective in severe depression, personally. When I've been off meds, I haven't been able to get a thing out of CBT; and when I've been on medication that was working, CBT was irrelevant. Anxiety disorders (except possibly generalised social phobia) are another story.
> I have no idea about the strength of the claim that thoughts are responsible for emotions or emotions are responsible for thoughts.
I think the distinction between the two is more blurred than a lot of simplistic theories make it appear.
> How can we possibly know any of this? We are only an N of 1, but it's the 1 that matters most to us:-) I think the "experiments" using control groups with this or other talk therapy are just not useful. It either works for the individual or not.
Yes, exactly! Psychologists want to be "scientific" (a phenomenon that's been known as "physics envy"), but their "experiments" are usually pretty bogus.
> >I did learn some tricks that have helped a lot with the panic attacks.
>
> Do those techniques still work for you? Just curious. I've done the breathing stuff and it works for about 15 minutes.I seldom have panic attacks anymore (although desipramine by itself doesn't seem to work as well as Parnate did). But yes, those techniques still help.
> What i mean is that I believe that there is sometimes just a mental component, sometimes just a physical component and sometimes both.
Ahh. I think I've said before that I don't find the mental-physical distinction to be meaningful. Also, I don't think it's necessarily true that endogenous depression will only respond to somatic treatments or that reactive depression will only respond to talk therapy.
> I find I can be stoic about certain side effects, like dry mouth, constipation, mild naseau and so forth, but am intolerant of others--like dramatic weight gain or sexual dysfunction.
That's true, different people have different priorities. Personally, if I find something that works, I make a serious effort to deal with the side effects.
> 40 lbs and sexual dysfunction--and marital difficulties associated therewith :-)
An effect of the tricyclic and also buprenorphine that I've been noticing is, err, dryness. I've been thinking of asking my pdoc for a cholinergic drug such as Aricept to combat this side effect.
> I agree. But it's actually not so bad. I have the file from my previous pdoc who notes my moods and life events during our visits and then I also was on Effexor for a long time (more than a year)--so we'll see.
Ahh so it's really not 100% retrospective; it's based on chart review. That's good.
> I have a fairly good memory of how bad things were or weren't
Me too, but remembering *when* sometimes eludes me! (Even on a monthly basis, as you're doing.) The only times I can reliably remember when I was feeling a certain month are when some significant, memorable event happened in that month.
> I'll let you know the results.
Cool! It will be interesting, I'm sure.
> I meant that some people are more internally driven while others are more dependent on others for their sense of self. You seemed to fall in the former camp--which is lucky if you were an odd duck of sorts.
Heh. Yes, I'm a bit of a loner, but I do have the usual basic human need for companionship.
> > > >I take Klonopin for RBD, and it works great.
>
> What's RBD?REM sleep behaviour disorder. (Physically acting out dreams while asleep. Can cause injury to self or partner.)
> Ok--more unusual stuff my pdoc said: He says that hypertensive epiosodes (not hypertension)
Umm. You mean, not the chronic hypertension that folks with cardiovascular disease often seem to have?
> is not common among people who are down-regulated, but are instead more common among people who are up-regulated (over-stimulated).
(Interesting use of the expressions "down-" and "up-regulated.") That's a possibility. I don't feel that I was especially stimulated or sedated by Parnate, except at first when it was rather activating. But it makes sense that if a stimulant mechanism were involved (presumably catecholaminergic, based on Parnate's chemical similarity to amphetamine), people who were more sensitive to that effect (i.e., who feel more stimulated on Parnate) would be more likely to have some other stimulant-like side effects. Basically, my take on the Parnate spontaneous hypertensive episodes is that Parnate probably has stimulant-like actions in addition to MAO inhibition (e.g., promoting catecholamine release), and that the stimulant actions (notably, pressor effects of dopamine) are potentiated by the MAO inhibition.
> He also says to try small amounts of the forbidden food at home with the antidote handy to see how I'll do with them.
That's a good plan.
> I'm fine with cheddar and jack cheeses so far.
Jack is probably okay; I'd avoid cheddar.
> How's your desipramine going, elizabeth? Are you augmenting with anything new?
My pdoc just got back from his vacation, and I'll be seeing him on Tuesday. So I'm still on the same stuff. The desipramine isn't working as well as it was at the high dose (300 mg/day), but I'm still noticing some benefit. My hope is that it will just take longer to work at the lower dose. Otherwise I'm just taking buprenorphine and occasionally Klonopin.
-elizabeth
Posted by Cam W. on August 17, 2001, at 5:12:44
In reply to Re: that other thread » Cam W., posted by Elizabeth on August 17, 2001, at 2:54:10
Elizabeth - I am hoping that the bullets I am putting up make it easier to see my answers.
>
> > > As I'm sure we all realise, "access" doesn't imply reading and understanding.
> > >
> > •I am not sure that all of the posters and lurkers would understand the implications.
>
> How so? (I'm afraid your explanation here has only served to make me more confused! :) )
>
•• I'm not sure that I will still make sense on this, but here goes. A person says he/she has access to journals, and then posts the abstracts. Wouldn't some of the lay public assume that this person at least understands what he is posting. For example, the layperson may believe that the person understands what the article is really saying, thus the layperson may assume the artical has been verified and is the truth, rather than a theory (or whatever). A more specific example; and doctors fall into this trap, too; a drug company puts out a study by a leading expert saying that their drug is significantly better than a competitor's drug, for a certain indication. But when you look at the data, the sample size this is derived from is very small, and the result is only significant using fancy statistics. The layperson may not understand that, from a clinical point of view, that the study is really worthless, unless it is confirmed by subsequent randomized-placebo-control trials in naturalistic settings using a much, much larger, and diverse, population. Therefore, the person using his access, can fool the layperson into thinking that the study was critiqued properly, and can take the information as gospel. Did I read too much into this?
>
> > The delayed weight gain with Paxil or the increase in non-insulin-dependent diabetes with Clozaril or Zyprexa users are examples of subjective experiences that were pooh-poohed because there was no objective information in the literature.
>
> I think that phenelzine can also contribute to type 2 diabetes, no?
>
•• Yeah, I think so, but not to the degree we are seeing it with Clozaril and Zyprexa. Even people who do not have risk factors (eg. not overweight or have not gained a lot of weight) are still becoming diabetic. I'll let minds greater than mine figure this one out. Also, the extent we are seeing it with atypicals over MAOIs is possibly due to the difference in sheer numbers of patients using these two classes of drugs.
>
> > The posts we answer here are of the subjective nature, where we have to be careful not to read into the case, something that isn't there (hard to do sometimes).
>
> Exactly. And that's one reason why I think that it's important not to generalise personal experience to other people. At the same time, we may discover by reading this board that other people have had similar experiences to our own, which suggests that the experience may be caused by the medication (or whatever) in question.
>
•• Good point.And a good exchange; it was fun. Thanks. - Cam
Posted by Lorraine on August 17, 2001, at 11:45:53
In reply to Re: I was gone but now I'm back » Lorraine, posted by Elizabeth on August 17, 2001, at 3:24:22
elizabeth:
> Hey, I lived in NC (Winston-Salem) for 8 years. Where were you (what part of NC, that is)?Ocean Isle to visit my cousins who were vacationing at the beach
>
> > I can't really say how I'm doing exactly. It's not completely clear to me.
>
> That's understandable. Sometimes it can take time for moods and such to cement.Plus, this sedating component to Parnate might be serotonin related? Now I think my reaction is my bodies response to Parnate--ie growing or shrinking neurotransmittors--I'll have to wait it out and see where I land. I may need to add a stimulant to it.
>
> > > > I think it just isn't that effective in severe depression, personally. When I've been off meds, I haven't been able to get a thing out of CBT; and when I've been on medication that was working, CBT was irrelevant. Anxiety disorders (except possibly generalised social phobia) are another story.My take is that that severe depression is so physical that monkeying with mind sets and mental gymnastics won't put a dent in it without some med support. If you have developed coping patterns for dealing with childhood abuse that are maladaptive and trigger shame spirals, you pretty much have to get in there and clean that stuff out because they cause deep mood dips (that's a technical term< g >) that are barely tolerable when you are normal and completely intolerable when you are depressed.
> > > I have no idea about the strength of the claim that thoughts are responsible for emotions or emotions are responsible for thoughts.
>
> I think the distinction between the two is more blurred than a lot of simplistic theories make it appear.It's blurred, but, for me at least, still useful in terms of determining how to tackle difficulties. Maybe it's backed into--is this something that changing my thinking or approach could help? Sometimes yes, sometimes no. When you have severe depression, swatting at it with meditation or exercise just seems pointless to me. But these things can make a difference when the depression is marginal (maybe the meds achieve response but not remission and this stuff makes the difference).
> > > Yes, exactly! Psychologists want to be "scientific" (a phenomenon that's been known as "physics envy"), but their "experiments" are usually pretty bogus.I don't know how much psychologists want to be scientific as opposed to how much they want to achieve respectability in a scientific community that doesn't value things that can't be measured or that don't fit the experimental design model in vogue today. My undergrad major was experimental psychology and I took a boat load of statistics classes and experimental design classes. It is very helpful for picking apart studies, but I find that I am still skeptical even of studies that fit the parameters of "good" scientific design. Maybe this is because so many of them show things that are false. For instance, the weight gain and sexual dysfunction side effects of the SSRIs are much higher than the studies would lead you to suspect. Now maybe this is the length of time of the study or the methodology of determining side effects (self report as opposed to asking), but it is easy to get misled by a study that is flawed in certain respects but presented in a nicely tied experimental design package. In a way, it goes back to the N of 1 and doctors saying "no, that side effect is not attributable to this med". The fact is they don't know and rather than coming clean with just how limited our knowledge is and deal with the amount of ambiguity out there, many doctors pretend (this isn't a conspiracy, the pretense gives the doctors comfort) a higher level of confidence than is warranted. In short, I think that the god of scientific methodology is a false god.
> > > I seldom have panic attacks anymore (although desipramine by itself doesn't seem to work as well as Parnate did). But yes, those techniques still help.Were the techniques to control self talk, like "this is just a panic attack. I'm not going to die" and breathing or something more?
> > >Also, I don't think it's necessarily true that endogenous depression will only respond to somatic treatments or that reactive depression will only respond to talk therapy.
Well, yeah. This is what makes it all so difficult because of the interactive nature of mind/brain stuff. But if you recognize this inherent limitation, I think the dichotomy can be useful (ie it's not wholly true, but then neither is it wholly false--it's just a useful "way of looking" at some of the issues).
> > > That's true, different people have different priorities. Personally, if I find something that works, I make a serious effort to deal with the side effects.I can see that you do. If my previous pdoc had been more open minded, I might have added a stimulant to the Effexor and stayed on it.
> > > An effect of the tricyclic and also buprenorphine that I've been noticing is, err, dryness. I've been thinking of asking my pdoc for a cholinergic drug such as Aricept to combat this side effect.Dryness is a constant companion of those who lack estrogen, like me. I use some of the better lubricants, although right now I'm using something called "wicked" (this may be an off lable use :-) I'm also doing that thing for arousal that someone posted here (a certain thigh creme with argenon mixed in)--it works, but is a bit messy.
> > > Ahh so it's really not 100% retrospective; it's based on chart review. That's good.
Yeah, Much better than relying on my memory alone.
> > > Me too, but remembering *when* sometimes eludes me! (Even on a monthly basis, as you're doing.) The only times I can reliably remember when I was feeling a certain month are when some significant, memorable event happened in that month.I have just found that it is so difficult to tell what is impacting what without a mood journal (daily--prospective). For instance, that supplement that I told you stopped my nail biting may not be what was affecting me because I'm still taking that supplement but I'm back to biting my cuticles. My pdoc thinks it was the Adderal that was affecting that activity. He said that he has had tricc??? (hair pullers) stop pulling hair on Adderal, surprised the putty out of him. So see a daily mood chart will have this info on it so that even if my "mind set" tells me it's the supplement that is supposed to calm nerves, the record is there for me to review later.
> > Ok--more unusual stuff my pdoc said: He says that hypertensive epiosodes (not hypertension)
>
> Umm. You mean, not the chronic hypertension that folks with cardiovascular disease often seem to have?no, I'm talking about the "cheese" reaction to MAOs.
>
> > is not common among people who are down-regulated, but are instead more common among people who are up-regulated (over-stimulated).
>
> (Interesting use of the expressions "down-" and "up-regulated.")Yeah, I know. It's a pretty simplistic way of looking at things (although simple does not mean wrong). The brain wave people (EEG Spectrum) looked at it this way also and used the same language.
> > >That's a possibility. I don't feel that I was especially stimulated or sedated by Parnate, except at first when it was rather activating. But it makes sense that if a stimulant mechanism were involved (presumably catecholaminergic, based on Parnate's chemical similarity to amphetamine), people who were more sensitive to that effect (i.e., who feel more stimulated on Parnate) would be more likely to have some other stimulant-like side effects. Basically, my take on the Parnate spontaneous hypertensive episodes is that Parnate probably has stimulant-like actions in addition to MAO inhibition (e.g., promoting catecholamine release), and that the stimulant actions (notably, pressor effects of dopamine) are potentiated by the MAO inhibition.
You point (re stimulant actions of Parnate being associated with hypertensive episode) is a good one. My pdoc wasn't talking about Parnate though--he meant all MAOs and would expect the same reactions on Nardil for someone who was down regulated. Maybe this is related to being a slow or fast metabolizer as well. He means that your system may be over or under stimulated to begin with and that this is associated with how you react to the dietary restrictions of MAOs.
> > > I'm fine with cheddar and jack cheeses so far.
>
> Jack is probably okay; I'd avoid cheddar.The cheddar was mild--not significantly aged.
> > > My pdoc just got back from his vacation, and I'll be seeing him on Tuesday. So I'm still on the same stuff. The desipramine isn't working as well as it was at the high dose (300 mg/day), but I'm still noticing some benefit. My hope is that it will just take longer to work at the lower dose. Otherwise I'm just taking buprenorphine and occasionally Klonopin.How many weeks are you on the desipramine now? Your patience is great and may well pay off. Let's hope.
Lorraine
Posted by Elizabeth on August 17, 2001, at 13:52:47
In reply to Re: that other thread » Elizabeth, posted by Cam W. on August 17, 2001, at 5:12:44
> Elizabeth - I am hoping that the bullets I am putting up make it easier to see my answers.
Ahh. They are -- nice.
> •• I'm not sure that I will still make sense on this, but here goes. A person says he/she has access to journals, and then posts the abstracts. Wouldn't some of the lay public assume that this person at least understands what he is posting.
Okay, I understand now. Yes, that is a good point. Understanding the nuances of what information can be gleaned from a study or an article is not a simple matter. (Good example about pharm companies!)
I'm not sure that I agree with the idea that studies should necessarily be carried out in more diverse populations. (Maybe I'm just misunderstanding what you were getting at.) I'm all for specificity, since drugs have different effects on people depending on the nature of the condition being treated as well as patient characteristics such as age, sex, etc.
> > I think that phenelzine can also contribute to type 2 diabetes, no?
> >
> •• Yeah, I think so, but not to the degree we are seeing it with Clozaril and Zyprexa.Really. That's surprising. I'm pretty sure I became insulin-resistant on Nardil; Zyprexa caused some cravings but it wasn't nearly as bad. Then again I was taking low-dose Zyprexa, and that might factor in.
> Even people who do not have risk factors (eg. not overweight or have not gained a lot of weight) are still becoming diabetic.
That's interesting that people develop type 2 diabetes without having gained weight on the drug. Do these individuals experience appetite stimulation (if you know)?
> Also, the extent we are seeing it with atypicals over MAOIs is possibly due to the difference in sheer numbers of patients using these two classes of drugs.
True. (I think it's the hydrazine MAOIs that cause it, not nonhydrazines like Parnate and selegiline.)
> And a good exchange; it was fun. Thanks. - Cam
Same to you. :)
-elizabeth
Posted by Elizabeth on August 17, 2001, at 14:29:54
In reply to Re: I was gone but now I'm back » Elizabeth, posted by Lorraine on August 17, 2001, at 11:45:53
> Ocean Isle to visit my cousins who were vacationing at the beach
I'm not sure exactly where that is, but W-S is nowhere near any beach.
> Plus, this sedating component to Parnate might be serotonin related?
It's hard to say. Messing with serotonin does throw your sleep biorhythms all out of whack. There are other (non-serotonergically mediated) effects that can contribute to drowsiness too (such as orthostatic hypotension).
> I may need to add a stimulant to it.
Careful with that, ok?
> My take is that that severe depression is so physical that monkeying with mind sets and mental gymnastics won't put a dent in it without some med support.
That sounds about right, yup. I really wanted to believe that CBT would be "the answer," too, so it wasn't like I didn't give it my best shot.
> If you have developed coping patterns for dealing with childhood abuse that are maladaptive and trigger shame spirals, you pretty much have to get in there and clean that stuff out because they cause deep mood dips (that's a technical term< g >) that are barely tolerable when you are normal and completely intolerable when you are depressed.
I understand, and this makes sense to me. I think that depression (without any deep childhood issues) can cause secondary problems such as demoralisation (just as panic disorder can lead to agoraphobia). Those secondary problems may resolve once the depression is treated, but if they don't, I think that talk therapy may be in order.
> I don't know how much psychologists want to be scientific as opposed to how much they want to achieve respectability in a scientific community that doesn't value things that can't be measured or that don't fit the experimental design model in vogue today.
That's pretty much what I meant. And I think that eliminating subjective experience from consideration in psychology is a mistake. (Reminds me of extremist behaviourism, a la B.F. Skinner.)
> My undergrad major was experimental psychology and I took a boat load of statistics classes and experimental design classes. It is very helpful for picking apart studies, but I find that I am still skeptical even of studies that fit the parameters of "good" scientific design. Maybe this is because so many of them show things that are false. For instance, the weight gain and sexual dysfunction side effects of the SSRIs are much higher than the studies would lead you to suspect.
I think this is an example of the effects that corporate pressure can have on research: if the funding's coming from the drug company, you want to get results that the drug company will like so they'll keep giving you money. So in situations where you have discretion, you [the researcher, that is] throw away data points that don't fit the curve, nudge the stats in the direction you want them to go, etc.
> Were the techniques to control self talk, like "this is just a panic attack. I'm not going to die" and breathing or something more?
That wasn't really a technique so much as a simple result of having someone point out to me that I was having panic attacks. I did some research on panic disorder, and it made me feel much more at ease, so that the panics were easier to cope with. The "techniques" I was referring to were things like diaphragmatic breathing and meditation.
> Well, yeah. This is what makes it all so difficult because of the interactive nature of mind/brain stuff. But if you recognize this inherent limitation, I think the dichotomy can be useful (ie it's not wholly true, but then neither is it wholly false--it's just a useful "way of looking" at some of the issues).
A model, you mean. Yes, that might be more accurate than to consider it the literal truth.
> > That's true, different people have different priorities. Personally, if I find something that works, I make a serious effort to deal with the side effects.
>
> I can see that you do.Well, there are a limited number of things that work, so... Buprenorphine has been a big challenge; it's much more intense (in terms of its effects, both desired and unwanted) than classic ADs were.
> If my previous pdoc had been more open minded, I might have added a stimulant to the Effexor and stayed on it.
So many people on this board could tell stories that begin, "If my previous pdoc had been more open minded..."
> Dryness is a constant companion of those who lack estrogen, like me.
Good point; I don't think estrogen supplementation is a good idea for me, though.
> I use some of the better lubricants, although right now I'm using something called "wicked" (this may be an off lable use :-)
Off label? Uh. What's it labelled for?
> I'm also doing that thing for arousal that someone posted here (a certain thigh creme with argenon mixed in)--it works, but is a bit messy.
Interesting!
> I have just found that it is so difficult to tell what is impacting what without a mood journal (daily--prospective).
I think that's true; they are useful. Unfortunately, when I first start taking something, I tend to be too depressed to be in any shape to keep a mood journal!
> For instance, that supplement that I told you stopped my nail biting may not be what was affecting me because I'm still taking that supplement but I'm back to biting my cuticles.
Same thing happened to me with lithium: I started taking it and a week later I was feeling much more alive and interested in things, so I assumed it was the lithium. In retrospect I think it was just a random fluctuation.
> My pdoc thinks it was the Adderal that was affecting that activity. He said that he has had tricc??? (hair pullers) stop pulling hair on Adderal, surprised the putty out of him.
That does seem like a symptom that could be exacerbated by stimulants, yes. (It's trichotillomania, BTW.)
> So see a daily mood chart will have this info on it so that even if my "mind set" tells me it's the supplement that is supposed to calm nerves, the record is there for me to review later.
I think that putting it in writing also has the potential to be an outlet for your thoughts about the treatment, so that you don't get preoccupied with it outside the journal.
> > Umm. You mean, not the chronic hypertension that folks with cardiovascular disease often seem to have?
>
> no, I'm talking about the "cheese" reaction to MAOs.The phrase I was confused about was "hypertensive episodes (not hypertension)." When you said "hypertension," did you mean sustained hypertension (as in CV disease)? If not, what did you mean?
> You point (re stimulant actions of Parnate being associated with hypertensive episode) is a good one.
I think of it as the Parnate interacting with itself: it has two different effects that interact. (The stimulant effect has never been confirmed, but there's a lot of suggestive evidence.)
> My pdoc wasn't talking about Parnate though--he meant all MAOs and would expect the same reactions on Nardil for someone who was down regulated.
I think Parnate and Nardil are not at all interchangeable. A person can be very tired on one and activated on the other.
> He means that your system may be over or under stimulated to begin with and that this is associated with how you react to the dietary restrictions of MAOs.
I could see that. What does it mean for people like me who tend to be slowed-down and tired but also have a hyperactive startle response?
> > Jack is probably okay; I'd avoid cheddar.
>
> The cheddar was mild--not significantly aged.OK, if you have that level of information about it, that's probably fine to use your judgment.
> How many weeks are you on the desipramine now? Your patience is great and may well pay off. Let's hope.
I sure am (hoping).
I started taking DMI on 2 July at 25 mg/day. I got to 100 mg/day (low-end effective dose) on 12 July. So it's been a good while.
-elizabeth
Posted by Cam W. on August 17, 2001, at 16:59:05
In reply to Re: that other thread » Cam W., posted by Elizabeth on August 17, 2001, at 13:52:47
Elizabeth -
>
> I'm not sure that I agree with the idea that studies should necessarily be carried out in more diverse populations. (Maybe I'm just misunderstanding what you were getting at.) I'm all for specificity, since drugs have different effects on people depending on the nature of the condition being treated as well as patient characteristics such as age, sex, etc.
>
• I believe that large scale naturalistic studies, using clinical situations, in the post-marketing surveillance stage of drug development is essential. If it were done more, we would have caught the delayed weight gain with Paxil, or the withdrawl syndrome of short-acting SRI-like drugs. The other, proper randomized, placebo-controlled clinical trials are necessary to produce a short-term therapy baseline, but these need to be extended to real world situations.
>
> > > I think that phenelzine can also contribute to type 2 diabetes, no?
> > >
> > •• Yeah, I think so, but not to the degree we are seeing it with Clozaril and Zyprexa.
>
> Really. That's surprising. I'm pretty sure I became insulin-resistant on Nardil; Zyprexa caused some cravings but it wasn't nearly as bad. Then again I was taking low-dose Zyprexa, and that might factor in.
>
• Dose does not seem to be strongly related to the incidence of the diabetes, either. It is probably a numbers game we are looking at. When you see 5 people taking Nardil and 100 people taking Zyprexa, it is going to look like the Zyprexa is a worse offender, because you see more of them.
>
> > Even people who do not have risk factors (eg. not overweight or have not gained a lot of weight) are still becoming diabetic.
>
> That's interesting that people develop type 2 diabetes without having gained weight on the drug. Do these individuals experience appetite stimulation (if you know)?• On the whole, we usually see both weight gain and diabetes, but I have read articles where no weight gain and diabetes occurred. I do not know much more than that, and it would have been interesting to see his baseline triglyceride levels prior to the initiation of therapy, as well as his family Hx for diabetes (ie. the people could have been borderline diabetics, to start with. These were not mentioned in the two different articles (can't find them quickly, of course), but the articles did not go into much detail on them. I do not know about appetite stimulation in the non-weight gainers.
Back at ya ;^)
- Cam
Posted by shelliR on August 17, 2001, at 20:51:23
In reply to Re: Update Lorainne, Elizabeth, et. al. » shelliR, posted by Lorraine on August 16, 2001, at 23:54:46
Update Lorainne, Elizabeth, et.al.
>
> I finished the Magic Daughter while I was away this weekend. I thought it was a great book. It did not overly dramatize the condition and I felt as though I understood how having alters or personalities operates. Mainly it seemed like such a job for her to just get her history down right in chronological order given all the memory gaps that she had. Her explanation of the effect the multiple personality disorder had on her--in terms of friends, relatives and so forth was distressing. Not an easy row < to hoe.I'm glad you liked it. I cried and cried the first night her kids had integrated. I think she wrote really well about how soothing it was to integrate (no more voices) and how sad it was to lose her kids. And I also liked the fact that she was not either "poor me" or "aren't I just so interesting." It was a struggle, and DID is a struggle. I don't know how common it is for people to continuing working once they discover they had DID. This last time I was in the hospital I got to know a past university professor ?(she had a phd but I'm not sure where she was on the university ladder) who had gotten fired about four years ago--one of her alters (teenaged boy, about 19) did lots of stuff that she didn't know about which resulted in her termination. It was one of those enough shame in childhood things, but also shame in adult life. Luckily for me I have been spared all of that trauma, so I don't mean it lightly when I say I don't have DID, although other patients in the hospital often just think I'm in denial as did my last therapist.
> I would love to see your website with your work sometime. I am curious about it and I know how important it is to you. My email address is lbj90068@yahoo.com
okay, will send. If you push anything you the first page with an underline, you'll get another page. I thought everyone would just know that, but I got a call this week from someone who said she saw my four pictures. (And I have about 20 something).
>
> [re therapist attachment]but that thing that kids do "look at me"; Mommy listen to me.
> After reading the book, it seemed that she was just desperate to have someone she could trust listen to her story--the need to tell the story and have it validated was I'm sure an over-powering compulsion. Is this closer to the mark?that's still not the hole I'm referring to, but it's okay; we can give up on this one--it's not so important to me that you understand exactly.
>
>
>
> > > >I was unable to work. I had planned to become a clinical psychologist, but wasn't together enough (I knew that, but even so got a masters), so this came out of going back to take a couple of art classes at my therapist's insistance at the time that I create some structure in my life. I now have absolutely no desire to be a therapist.
>
> The same therapist you are seeing now? Mine is pushing me to write. I do have one published poem and it is about her:-)
No, it was two therapists ago. So yours wants to read more about herself? < g >. Do you have an urge to write more? Where is your poem published, that's hard feat.
>
> .
> It is so hard to tell what is causing what during these drug trials, isn't it? Are these confounding, compounding or primary variables?
I am completely mixed up. My therapist was upset that I gave up on parnate and I have probably more disappointment waiting when my pdoc comes back on Monday. I am not scheduled to see him until Thursday, but I'm feeling pretty desparate, so I'm to call on Monday and see if anyone cancelled or he can fit me in. His coverage guy told me that he's switched people from parnte to nardil without any waiting period, but that it is probably safer to wait a week .
Someone on this board was taking both nardil and a small amount of parnate at the same time. That I've never heard of, but it was working for her.I had a horrible session on Thurday with therapist and I've cancelled Monday with her so I could leave open all day in case the pdoc can see me. But honestly at this point, therapy just makes me feel worse because I can't work on issues when I feel so depressed and so scared. It's mainly letting people down on the job front. But I am feeling very stuck. Thursday was the first time, I really wanted her to be warmer toward me. I'm sure I was very frustrating because she wanted to work on ways of self-soothing when I feel that bad, and I just wanted to go home and back to bed. But even though my insurance pays, it won't pay if I don't show up and I have to cancel 24 hours in advance or pay $185 dollars (an hour and a half on Thursdays). So at least Monday is cancelled, and I won't go Thursday if I am still feeling bad on Wednesday. I'd had therapists that if I felt horrible I could just lie down there and feel safe for that time, but it wasn't going in that direction last Thursday. And I guess she's just doing her job of helping me be able to handle things by myself. (She said it waa my decision, that I could leave, but then I asked how she would feel if I left and felt like I had to call her later. She said, a bit annoyed, but not horribly angry. I was feeling too bad to handle even slight annoyance from her so I stayed. And I didn't need to call later; just drugged myself up and went to sleep.)
I don't know if I did the right thing with stopping parnate, but I do know that if I start out a drug with bad side effects, e.g., complete fatigue and nausea, and complete a whole trial, a month to six weeks, it never has turned out well--always been a waste of time. So that's what I based my decision on. I did a search of the whole archives and almost everyone who had a good experience with parnate had a lessening of depression very quicky. (Then sometimes they went through a murkier period like you are), but you still fit the success category because it will take at least two to four weeks to totally feel the effect. But that early blip of feeling good seems like "the" sign. Jah sounded like me--went through nausea and exhausion and kept trying and finally gave up at the end of six weeks. I didn't want to go through this possibly for another five weeks. I had promised myself last summer that if I didn't feel right about a drug, I would give up in a few days. This was after many long drug trials, the last of which was topomax and I was sleeping 18 hours a day, and my pdoc (last one) saying , go up, go up more.
I think it's time for me to switch from oxycontin to buprenorphine. Because 10mg of oxy is not enough now and 20 is too much and there is nothing inbetween. Also the fact that 10mg doesn't work for me anymore is a disappointment to say the least, although I wish I had started it with nardil, because it was always meant for me to take with an AD and I've gone on and off selegiline, prozac and parnate in the time I've been taking the oxycontin and done a long washout period after and again after prozac. I wonder if I would have not created a tolerence if I had stayed on one anti-depressant. I don't know my doctor's feelings about buprenorphine. I brought it up once and he dismissed it by saying the oxy was fine, but I need to go over that again. Also I am willing to try nardil with concerta, only then I'd have to give up the oxy--too much stimulation. If I come out of his office next week with a presciption for bup, then I'll be satisfied and that is what is getting me through this weekend. That and hydrocodone and klonopin.
>
>
> Just back today from North Carolina.
I was thinking you had been away for a vacation.I was supposed to drive to my sister's today and my parents tonight, but I felt too awful. I'll try again tomorrow to just do one night with my parents. They're only 3 hours away, but I was too depressed, and then too drugged to drive.
Shelli
Posted by Lorraine on August 17, 2001, at 23:23:13
In reply to Re: I was gone but now I'm back » Lorraine, posted by Elizabeth on August 17, 2001, at 14:29:54
Elizabeth:
> > > Plus, this sedating component to Parnate might be serotonin related?
>
> It's hard to say. Messing with serotonin does throw your sleep biorhythms all out of whack. There are other (non-serotonergically mediated) effects that can contribute to drowsiness too (such as orthostatic hypotension).then maybe remedies for orthostatic hypotension would be effective--eat more salt and drink more water?
>
> > > I may need to add a stimulant to it.
>
> Careful with that, ok?I tried it last week and I was very careful. I added less than 1 mg of Adderal to the mix, wasn't happy with it then, but the sands are still moving under my feet so who knows? I will be careful.
> > > I understand, and this makes sense to me. I think that depression (without any deep childhood issues) can cause secondary problems such as demoralisation (just as panic disorder can lead to agoraphobia). Those secondary problems may resolve once the depression is treated, but if they don't, I think that talk therapy may be in order.i guess it works both ways, yes.
> > > I think this is an example of the effects that corporate pressure can have on research: if the funding's coming from the drug company, you want to get results that the drug company will like so they'll keep giving you money. So in situations where you have discretion, you [the researcher, that is] throw away data points that don't fit the curve, nudge the stats in the direction you want them to go, etc.Well a drug company's mind set is pretty easy to determine, but I think any mind set brought to the equation (notwithstanding the null hypothesis) affects the framing of the question and the interpretation of the results.
> > > So many people on this board could tell stories that begin, "If my previous pdoc had been more open minded..."Isn't that the truth? How about if my SIL, my ex-boss, my son etc were more open minded? This is the frame of reference issue that I keep harping on. Course, I suppose if they agreed with me.....< g >
> > > Good point; I don't think estrogen supplementation is a good idea for me, though.Me neither!
>
> > I use some of the better lubricants, although right now I'm using something called "wicked" (this may be an off lable use :-)
>
> Off label? Uh. What's it labelled for?It's a very small tube so it's hard to imagine what else it could be used for. But I suppose its on label use is massage
>
> I think that's true; they are useful. Unfortunately, when I first start taking something, I tend to be too depressed to be in any shape to keep a mood journal!I can relate to that.
>
> > My pdoc thinks it was the Adderal that was affecting that activity. He said that he has had tricc??? (hair pullers) stop pulling hair on Adderal, surprised the putty out of him.
>
> That does seem like a symptom that could be exacerbated by stimulants, yes. (It's trichotillomania, BTW.)No, he believes that Adderal irradicated the symptom of hair pulling and was surprised that it had. He was speculating that perhaps it was the Adderal that stopped me from biting my cuticles since I stopped at about the time I started Adderal and resumed around the time I stopped Adderal.
> I think that putting it in writing also has the potential to be an outlet for your thoughts about the treatment, so that you don't get preoccupied with it outside the journal.
Probably.
> > > The phrase I was confused about was "hypertensive episodes (not hypertension)." When you said "hypertension," did you mean sustained hypertension (as in CV disease)? If not, what did you mean?
I meant the "cheese" reaction to MAOs.
>>
> > You point (re stimulant actions of Parnate being associated with hypertensive episode) is a good one.
>
> I think of it as the Parnate interacting with itself: it has two different effects that interact. (The stimulant effect has never been confirmed, but there's a lot of suggestive evidence.)
>
> > My pdoc wasn't talking about Parnate though--he meant all MAOs and would expect the same reactions on Nardil for someone who was down regulated.
>
> I think Parnate and Nardil are not at all interchangeable. A person can be very tired on one and activated on the other.Right. He agrees. He says that you haven't eliminated the class of MAOs until you have tried them all b/c they are all different. But they do have in common this hypertensive crises stuff, don't they? And this is where he sees the similarity in terms of an individual's response. Those who are up-regulated would tend to be more prone to hypertensive crisis than those who are down-regulated like me.
>
> > He means that your system may be over or under stimulated to begin with and that this is associated with how you react to the dietary restrictions of MAOs.
>
> I could see that. What does it mean for people like me who tend to be slowed-down and tired but also have a hyperactive startle response?Probably he would say this indicates a need for anti-convulsants. But then he wouldn't say this unless the QEEG backed it up.
Take good care elizabeth, nice chatting with you as usual.Lorraine
Posted by Lorraine on August 17, 2001, at 23:56:27
In reply to Re: Update Lorainne, Elizabeth, et. al. » Lorraine, posted by shelliR on August 17, 2001, at 20:51:23
Shelli:
I do feel for you on this Parnate trial stuff. I figured out once that if I just kept trying drugs sequentially for the full trial period, I might well be dead without anything working. So I've become pretty insistent that some positive effects occur quickly. Anyway, when I read all of your posts in one sitting last night, it looked like it wasn't clear to you what was causing the problem (are we ever?) Sounded like maybe it was having two periods so closely spaced together and PMS in between? At one point I thought you said you felt the depression had lifted and if it weren't for the PMS stuff.... Well, it's very difficult to sort this stuff out with my own body, but at some point you made a determination that the Parnate wasn't doing it for you. Good luck getting in early. It must be terrible to be between meds. Course for me now, I suspect that I'll just pick up on the old Adderal and Neurontin combo if I need to quit Parnate. That combo really did tide me over.
> > > I'm glad you liked it. I cried and cried the first night her kids had integrated.I thought of your comment about not wanting integration when I read that.
> > >so I don't mean it lightly when I say I don't have DID, although other patients in the hospital often just think I'm in denial as did my last therapist.
Wouldn't you expect have strangers recognize you if you had DID or at least memory gaps? I don't know, my hunch is that you know yourself better than they do.
> > > okay, will send.Great! I look forward to seeing your work.
> >
> > [re therapist attachment]but that thing that kids do "look at me"; Mommy listen to me.
> > After reading the book, it seemed that she was just desperate to have someone she could trust listen to her story--the need to tell the story and have it validated was I'm sure an over-powering compulsion. Is this closer to the mark?
>
> that's still not the hole I'm referring to, but it's okay; we can give up on this one--it's not so important to me that you understand exactly.A little frustrating b/c I have the sense that if we were actually talking about this face-to-face, we would have made the connection. sigh....
> No, it was two therapists ago. Do you have an urge to write more? Where is your poem published, that's hard feat.Sometimes I do have the urge. The problem is that I would like to write a longer work and my moods haven't stabilized to the point where I want to make the commitment to the process. For instance, I have an outline of a book--it was outlined last January, but I haven't been able to do any work on it at all. The poem was published in "On the Bus", which is edited by my teacher Jack Grapes so getting it published wasn't that hard. I had some more poems in progress. You've inspired me to turn back to them:-)
> > >My therapist was upset that I gave up on parnate and I have probably more disappointment waiting when my pdoc comes back on Monday.
I'm so sorry. Just what you need right, a little criticism when your down. I suppose I feel entitled to have my therapist be my friend when I am in need--the one person in my life who is paid to be on my side when the chips are down.
> > > I had a horrible session on Thurday with therapist and I've cancelled Monday with her so I could leave open all day in case the pdoc can see me. But honestly at this point, therapy just makes me feel worse because I can't work on issues when I feel so depressed and so scared.
Have you ever asked her directly to be supportive at these times? To say, "I know we have a lot of issues to work on but right now, I just need your support to get through this period?"
> > >It's mainly letting people down on the job front.
Think of it as a bout with the stomach flu?
> > >I'm sure I was very frustrating because she wanted to work on ways of self-soothing when I feel that bad, and I just wanted to go home and back to bed.
Sometimes we are too sick to work on issues--even self-soothing.
> > >I'd had therapists that if I felt horrible I could just lie down there and feel safe for that time, but it wasn't going in that direction last Thursday. And I guess she's just doing her job of helping me be able to handle things by myself.
When things were really rough for me, I had my therapist do some guided imagery with healing messages. I could lay on the floor and feel taken care of and she could feel useful.
> I don't know if I did the right thing with stopping parnate,We never Know, we just trust our instincts.
>
> I think it's time for me to switch from oxycontin to buprenorphine. Because 10mg of oxy is not enough now and 20 is too much and there is nothing inbetween.No pill splitting allowed? Even if they are capsules, you can split them by getting empty capsules at the health food store and measuring it out. I assume you have non-splittable tablets?
> >
> > Just back today from North Carolina.
> I was thinking you had been away for a vacation.I'm in and out of town until the kids are back in school--a couple of weeks from now. Vacations are an effort for me though, I must admit.
> > > I was supposed to drive to my sister's today and my parents tonight, but I felt too awful. I'll try again tomorrow to just do one night with my parents. They're only 3 hours away, but I was too depressed, and then too drugged to drive.All you can do is do what you can with the resources you have at the time. It will be sufficient. It has to be.
Lorraine
PS Today Parnate was good to me.
Posted by jotho on August 18, 2001, at 9:20:55
In reply to Re: that other thread » Elizabeth, posted by Cam W. on August 17, 2001, at 16:59:05
Hi...
Just a quick one. Saw your posts regarding zyprexa and diabetesII. Am i right in assuming this would only be a concern when using it as a anti-P, and not of great concern in low dosage, say 10mg. and under?
Thanks always, Elizabeth and Cam, for your time and knowledge......jotho
Posted by Cam W. on August 18, 2001, at 14:09:08
In reply to Re: that other thread--Elizabeth and » Cam W., posted by jotho on August 18, 2001, at 9:20:55
Jotho - It is a small concern when using Zyprexa or Clozaril at any dose. It is best to have your blood sugars monitored when taking these meds, just in case. The blood sugar elevation doesn't happen to everyone, but they cannot predict who it will happen to. - Cam
Posted by shelliR on August 20, 2001, at 21:32:38
In reply to Re: Update Lorainne, Elizabeth, et. al. » shelliR, posted by Lorraine on August 17, 2001, at 23:56:27
> Shelli:
>
> I do feel for you on this Parnate trial stuff. I figured out once that if I just kept trying drugs sequentially for the full trial period, I might well be dead without anything working. So I've become pretty insistent that some positive effects occur quickly. Anyway, when I read all of your posts in one sitting last night, it looked like it wasn't clear to you what was causing the problem (are we ever?) Sounded like maybe it was having two periods so closely spaced together and PMS in between? At one point I thought you said you felt the depression had lifted and if it weren't for the PMS stuff.... Well, it's very difficult to sort this stuff out with my own body, but at some point you made a determination that the Parnate wasn't doing it for you. Good luck getting in early. It must be terrible to be between meds. Course for me now, I suspect that I'll just pick up on the old Adderal and Neurontin combo if I need to quit Parnate. That combo really did tide me over.I looked back at my notes last week, and I never felt any anti-depressant effects from parnate--but I wasn't really expecting any so fast. I had sickness in my stomach and was really tired which I first attributed to PMS, but when it continued after I got my period, I realized then that it was the parnate. So I went down again to 10mg, felt okay, but raising to 15 made me sick again. Then I gave up after 8 days altogether, 5 days at 15mg It's hard to know when to give up, but almost everyone who succeeded with parnate, had that little blip at the beginning of energy and good feeling. And I have to take into account that my body does not seem to adjust to AD side effects. Yes, this may have been the first time, but it is hard, because my business is busy and I'm supposed to go to New Mexico around Labor Day. Have tickets, arrangements, all put into place. It's much different to do a trial when you are working--it's that added, I got nothing done *again* today. I took off ten days from work earlier this summer, and some of these same customers were involved then, also (now pictures are to be ready, then I was changing appointments.) Not that it doesn't suck either way--it feels crummy to feel bad, job or no job, I know. It's the responsibility part, and I try to convince myself that I am not building rocketships, but still it's hard to disappoint people and break promises.
I didn't go away this weekend. I felt too depressed and defeated, but at least I did get a bit of work done. But only a bit.
>> > > >so I don't mean it lightly when I say I don't have DID, although other patients in the hospital often just think I'm in denial as did my last therapist.
> Wouldn't you expect have strangers recognize you if you had DID or at least memory gaps? I don't know, my hunch is that you know yourself better than they do.
>
The wording of the DSM-IV makes it possible to fit or not fit yourself into the category if you have alters. They use very vague wording and never mention not having co-consciousness--just memory gaps. And memory gaps are never firmly connected to the present and I have lots of memory gaps in the distant past. The definition was a compromise between the hard-core definitions and some of the weaker, more open definitions.re writing:
> Sometimes I do have the urge. The problem is that I would like to write a longer work and my moods haven't stabilized to the point where I want to make the commitment to the process. For instance, I have an outline of a book--it was outlined last January, but I haven't been able to do any work on it at all. The poem was published in "On the Bus", which is edited by my teacher Jack Grapes so getting it published wasn't that hard. I had some more poems in progress. You've inspired me to turn back to them:-)Is it a novel that you have outlined?
>re therapist:
> Have you ever asked her directly to be supportive at these times? To say, "I know we have a lot of issues to work on but right now, I just need your support to get through this period?"
she knows that I felt she was was not being supportive; she sees it differently. I didn't go today, and I'm not sure about Thursday. After that I can't just keep canceling; I'll have to start again, or terminate for now. I'll see how my pdoc session goes tomorrow. I'm blocking out right now how much I like her and how much she's helped me in the past, I don't see any way to comfortably relate to her when I am going through these med changes.> > > >It's mainly letting people down on the job front.
> Think of it as a bout with the stomach flu?
yes, a recurring one, with no sure time frame.
>>
Tomorrow I'll see my pdoc and talk about going back on nardil and using that as my base. Then maybe add either concerta to the nardil or try buprenorphine (if I can tolerate it) with nardil, or stay with oxycontin with nardil. Those are the three things I see for now because I'm not willing to make any more big changes this late in the summer.
> > >
> > > Just back today from North Carolina.
That was a long way for just a few days.
>
> I'm in and out of town until the kids are back in school--a couple of weeks from now. Vacations are an effort for me though, I must admit.
The travel, or the vacation itself?What is your eleven year old daughter like? I have a wonderful 14 year old neice, but she is now, of course, fully emersed in being a teenager. Friends, boys, clothes, the whole thing. She's a pretty happy, confident kid, a complete extrovert. Foreign to me, but I'm happy that things are good for her and that it doesn't seem like such a hard age to her.
>
> PS Today Parnate was good to me.
I think it's going to be good for you; you have all the right signs. I hope soShelli
Posted by Elizabeth on August 22, 2001, at 13:00:02
In reply to Re: that other thread » Elizabeth, posted by Cam W. on August 17, 2001, at 16:59:05
> • I believe that large scale naturalistic studies, using clinical situations, in the post-marketing surveillance stage of drug development is essential. If it were done more, we would have caught the delayed weight gain with Paxil, or the withdrawl syndrome of short-acting SRI-like drugs.
Good point -- that information really needs to make it into the product labelling for these drugs. But how do we provide an incentive for the drug companies to investigate possible bad effects of their products once the products have been approved for marketing?
> > Really. That's surprising. I'm pretty sure I became insulin-resistant on Nardil; Zyprexa caused some cravings but it wasn't nearly as bad. Then again I was taking low-dose Zyprexa, and that might factor in.
> >
> • Dose does not seem to be strongly related to the incidence of the diabetes, either.Even when it's below the therapeutic dose for psychosis? I was taking 2.5-5 mg/day.
> It is probably a numbers game we are looking at. When you see 5 people taking Nardil and 100 people taking Zyprexa, it is going to look like the Zyprexa is a worse offender, because you see more of them.
Is Zyprexa really that common compared to Nardil?
> I do not know about appetite stimulation in the non-weight gainers.
I definitely experienced appetite stimulation on both Zyprexa and Nardil. I'm interested in finding out what's going on with people who say they gained weight without altering their eating patterns.
Your turn.
-elizabeth
Posted by Lorraine on August 22, 2001, at 13:12:02
In reply to Re: Update Lorainne, Elizabeth, et. al. » Lorraine, posted by shelliR on August 20, 2001, at 21:32:38
> > Shelli:
> >
> > I do feel for you on this Parnate trial stuff. I figured out once that if I just kept trying drugs sequentially for the full trial period, I might well be dead without anything working. So I've become pretty insistent that some positive effects occur quickly. Anyway, when I read all of your posts in one sitting last night, it looked like it wasn't clear to you what was causing the problem (are we ever?) Sounded like maybe it was having two periods so closely spaced together and PMS in between? At one point I thought you said you felt the depression had lifted and if it weren't for the PMS stuff.... Well, it's very difficult to sort this stuff out with my own body, but at some point you made a determination that the Parnate wasn't doing it for you. Good luck getting in early. It must be terrible to be between meds. Course for me now, I suspect that I'll just pick up on the old Adderal and Neurontin combo if I need to quit Parnate. That combo really did tide me over.
>
> I looked back at my notes last week, and I never felt any anti-depressant effects from parnate--but I wasn't really expecting any so fast.This was the entry I was talking about Shelli:
"But, for instance, I didn't wake up depressed yesterday or today, so maybe it's having some sort of small effects, or it's just that my hormones aren't acting crazy."
But maybe I misread that and you were talking about oxycontin?
> > >It's hard to know when to give upSometimes it's more important to simply make a decision than to spend a lot of time angonizing over whether it is the "right" one while your life passes you by. I mean you never "know" with these things and sometimes movement is the best thing.
> > >Not that it doesn't suck either way--it feels crummy to feel bad, job or no job, I know. It's the responsibility part, and I try to convince myself that I am not building rocketships, but still it's hard to disappoint people and break promises.
I know what you are talking about Shelli--it's the very thing that prevents me from making a commitment to the future--making plans, deciding what to do--I have no idea whether I will be up to fullfilling the plans I make today when tomorrow comes--not until I'm stabilized. So even if someone without a mental illness takes times off for illness, I don't think it feels the same, and, you don't know how long you will be out of commission whereas the flu is a couple of days max. The uncertainty is part of it.
> > > The wording of the DSM-IV makes it possible to fit or not fit yourself into the category if you have alters.
I still think that you would know or feel or intuit if you were DID. Maybe the definition sucks and should include the coconscious component as a factor. I have memory gaps. Don't we all?
> > > Is it a novel that you have outlined?Yes.
>
> > > she knows that I felt she was was not being supportive; she sees it differently. I didn't go today, and I'm not sure about Thursday. After that I can't just keep canceling; I'll have to start again, or terminate for now.It seems like she views you as malingering in a sense--coming up with excuses not to do the hard work of therapy and that maybe what you need is a dose of "tough love". But sometimes we are not able to work at the job or with a therapist. I wonder if a hiatus would do you both good until you stabilize.
> > >I'll see how my pdoc session goes tomorrow.
And????? Drum roll please.... What happpened?
> > > >
> > > > Just back today from North Carolina.
> That was a long way for just a few days.The truth is I hate being away from home. Vacations bother me. I don't find them relaxing. And, when I planned the trip, I wasn't sure if I could depend on my mood.
> > > The travel, or the vacation itself?The vacation itself. I have a lot of comfort routines here at home.
> > > What is your eleven year old daughter like?She's wonderful. She has the "gift of mood"--she's upbeat, enthusiastic, bright, caring...really great. This summer she finally decided she was ready for a bra. Very big step. Lots of fun for me to watch her growing and changing. I'm hoping that her teenage years won't be too rough on us.
> >
> > PS Today Parnate was good to me.
> I think it's going to be good for you; you have all the right signs. I hope soWell, I've been having these terrible headaches when I wake up in the morning every day. So I have a call into my doctor to see if these headaches are precursors to a spontaneous hypertensive crises. I also am having trouble sleeping. My mood support though is pretty good--not home free but good. So we'll see.
Posted by Elizabeth on August 22, 2001, at 13:20:26
In reply to Re: I was gone but now I'm back, posted by Lorraine on August 17, 2001, at 23:23:13
> > There are other (non-serotonergically mediated) effects that can contribute to drowsiness too (such as orthostatic hypotension).
>
> then maybe remedies for orthostatic hypotension would be effective--eat more salt and drink more water?It's worth a try, sure.
> I tried it last week and I was very careful. I added less than 1 mg of Adderal to the mix, wasn't happy with it then, but the sands are still moving under my feet so who knows? I will be careful.
Good. How do you accurately measure out 1 mg of Adderall, though???
> Well a drug company's mind set is pretty easy to determine, but I think any mind set brought to the equation (notwithstanding the null hypothesis) affects the framing of the question and the interpretation of the results.
Yes, me too.
> > So many people on this board could tell stories that begin, "If my previous pdoc had been more open minded..."
>
> Isn't that the truth? How about if my SIL, my ex-boss, my son etc were more open minded? This is the frame of reference issue that I keep harping on. Course, I suppose if they agreed with me.....< g >"If _______ were more open-minded, ..."
[re "Wicked"]
> It's a very small tube so it's hard to imagine what else it could be used for. But I suppose its on label use is massageIsn't "massage" just a euphemism? < g > Seriously, can you post the ingredients? (just curious) Is it water-based?
> > That does seem like a symptom that could be exacerbated by stimulants, yes. (It's trichotillomania, BTW.)
>
> No, he believes that Adderal eradicated the symptom of hair pulling and was surprised that it had.I'd be surprised too. Stimulants tend to cause compulsive behaviours such as messing with your hair or picking at your skin, not alleviate them! But regardless of whether it makes sense or not < g >, I'm glad Adderall helped you. Might be a clue as to where the solution lies, if nothing else.
> > The phrase I was confused about was "hypertensive episodes (not hypertension)." When you said "hypertension," did you mean sustained hypertension (as in CV disease)? If not, what did you mean?
>
> I meant the "cheese" reaction to MAOs.So "hypertension" means the cheese reaction? Then what does "hypertensive episodes" mean???
> > I think Parnate and Nardil are not at all interchangeable. A person can be very tired on one and activated on the other.
>
> Right. He agrees. He says that you haven't eliminated the class of MAOs until you have tried them all b/c they are all different.That's true. Nardil and Marplan are probably the most similar two MAOIs. Parnate is completely different, as is selegiline.
> But they do have in common this hypertensive crises stuff, don't they?
The food-drug interactions are a consequence of their MAO-inhibiting action, a property they all share. But like all drugs, MAOIs probably have other pharmacologic actions in addition to the ones we know about. This is probably why they differ.
> And this is where he sees the similarity in terms of an individual's response. Those who are up-regulated would tend to be more prone to hypertensive crisis than those who are down-regulated like me.
Umm. Well, I'm still confused about your use of the expressions "up-regulated" and "down-regulated," so I'm not sure how to make sense of that one.
> > I could see that. What does it mean for people like me who tend to be slowed-down and tired but also have a hyperactive startle response?
>
> Probably he would say this indicates a need for anti-convulsants.Mmm. Too bad anticonvulsants (Depakote, Lamictal, Neurontin) never did much for me (except for the benzodiazepines).
> Take good care elizabeth, nice chatting with you as usual.
You too :)
-elizabeth
Posted by Cam W. on August 22, 2001, at 13:55:36
In reply to Re: that other thread » Cam W., posted by Elizabeth on August 22, 2001, at 13:00:02
> But how do we provide an incentive for the drug companies to investigate possible bad effects of their products once the products have been approved for marketing?
>
• That's a good question. I do believe that even if drug companies are forthcoming with information, it will still be missed. For example, that Effexor withdrawl; I knew about the withdrawl in 1997, before an XR version was made. The company, since at least 1998 (perhaps before) had the withdrawl information in it's product monograph. I guess if you don't scream it out, not everyone listens (or has the time to read the monograph fully). It would be silly for a company (who really has to answer to shareholders) to point out the bad issues of their product. That's what competitors are for.
>
>
> Even when it's below the therapeutic dose for psychosis? I was taking 2.5-5 mg/day.
>
• Pyschosis can be treated with low doses, as well. I don't think that there is an dose/effect gradient, as seen with Effexor.• I was talking to the Zyprexa rep yesterday (met him in Starbucks interviewing a new rep), and he says that the increased incidence of type II diabetes is only seen in patients with schizophrenia (he later amended that to be, that patients with schizophrenia were the only one's studied, so far). The reason he states that there increased numbers of people getting diabetes from taking Clozaril and Zyprexa is that people with schizophrenia are 4 times as likely as the general population to get diabetes. I asked if this number included unmedicated people and he didn't know. He also blamed increased appetite and poorer than normal dietary skills (eg chips & pop diets), as being risk factors. I really can't believe that we have a number of people with schizophrenia have borderline triglyceride levels and coincidentally become diabetic after starting these two atypical antipsychotics. I have seen people without schizophrenia become diabetic, but I am sorry that I never paid attention to relative numbers.
>
> Is Zyprexa really that common compared to Nardil?• Zyprexa is prescribed much more than Nardil and for numerous indications, at least here in the north. Nardil is used as a last resort in treatment-resistant depression. Zyprexa seems to be used before Nardil, even though there is little evidence of efficacy for it's long-term use in depression.
- Cam
Posted by Lorraine on August 22, 2001, at 15:16:43
In reply to Re: I was gone but now I'm back » Lorraine, posted by Elizabeth on August 22, 2001, at 13:20:26
> > I tried it last week and I was very careful. I added less than 1 mg of Adderal to the mix, wasn't happy with it then, but the sands are still moving under my feet so who knows? I will be careful.
>
> Good. How do you accurately measure out 1 mg of Adderall, though???What do you mean by accurately:-) (1.25 is 1/4 of 5 mg tablet split inaccurately give or take .25 mg). You are a stickler for accuracy aren't you< vbg >
>
> [re "Wicked"]
> > It's a very small tube so it's hard to imagine what else it could be used for. But I suppose its on label use is massage
>
> Isn't "massage" just a euphemism? < g > Seriously, can you post the ingredients? (just curious) Is it water-based?Actually, it turns out it is for "tanning"--it has "tantilizing hot action" and comes in 4 ml tubules to be added to your regular tanning lotion. But, hey, that doesn't stop me....I suppose on of the more customary lubricants like "silk" or such would be good. I just like the tantilizing hot action, what can I say? < g >
> > > The phrase I was confused about was "hypertensive episodes (not hypertension)." When you said "hypertension," did you mean sustained hypertension (as in CV disease)? If not, what did you mean?
> >
> > I meant the "cheese" reaction to MAOs.
>
> So "hypertension" means the cheese reaction? Then what does "hypertensive episodes" mean???is all of this over an "on" rather than an "ve" ending? Elizabeth, are you being accurate (in which event we are doomed b/c like Shelli, I can't even spell) or are you playing? My husband loves to play with words, but without seeing your expression or hearing the tone of your voice, I can't tell which "accuracy" vs "fun" is your focus. How about "I will not confuse hypertensive crisis with hypertension" one hundred times on the blackboard, like Bart of the Simpsons.
> > >But like all drugs, MAOIs probably have other pharmacologic actions in addition to the ones we know about. This is probably why they differ.
>
> > And this is where he sees the similarity in terms of an individual's response. Those who are up-regulated would tend to be more prone to hypertensive crisis than those who are down-regulated like me.
>
> Umm. Well, I'm still confused about your use of the expressions "up-regulated" and "down-regulated," so I'm not sure how to make sense of that one.I shouldn't insist on his language actually because it is confusing. He means over-stimulated vs under-stimulated and he determines this based on your QEEG.
>
> > > I could see that. What does it mean for people like me who tend to be slowed-down and tired"under-stimulated"
> >
> > Probably he would say this indicates a need for anti-convulsants.
>
> Mmm. Too bad anticonvulsants (Depakote, Lamictal, Neurontin) never did much for me (except for the benzodiazepines).
>Too bad, but then again maybe your brain wave activity wouldn't show spiking suggestive of temporal lobe epilepsy.
How is you med trial fairing these days? The Parnate is giving me consistent "bad" headaches when I first arise before I take any meds and continues to disrupt my sleep mercilessly. I have an appointment tomorrow. I have read that frequent bad headaches can be a prenome (?) of spontaneous hypertensi--drum roll please--ve crises.
Posted by Lorraine on August 22, 2001, at 15:23:46
In reply to Re: that other thread » Elizabeth, posted by Cam W. on August 22, 2001, at 13:55:36
Cam: Jumping in--hope you don't mind. I've been taking Parnate for about 3 weeks and have been waking up every morning with a splitting headache before taking any meds. It goes away about an hour after I get up--although sometimes I lay in bed waiting for it to lighten--it is pretty intense. I have read that frequent headaches can be a precursor of spontaneous hypertensive reactions and require immediate attention. I'm seeing my pdoc tomorrow to discuss this, but I would appreciate any thoughts you might be willing to share about this.
Thanx.Lorraine
Posted by shelliR on August 22, 2001, at 19:59:15
In reply to Re: Update Lorainne, Elizabeth, et. al. » shelliR, posted by Lorraine on August 22, 2001, at 13:12:02
Hi Lorraine.
re parnate:
> > I looked back at my notes last week, and I never felt any anti-depressant effects from parnate--but I wasn't really expecting any so fast.
> This was the entry I was talking about Shelli:
> "But, for instance, I didn't wake up depressed yesterday or today, so maybe it's having some sort of small effects, or it's just that my hormones aren't acting crazy."wow, I don't remember that and I can't find when that was. That definitely sounds like a blip to me. Maybe I did give up too soon. But I did feel really tired and sick; I do remember that.
re commitments:
> I know what you are talking about Shelli--it's the very thing that prevents me from making a commitment to the future--making plans, deciding what to do--I have no idea whether I will be up to fullfilling the plans I make today when tomorrow comes--not until I'm stabilized. So even if someone without a mental illness takes times off for illness, I don't think it feels the same, and, you don't know how long you will be out of commission whereas the flu is a couple of days max. The uncertainty is part of it.Exactly. I have to be vague when I say I'm sick because of that time element. Last time, I told people I was in the hospital for testing. And of course, no one asks about specifics. I do assure everyone that it's nothing serious, just that there is not a definite period of time when it will be over. Because if you keep getting stomach flus, people start thinking that you're just blowing them off.
>re DID:
> > > > The wording of the DSM-IV makes it possible to fit or not fit yourself into the category if you have alters.
> I still think that you would know or feel or intuit if you were DID. Maybe the definition sucks and should include the coconscious component as a factor. I have memory gaps. Don't we all?Well, not everyone has alters. So you already know you're different from most people. And then it does really get into what the definition of DID is. I feel that I fall on the not DID side because I feel more similar to people who don't have DID, rather than those who do. Having kids inside at this point does not disrupt my life. Depression does. And then when I say I have memory gaps, I'm talking years when I remember absolutely nothing about my family. Not normal memory gaps. I can remember school, but nothing at home. I do think the definition could have been better. And as I mentioned to Elizabeth a while back, there is one psychiatrist who broke down the diagnosis of ddnos into very specific categories. I would be co-conscious DID, which says so much more than dissociative disorder, non-specified. I think that was the way to go, rather than to make the DID category so vague as to be subjective, especially since it is somewhat of a controversial diagnosis to begin with.
>
re my therapist:
> > > > she knows that I felt she was was not being supportive; she sees it differently. I didn't go today, and I'm not sure about Thursday. After that I can't just keep canceling; I'll have to start again, or terminate for now.
>
> It seems like she views you as malingering in a sense--coming up with excuses not to do the hard work of therapy and that maybe what you need is a dose of "tough love". But sometimes we are not able to work at the job or with a therapist. I wonder if a hiatus would do you both good until you stabilize.I'll see her tomorrow. I don't know. It is sort of sad to think that I can't connect with my therapist unless I am feeling stable. But maybe that's reality. I am feeling like she must not care about me very much. But maybe that's okay, or maybe not even true. I don't know; I just know I didn't want to be in touch with her last weekend when I was at my lowest.
> > > >I'll see how my pdoc session goes tomorrow.
> And????? Drum roll please.... What happpened?Okay, he upped my oxycontin, rejected any consideration of trying buprenorphine ( instead of the oxy), and put me on wellbutrin.
There's a post to Jahl from last night that gives more details. My pdoc is not a fan of buprenorphine. And he's not a big fan of MAOIs because it limits his choices of combinations. I was very suicidal, so I think the increase of oxy was to keep me alive until something else (wellbutrin, maybe) kicks in. I was there for five minutes and will see him again on Thursday--tomorrow.
I can't even discribe how low I had gotten. And tt scares me to think it is not over yet. But he did seem to be in the trenches with me, at least for now.This morning I felt stoned from the oxy, then okay with the wellbutrin, then totally crazy and hopeless. Now I am pretty calm, but untrusting that I won't feel like I *have* to die again. I'm glad that Jahl reminded me of the lability aspect of the wellbutrin, because it's enabling me to keep a minisule perspective right now. I made an appointment with someone for next week which was a crazy thing to do, (I should not be scheduling anyone that is not already scheduled before I leave on labor day) then I called back and left a message that I have to cancel (in about 500 words or more); so I am feeling off-center and very unprofessional. But at least she is off the schedule for next week.
vacations:
> The truth is I hate being away from home. Vacations bother me. I don't find them relaxing. And, when I planned the trip, I wasn't sure if I could depend on my mood.Did you used to like vacations. I mean, is this part of the depression? Do you ever just go away with your husband?
> > > > What is your eleven year old daughter like?
>
> She's wonderful. She has the "gift of mood"--she's upbeat, enthusiastic, bright, caring...really great. This summer she finally decided she was ready for a bra. Very big step. Lots of fun for me to watch her growing and changing. I'm hoping that her teenage years won't be too rough on us.I hope they won't be rough on her :-)
>
> Well, I've been having these terrible headaches when I wake up in the morning every day. So I have a call into my doctor to see if these headaches are precursors to a spontaneous hypertensive crises. I also am having trouble sleeping. My mood support though is pretty good--not home free but good. So we'll see.I 've only just heard about spontaneous hypertensive crises in the last week. (Of course, I've never had one). It's good to see what your doctor thinks. Have you taken your BP at home during these headaches? I'm glad you are feeling some support from the parnate.
Talk to you soon,
Shelli
Posted by Cam W. on August 22, 2001, at 20:09:13
In reply to Re: Waking Parnate headaches mean? » Cam W., posted by Lorraine on August 22, 2001, at 15:23:46
Lorraine - I don't think that is anything to worry about. It could just be a change in air pressure or something like that. It would be good to mention it to your doctor, though; just to see his/her reaction to this. You haven't changed anything in your diet, or aren't taking anything different at bedtime, are you?
Elizabeth may be a better person to ask this of; she has far more experience with MAOIs than I have.
FWIW - Cam
Posted by Lorraine on August 22, 2001, at 21:30:57
In reply to Re: Waking Parnate headaches mean? » Lorraine, posted by Cam W. on August 22, 2001, at 20:09:13
> Lorraine - I don't think that is anything to worry about. It could just be a change in air pressure or something like that. It would be good to mention it to your doctor, though; just to see his/her reaction to this. You haven't changed anything in your diet, or aren't taking anything different at bedtime, are you?
No, no changes at bedtime. Plus I may be getting hives. Just the start of bumps on my arms. What a mess life is sometimes.
>
> Elizabeth may be a better person to ask this of; she has far more experience with MAOIs than I have.Yeah, I always ask Elizabeth. She's great. Thanks for responding Cam.
Lorraine
Posted by Daveman on August 23, 2001, at 1:36:27
In reply to Re: that other thread » Elizabeth, posted by Cam W. on August 22, 2001, at 13:55:36
Cam:
Interesting. The thing I keep running up against is people claiming they "didn't know" about this effect or that. Whose fault is that, really? Full disclosure is part of the treating doctor's obligation, it seems to me. Each time my docs have started me on meds, they have told me about the possible side effects. I was told in very explicit terms that the SSRI's cause sexual disfunction. When I was started on Paxil, I was told of the side effects such as somnolence. With Celexa, I was cautioned I would experience nausea in the start-up. With Remeron, I was told I would probably gain weight. Each time, when this happened (and yes it all happened), I was prepared to deal with it. I also educated myself through sites such as this one, which was particulary helpful dealing with my fears of addiction when I was taking Xanax (it didn't happpen).
I'm rambling- what's my point? I guess it is that the information is out there, particularly regarding the SSRI's, pro and con. Doctors who don't choose to inform themselves thusly should not be prescribing these medications. Forewarned is forearmed.
Dave
> > But how do we provide an incentive for the drug companies to investigate possible bad effects of their products once the products have been approved for marketing?
> >
> • That's a good question. I do believe that even if drug companies are forthcoming with information, it will still be missed. For example, that Effexor withdrawl; I knew about the withdrawl in 1997, before an XR version was made. The company, since at least 1998 (perhaps before) had the withdrawl information in it's product monograph. I guess if you don't scream it out, not everyone listens (or has the time to read the monograph fully). It would be silly for a company (who really has to answer to shareholders) to point out the bad issues of their product. That's what competitors are for.
> >
> >
> > Even when it's below the therapeutic dose for psychosis? I was taking 2.5-5 mg/day.
> >
> • Pyschosis can be treated with low doses, as well. I don't think that there is an dose/effect gradient, as seen with Effexor.
>
> • I was talking to the Zyprexa rep yesterday (met him in Starbucks interviewing a new rep), and he says that the increased incidence of type II diabetes is only seen in patients with schizophrenia (he later amended that to be, that patients with schizophrenia were the only one's studied, so far). The reason he states that there increased numbers of people getting diabetes from taking Clozaril and Zyprexa is that people with schizophrenia are 4 times as likely as the general population to get diabetes. I asked if this number included unmedicated people and he didn't know. He also blamed increased appetite and poorer than normal dietary skills (eg chips & pop diets), as being risk factors. I really can't believe that we have a number of people with schizophrenia have borderline triglyceride levels and coincidentally become diabetic after starting these two atypical antipsychotics. I have seen people without schizophrenia become diabetic, but I am sorry that I never paid attention to relative numbers.
> >
>
>
> > Is Zyprexa really that common compared to Nardil?
>
> • Zyprexa is prescribed much more than Nardil and for numerous indications, at least here in the north. Nardil is used as a last resort in treatment-resistant depression. Zyprexa seems to be used before Nardil, even though there is little evidence of efficacy for it's long-term use in depression.
>
> - Cam
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