![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 49. This is the beginning of the thread.
Posted by JohnSky on July 13, 2007, at 9:54:38
Hello. I have been on the 6mg patch for 15 days now. When I started the patch from day 1 my anxiety jumped up. Through this period my anxiety has risen and held at a high level to date. I'm very sensitive to medications. I feels like torture at times and has me thinking about the anxiety alot. I take a benzo and gabapentin to help with the anxiety but it doesn't cut into it enough. Today I cut the patch in half (I hope you can do that) to see how where the anxiety goes. I thought I could hold at 3mg and work back up to 6mg very slowly.
My pharmacist says don't cut the patch.I really want to give EMSAM a fair trial because I already seem to be feeling better from a depression perspective... And I have taken about every other med there is.
My questions:
1. Is cutting the patch OK?
2. Have others experienced the intense anxiety
of starting EMSAM and has it gone away.. and
how long did it take?I just can't take too much more of the anxiety/agitation from the EMSAM, but I am willing to tough it out another week or so if there is a decent chance the anxiety will go down.
Would love to hear from others on this.
Posted by KayeBaby on July 13, 2007, at 11:28:15
In reply to EMSAM Question Again - Help, posted by JohnSky on July 13, 2007, at 9:54:38
> Hello. I have been on the 6mg patch for 15 days now. When I started the patch from day 1 my anxiety jumped up. Through this period my anxiety has risen and held at a high level to date. I'm very sensitive to medications. I feels like torture at times and has me thinking about the anxiety alot. I take a benzo and gabapentin to help with the anxiety but it doesn't cut into it enough. Today I cut the patch in half (I hope you can do that) to see how where the anxiety goes. I thought I could hold at 3mg and work back up to 6mg very slowly.
> My pharmacist says don't cut the patch.
>
> I really want to give EMSAM a fair trial because I already seem to be feeling better from a depression perspective... And I have taken about every other med there is.
>
> My questions:
>
> 1. Is cutting the patch OK?Yes.
>
> 2. Have others experienced the intense anxiety
> of starting EMSAM and has it gone away.. and
> how long did it take?I only had transient mild anxiety and the little that I had is gone. I have been on it for 12 weeks. It was only the first maybe 3 weeks or so for me.
> I just can't take too much more of the anxiety/agitation from the EMSAM, but I am willing to tough it out another week or so if there is a decent chance the anxiety will go down.
>
> Would love to hear from others on this.If you see any glimmers of hope on this med do what you can to stay with it. If your Dr. won' t prescribe a benzo (which is just bunk)try Namenda. It help with anxiety and is safe and non-addictive. Do what ever it takes to stay on it 6 weeks minimum. It didn't really get going good tll then for me-week 5 or 6.
Hang in there,
Kaye
Posted by Phillipa on July 13, 2007, at 11:28:38
In reply to EMSAM Question Again - Help, posted by JohnSky on July 13, 2007, at 9:54:38
I have been following the EMSAM threads for the year its been out and other doctors have let people cut the patch just dont get it on your hands and wrap the other half up. Also I believe they are scored. Good luck. Love Phillipa
Posted by Darkness At Noon on July 13, 2007, at 12:28:12
In reply to EMSAM Question Again - Help, posted by JohnSky on July 13, 2007, at 9:54:38
> Today I cut the patch in half (I hope you can do that) to see how where the anxiety goes. I thought I could hold at 3mg and work back up to 6mg very slowly.
> My pharmacist says don't cut the patch.> 1. Is cutting the patch OK?
My pdoc explicitly told me to cut the patch so I could taper up from half a patch to the full patch.
Some common-sense precautions: store the unused half-patch in a sealed plastic baggie, to prevent water damage, oxidation, whatever. Use the half-patch before starting another patch, to minimize possible degradation. Wash scissors and hands thoroughly afterwards, to remove any selegiline residue (which might otherwise get into your eyes, mucus membrame, etc.).
Basically, the drug companies are covering their butts against extreme cases, like not using the other half-patch for a year after it's lost potency, or an infant chewing on the patch.
Posted by dewdropinn on July 13, 2007, at 14:03:00
In reply to EMSAM Question Again - Help, posted by JohnSky on July 13, 2007, at 9:54:38
EMSAM can be an absolutely fantastic drug -- but the dosing parameters and best practices for using the med are still not clearly defined.
First off, you can definitely cut the patches to either reduce the dose or to raise it incrimentally. I have no idea why Bristol-Meyers has advised against this because it simply is not a problem, and it provides greater flexibility in dosing. Doctors are already starting to figure this out, so I anticipate that the guidelines will be amended in the future.
Secondly, EMSAM can have dramatically differing effects depending upon dosage -- and these dose dependent effects are somewhat counter-intuitive. The lower doses frequently produce anxiety, aggitation, and insomnia particularly during the early phases of treatment. The higher doses can frequently ameliorate these side effects while producing stronger and more sustained benefits for depression and anxiety. Basically, the lower doses inhibit MAO-B, the substance that breaks down dopamine and norepinephrine, but it may not significanly impact MAO-A, which is involved with the breakdown of serotonin, dopamine and norepinephrine. So, with the 6mg dose, you get activation but you may also get anxiety -- as you raise the dose, you get a true antidepressant response, which also helps with anxiety.
I would strongly advise that you remove the patch before bed time -- it can definitely compromise sleep -- it certainly did for me at first, but once I started removing the patch at bedtime, this side effect went away.
So, you certainly can cut the patch and test your response at the lower doses. I would also recommend exploring the possibility of raising the dose to 9mg (my dose level), because this may resolve the side effects your are currently dealing with.
EMSAM is a great drug, and I think once doctors figure out exactly how to administer it, it will become a mainstay of psychiatric pharmacopia.
Drew
> Hello. I have been on the 6mg patch for 15 days now. When I started the patch from day 1 my anxiety jumped up. Through this period my anxiety has risen and held at a high level to date. I'm very sensitive to medications. I feels like torture at times and has me thinking about the anxiety alot. I take a benzo and gabapentin to help with the anxiety but it doesn't cut into it enough. Today I cut the patch in half (I hope you can do that) to see how where the anxiety goes. I thought I could hold at 3mg and work back up to 6mg very slowly.
> My pharmacist says don't cut the patch.
>
> I really want to give EMSAM a fair trial because I already seem to be feeling better from a depression perspective... And I have taken about every other med there is.
>
> My questions:
>
> 1. Is cutting the patch OK?
>
> 2. Have others experienced the intense anxiety
> of starting EMSAM and has it gone away.. and
> how long did it take?
>
> I just can't take too much more of the anxiety/agitation from the EMSAM, but I am willing to tough it out another week or so if there is a decent chance the anxiety will go down.
>
> Would love to hear from others on this.
Posted by JohnSky on July 13, 2007, at 15:29:42
In reply to Re: EMSAM Question Again - Help, posted by dewdropinn on July 13, 2007, at 14:03:00
Thank you all for your helpful replies. My doc called me back this morning and told me not to cut the patch, because he said no one knows how it effects dosing. This after I used half a patch this morning and felt much less anxiety. Now I need to decide whether or not to follow doctor's orders. He did tell me to take off the patch at night which will be good as my sleep (even with sleep meds added on) is not good. I put the rest of the patch on after I talked to my doc this morning and my anxiety is right back up there again. I just don't know whether it will settle down at my current dose or if I need to go up the dose to get the anxiety to drop away as suggested. I do know I can't take more than 3 or 4 more days of this anxiety. It feels like awfull.
I have always been sensitive to medications. I wish I could have a nice easy start-up. Oh well.John
Posted by tendency on July 13, 2007, at 15:43:04
In reply to Re: EMSAM Question Again - Help, posted by JohnSky on July 13, 2007, at 15:29:42
May want to try 100mg of sublingual 5HTP 1/2 hour before bed as a sleep aid if you haven't already.
Posted by JohnSky on July 13, 2007, at 15:58:22
In reply to Re: EMSAM Question Again - Help, posted by JohnSky on July 13, 2007, at 15:29:42
What I forgot to mention is why I want to try and make the medication work for me:
I have tried about 15 drugs without any really helping. Just 3 weeks ago I felt very depressed with some vey dark throughts. Within days of starting EMSAM I felt less depressed and for the most part the dark thoughts disappered.
My gut tells me this medication may help me because Nardil (a cousin to this drug) helped me a long time ago. So I want to keep trying to stay on EMSAM if I can deal with the anxiety. I am taking lorazepam and gabapentin for the anxiety but it doesn't take the anxiety down to a decent level. Just takes a nick out of it. Maybe I should take a supplement as well to help with the anxiety. My worry is the anxiety from EMSAM will never go away... meaning my body just won't adjust to it.
I know the medication is causing the anxiety because the anxiety dropped this morning when I used a half patch.Thanks again.
John
Posted by dewdropinn on July 13, 2007, at 18:24:12
In reply to Re: EMSAM Question Again - Help, posted by JohnSky on July 13, 2007, at 15:58:22
I'm in the same boat with you -- I've taken a ton of drugs over the years.
If I were not taking lamictal, I would experience a considerable amount of anxiety with EMSAM -- and on the very rare days when I forget to take lamictal, the anxiety really kicks in. Lamictal basically lays the foundation that enables EMSAM to do it's job. Down the road, you may want to explore adding a mood stabilizer to your regiment -- they can smooth out mood, improve insomnia and sleep phase disorders, and augment antidepressants. Depakote and lithium are pretty gnarly, but the rest of them are very tolerable meds.
I get the impression that you're really struggling with this anxiety. If cutting the patch reduced the anxiety and didn't result in worsening of depression, then this seems like a viable course of action. Decreasing the dose doesn't pose any risk, so even if it's not doctor sanctioned, it can't hurt you, and it might be your answer. I'm not suggesting that you shouldn't work with your doctor on this of course, but it seems like a reasonable solution.
I noticed that one of the other posters made some mention of 5-htp. This can theoretically be mixed with low dose selegiline in the pill or liquid form (e.g. 1-5mg as opposed to the 20-40mg dose delivered by the patch) -- but because the patch is a full MAOI, a combination of any serotonergic medication or supplement, like 5-htp, can be fatal and is obviously best avoided. Given your experience with MAOIs, I'm guessing you already know all about this.
I wish you the best of luck, and look forward to hearing about your progress.
Drew
> What I forgot to mention is why I want to try and make the medication work for me:
>
> I have tried about 15 drugs without any really helping. Just 3 weeks ago I felt very depressed with some vey dark throughts. Within days of starting EMSAM I felt less depressed and for the most part the dark thoughts disappered.
> My gut tells me this medication may help me because Nardil (a cousin to this drug) helped me a long time ago. So I want to keep trying to stay on EMSAM if I can deal with the anxiety. I am taking lorazepam and gabapentin for the anxiety but it doesn't take the anxiety down to a decent level. Just takes a nick out of it. Maybe I should take a supplement as well to help with the anxiety. My worry is the anxiety from EMSAM will never go away... meaning my body just won't adjust to it.
> I know the medication is causing the anxiety because the anxiety dropped this morning when I used a half patch.
>
> Thanks again.
>
> John
Posted by aegle on July 14, 2007, at 8:52:35
In reply to Re: EMSAM Question Again - Help, posted by JohnSky on July 13, 2007, at 15:58:22
John, my experience with Emsam has been very similar to yours. I started taking it in March of this year.
At 6mg, my anxiety level increased dramatically and felt little active relief from depression. The most obvious symptom that the medication was working was a reduction in thoughts of self-harm by about 90%.
I managed the anxiety by using benzos (Xanax, in my case), along with the other methods of self-care - aerobic exercise, eliminating caffeine from my diet, using relaxation exercises - and those helped me get through.
My psychiatrist was hesitant to increase my dosage given the foregoing, but a family health crisis precipitated a severe mood dip, so after eight weeks on 6mg, we increased my dose to the 9mg patch. The relief is palpable. Instead of increasing, my anxiety level dropped to a lower level and my symptoms of depression have lifted more than I could have thought possible.
I've gotten a tremendous boost in energy and motivation, and as an atypical depressive, these effects are very welcome. As I'm able to be more active, my mood is far brighter. I feel more optimistic today than I have in 14 years after medication trials with every other SSRI, SNRI and augmenting strategy (mood stabilizers, atypical antipsycholitcs, stimulants). I'm considering returning to work full-time after a long absence.
For me, Emsam is a miracle drug, but it can't fix everything. I often feel "tired but wired" in mid-afternoon, but that passes. I need to take a small dose of Seroquel (12.5mg) with Xanax in order to fall asleep. And, I'm still dealing with some anxiety and a fairly high level of irritability. However, the latter have been aspects of my personality for as long as I can remember and can not be attributed to this medication. I'd adore it if all those issues could be relieved with medications, but (again) after numerous med trials and 11 years on Effexor, I know now that will be my work.
I strongly urge you to consider staying with the medication. If your experience continues to mirror that of the other participants here, an increase to 9mg could provide the relief you've been seeking. The fact that you're experiencing an uptick in anxiety, while extremely uncomfortable, is also a promising sign - it means you'll most likely be an MAOI responder.
With regard to cutting the patch, I read in the babble archives of a patient (Robert David) who contacted one of the researchers on the Emsam trials and was told it was acceptable to cut the patch. Here's a link to that post:
http://www.dr-bob.org/babble/20060520/msgs/646774.html
Wishing you relief soon.
Posted by JohnSky on July 16, 2007, at 9:56:49
In reply to Re: EMSAM Question Again - Help » JohnSky, posted by aegle on July 14, 2007, at 8:52:35
Thank you for your replay aegle. Glad to hear you detailed experence.... and glad to hear I'm not alone in how I am responding.
A couple of questions:
1. While on the 6mg patch how many weeks was your anxiety severly elevated and when did it come down.... or maybe it just came down when you went to 9mg? I am taking a benzo and some seroquel that helps some, I exercise, and I do relaxation breathing.
2. The last three nights I have taken the patch off per doc orders. I sleep better but I feel down in the morning until the patch kicks in late morning... then the anxiety comes back. Doing this I can't imagine I am getting a full 6mg for a day?
3. What sort of dietary restrictions do you deal with on the 9mg patch?
4. If the anxiety keeps up I am going to stop the medication at the 3 week mark (Thursday)... unless my doc has another choice... maybe going up to the 9mg mark is the trick based on the replies I am getting.
John
> John, my experience with Emsam has been very similar to yours. I started taking it in March of this year.
>
> At 6mg, my anxiety level increased dramatically and felt little active relief from depression. The most obvious symptom that the medication was working was a reduction in thoughts of self-harm by about 90%.
>
> I managed the anxiety by using benzos (Xanax, in my case), along with the other methods of self-care - aerobic exercise, eliminating caffeine from my diet, using relaxation exercises - and those helped me get through.
>
> My psychiatrist was hesitant to increase my dosage given the foregoing, but a family health crisis precipitated a severe mood dip, so after eight weeks on 6mg, we increased my dose to the 9mg patch. The relief is palpable. Instead of increasing, my anxiety level dropped to a lower level and my symptoms of depression have lifted more than I could have thought possible.
>
> I've gotten a tremendous boost in energy and motivation, and as an atypical depressive, these effects are very welcome. As I'm able to be more active, my mood is far brighter. I feel more optimistic today than I have in 14 years after medication trials with every other SSRI, SNRI and augmenting strategy (mood stabilizers, atypical antipsycholitcs, stimulants). I'm considering returning to work full-time after a long absence.
>
> For me, Emsam is a miracle drug, but it can't fix everything. I often feel "tired but wired" in mid-afternoon, but that passes. I need to take a small dose of Seroquel (12.5mg) with Xanax in order to fall asleep. And, I'm still dealing with some anxiety and a fairly high level of irritability. However, the latter have been aspects of my personality for as long as I can remember and can not be attributed to this medication. I'd adore it if all those issues could be relieved with medications, but (again) after numerous med trials and 11 years on Effexor, I know now that will be my work.
>
> I strongly urge you to consider staying with the medication. If your experience continues to mirror that of the other participants here, an increase to 9mg could provide the relief you've been seeking. The fact that you're experiencing an uptick in anxiety, while extremely uncomfortable, is also a promising sign - it means you'll most likely be an MAOI responder.
>
> With regard to cutting the patch, I read in the babble archives of a patient (Robert David) who contacted one of the researchers on the Emsam trials and was told it was acceptable to cut the patch. Here's a link to that post:
>
> http://www.dr-bob.org/babble/20060520/msgs/646774.html
>
> Wishing you relief soon.
>
>
>
>
>
Posted by aegle on July 16, 2007, at 13:17:03
In reply to Re: EMSAM Question Again - Help, posted by JohnSky on July 16, 2007, at 9:56:49
JohnSky, my reply is interwoven among your post below.
> Thank you for your replay aegle. Glad to hear you detailed experence.... and glad to hear I'm not alone in how I am responding.
You're welcome. Psychobabble is great that way; at least one person here can generally relate to a medication's side effects and validate your experience.
>
> A couple of questions:
>
> 1. While on the 6mg patch how many weeks was your anxiety severly elevated and when did it come down.... or maybe it just came down when you went to 9mg? I am taking a benzo and some seroquel that helps some, I exercise, and I do relaxation breathing.To my best recollection, it took about five weeks on the 6mg patch to feel a reduction in the anxiety surge I experienced immediately after beginning the patch. I distinctly remember the night I had a far better quality of sleep without increasing my sleep med dose. That marked the beginning of reduced anxiety levels during waking hours.
What's difficult for me is to tease out the reason why my anxiety level began to diminish. I'd had no increase or decrease in external stressors at that time, so my guess is that higher anxiety is a normal side effect in those prone to it at the beginning of treatment with this particular med. I could spend some quality time researching the pharmacological reasons for that, or simply ask my psychiatrist, but there are other issues that are more pressing for me at this time.
>
> 2. The last three nights I have taken the patch off per doc orders. I sleep better but I feel down in the morning until the patch kicks in late morning... then the anxiety comes back. Doing this I can't imagine I am getting a full 6mg for a day?It's hard to say what dose you're getting, because with transdermal dosing, the medication is more available immediately in the bloodstream because it doesn't have to go through a first pass in the digestive system. The one thing we do know is that you're not getting the full daily 20mg dose (6mg patch worn for 24 hours) because your patch is off while you sleep.
For what it's worth, my psychiatrist and I discussed the option of removing the patch while I slept and we decided against it. For one thing, I needed the most anti-depressant effect I could get; I'd been at a very low point. The second was that I was managing to get sleep (about five to six hours a night with few arousals) using a nightly dose of 50mg of Seroquel.
Obviously since that time, I've been able to reduce my Seroquel dose to 12.5mg a night and I hope to wean off it completely within the next month. The sleep issue as gotten far better with time.
>
> 3. What sort of dietary restrictions do you deal with on the 9mg patch?Following the recommended MAOI diet strictly at first was not been a problem for me. Over time, I've experimented with adding back some aged cheese and small amounts of soy sauce. I kept a blood pressure cuff handy when I tried these experiments, and I did just fine.
It's important to note that there's never been a reported case of hypertensive crisis from food with the Emsam patch at any dose. I've read that Bristol-Meyers Squibb has petitioned the FDA to drop the food restrictions normally associated with MAOIs to be dropped for all doses of Emsam.
> 4. If the anxiety keeps up I am going to stop the medication at the 3 week mark (Thursday)... unless my doc has another choice... maybe going up to the 9mg mark is the trick based on the replies I am getting.That's an option. The other is to give the 6mg patch a full six weeks to see how you react, if you can manage the anxiety. Everyone responds to medications in their own way and in their own time (that's why there are so many psych med options), so you may experience a reduction in the anxiety yet.
Unsolicited book recommendation: The Anxiety and Phobia Workbook by Edmund J. Bourne. It's easily found online at Amazon or other booksellers and it's a quick way to work on the roots of your anxiety and the thought patterns that can perpetuate and exacerbate it. If you're not a fan of cognitive behavioral therapy, though, I'd pass this one by.
Whatever you choose to do, continued good wishes for some real relief.
>
> John
>
> > John, my experience with Emsam has been very similar to yours. I started taking it in March of this year.
> >
> > At 6mg, my anxiety level increased dramatically and felt little active relief from depression. The most obvious symptom that the medication was working was a reduction in thoughts of self-harm by about 90%.
> >
> > I managed the anxiety by using benzos (Xanax, in my case), along with the other methods of self-care - aerobic exercise, eliminating caffeine from my diet, using relaxation exercises - and those helped me get through.
> >
> > My psychiatrist was hesitant to increase my dosage given the foregoing, but a family health crisis precipitated a severe mood dip, so after eight weeks on 6mg, we increased my dose to the 9mg patch. The relief is palpable. Instead of increasing, my anxiety level dropped to a lower level and my symptoms of depression have lifted more than I could have thought possible.
> >
> > I've gotten a tremendous boost in energy and motivation, and as an atypical depressive, these effects are very welcome. As I'm able to be more active, my mood is far brighter. I feel more optimistic today than I have in 14 years after medication trials with every other SSRI, SNRI and augmenting strategy (mood stabilizers, atypical antipsycholitcs, stimulants). I'm considering returning to work full-time after a long absence.
> >
> > For me, Emsam is a miracle drug, but it can't fix everything. I often feel "tired but wired" in mid-afternoon, but that passes. I need to take a small dose of Seroquel (12.5mg) with Xanax in order to fall asleep. And, I'm still dealing with some anxiety and a fairly high level of irritability. However, the latter have been aspects of my personality for as long as I can remember and can not be attributed to this medication. I'd adore it if all those issues could be relieved with medications, but (again) after numerous med trials and 11 years on Effexor, I know now that will be my work.
> >
> > I strongly urge you to consider staying with the medication. If your experience continues to mirror that of the other participants here, an increase to 9mg could provide the relief you've been seeking. The fact that you're experiencing an uptick in anxiety, while extremely uncomfortable, is also a promising sign - it means you'll most likely be an MAOI responder.
> >
> > With regard to cutting the patch, I read in the babble archives of a patient (Robert David) who contacted one of the researchers on the Emsam trials and was told it was acceptable to cut the patch. Here's a link to that post:
> >
> > http://www.dr-bob.org/babble/20060520/msgs/646774.html
> >
> > Wishing you relief soon.
> >
> >
> >
> >
> >
>
>
Posted by JohnSky on July 17, 2007, at 9:24:47
In reply to Re: EMSAM Question Again - Help, posted by aegle on July 16, 2007, at 13:17:03
Thanks again for the detailed reply. I seem to be riding a roller coaster on this med. Even with taking a benzo and seroquel I could barely relax last night. My heart was racing some and it took me 3 hours to fall asleep. I just couldn't "let go" and fall asleep even though I take my 6mg patch off at night. I seemed stuck in a series of worries. I should have go out of bed and written down my worries so I clearly had them written down and out of my mind. I'm exhausted but it is just one night of sleep.
I need to decide whether to proceed with this medication. To get the full 6mg treatment. I wonder if cutting the patch in half and taking half during the day, and then half at night is a viable alternative? Does anyone know if cutting the patch in half gives half the amount of medication?
Thanks
==========================================
> JohnSky, my reply is interwoven among your post below.
>
> > Thank you for your replay aegle. Glad to hear you detailed experence.... and glad to hear I'm not alone in how I am responding.
>
> You're welcome. Psychobabble is great that way; at least one person here can generally relate to a medication's side effects and validate your experience.
>
>
> >
> > A couple of questions:
> >
> > 1. While on the 6mg patch how many weeks was your anxiety severly elevated and when did it come down.... or maybe it just came down when you went to 9mg? I am taking a benzo and some seroquel that helps some, I exercise, and I do relaxation breathing.
>
> To my best recollection, it took about five weeks on the 6mg patch to feel a reduction in the anxiety surge I experienced immediately after beginning the patch. I distinctly remember the night I had a far better quality of sleep without increasing my sleep med dose. That marked the beginning of reduced anxiety levels during waking hours.
>
> What's difficult for me is to tease out the reason why my anxiety level began to diminish. I'd had no increase or decrease in external stressors at that time, so my guess is that higher anxiety is a normal side effect in those prone to it at the beginning of treatment with this particular med. I could spend some quality time researching the pharmacological reasons for that, or simply ask my psychiatrist, but there are other issues that are more pressing for me at this time.
>
> >
> > 2. The last three nights I have taken the patch off per doc orders. I sleep better but I feel down in the morning until the patch kicks in late morning... then the anxiety comes back. Doing this I can't imagine I am getting a full 6mg for a day?
>
> It's hard to say what dose you're getting, because with transdermal dosing, the medication is more available immediately in the bloodstream because it doesn't have to go through a first pass in the digestive system. The one thing we do know is that you're not getting the full daily 20mg dose (6mg patch worn for 24 hours) because your patch is off while you sleep.
>
> For what it's worth, my psychiatrist and I discussed the option of removing the patch while I slept and we decided against it. For one thing, I needed the most anti-depressant effect I could get; I'd been at a very low point. The second was that I was managing to get sleep (about five to six hours a night with few arousals) using a nightly dose of 50mg of Seroquel.
>
> Obviously since that time, I've been able to reduce my Seroquel dose to 12.5mg a night and I hope to wean off it completely within the next month. The sleep issue as gotten far better with time.
>
>
> >
> > 3. What sort of dietary restrictions do you deal with on the 9mg patch?
>
> Following the recommended MAOI diet strictly at first was not been a problem for me. Over time, I've experimented with adding back some aged cheese and small amounts of soy sauce. I kept a blood pressure cuff handy when I tried these experiments, and I did just fine.
>
> It's important to note that there's never been a reported case of hypertensive crisis from food with the Emsam patch at any dose. I've read that Bristol-Meyers Squibb has petitioned the FDA to drop the food restrictions normally associated with MAOIs to be dropped for all doses of Emsam.
>
>
> > 4. If the anxiety keeps up I am going to stop the medication at the 3 week mark (Thursday)... unless my doc has another choice... maybe going up to the 9mg mark is the trick based on the replies I am getting.
>
> That's an option. The other is to give the 6mg patch a full six weeks to see how you react, if you can manage the anxiety. Everyone responds to medications in their own way and in their own time (that's why there are so many psych med options), so you may experience a reduction in the anxiety yet.
>
> Unsolicited book recommendation: The Anxiety and Phobia Workbook by Edmund J. Bourne. It's easily found online at Amazon or other booksellers and it's a quick way to work on the roots of your anxiety and the thought patterns that can perpetuate and exacerbate it. If you're not a fan of cognitive behavioral therapy, though, I'd pass this one by.
>
> Whatever you choose to do, continued good wishes for some real relief.
>
>
> >
> > John
> >
> > > John, my experience with Emsam has been very similar to yours. I started taking it in March of this year.
> > >
> > > At 6mg, my anxiety level increased dramatically and felt little active relief from depression. The most obvious symptom that the medication was working was a reduction in thoughts of self-harm by about 90%.
> > >
> > > I managed the anxiety by using benzos (Xanax, in my case), along with the other methods of self-care - aerobic exercise, eliminating caffeine from my diet, using relaxation exercises - and those helped me get through.
> > >
> > > My psychiatrist was hesitant to increase my dosage given the foregoing, but a family health crisis precipitated a severe mood dip, so after eight weeks on 6mg, we increased my dose to the 9mg patch. The relief is palpable. Instead of increasing, my anxiety level dropped to a lower level and my symptoms of depression have lifted more than I could have thought possible.
> > >
> > > I've gotten a tremendous boost in energy and motivation, and as an atypical depressive, these effects are very welcome. As I'm able to be more active, my mood is far brighter. I feel more optimistic today than I have in 14 years after medication trials with every other SSRI, SNRI and augmenting strategy (mood stabilizers, atypical antipsycholitcs, stimulants). I'm considering returning to work full-time after a long absence.
> > >
> > > For me, Emsam is a miracle drug, but it can't fix everything. I often feel "tired but wired" in mid-afternoon, but that passes. I need to take a small dose of Seroquel (12.5mg) with Xanax in order to fall asleep. And, I'm still dealing with some anxiety and a fairly high level of irritability. However, the latter have been aspects of my personality for as long as I can remember and can not be attributed to this medication. I'd adore it if all those issues could be relieved with medications, but (again) after numerous med trials and 11 years on Effexor, I know now that will be my work.
> > >
> > > I strongly urge you to consider staying with the medication. If your experience continues to mirror that of the other participants here, an increase to 9mg could provide the relief you've been seeking. The fact that you're experiencing an uptick in anxiety, while extremely uncomfortable, is also a promising sign - it means you'll most likely be an MAOI responder.
> > >
> > > With regard to cutting the patch, I read in the babble archives of a patient (Robert David) who contacted one of the researchers on the Emsam trials and was told it was acceptable to cut the patch. Here's a link to that post:
> > >
> > > http://www.dr-bob.org/babble/20060520/msgs/646774.html
> > >
> > > Wishing you relief soon.
> > >
> > >
> > >
> > >
> > >
> >
> >
>
>
Posted by Darkness At Noon on July 17, 2007, at 13:14:14
In reply to Re: EMSAM Question Again - Help, posted by JohnSky on July 17, 2007, at 9:24:47
> I need to decide whether to proceed with this medication. To get the full 6mg treatment. I wonder if cutting the patch in half and taking half during the day, and then half at night is a viable alternative? Does anyone know if cutting the patch in half gives half the amount of medication?
In theory, the patch delivers a steady dose of selegiline for 24 hours. Which means that wearing half a patch during the day, and then replacing it with the other half at night, is no different than keeping the same patch on 24 hours.
According to my pdoc, and my own experience, cutting the patch in half gives half the medication.
Posted by JohnSky on July 17, 2007, at 13:16:33
In reply to Re: EMSAM Question Again - Help, posted by JohnSky on July 17, 2007, at 9:24:47
I appreciate all the great advice I've received.
I am currently taking the 6mg patch and taking it off at night (over the last 3 nights) but I don't seem to be getting the same energy boost as when I left the patch on all day. I'm worried that the 4 or so mgs I am getting isn't enought to pull me out of depression. Taking the patch off at night has helped some with the anxiety the patch caused.
I am thinking of two choices:
1. Cut the 6mg in half and put one half on in the morning and then the other half 12 hours later. This way I get 6mg during the day and the 3mg dosages doesn't whack me as hard as one 6mg patch.
2. Leave the 6mg patch on the full 24 hours.
Taking the patch off at night has lessened my anxiety some... or maybe I am just getting used to the patch when I put it on in the morning.My goal is to stay on the patch as I think it will help me but I somehow need to manage the anxiety syptoms.
Any thoughts?
Posted by Phillipa on July 17, 2007, at 20:10:16
In reply to Patch decision - What to do?, posted by JohnSky on July 17, 2007, at 13:16:33
Are you sure you need the full 6mg? as when I was going to go on it my pdoc said a quarter of the patch would be enough for me. Now she says it's too stimulating for me so for now no patch at all. Love Phillipa
Posted by dewdropinn on July 19, 2007, at 12:41:33
In reply to Patch decision - What to do?, posted by JohnSky on July 17, 2007, at 13:16:33
I would consider going up to 9mg and removing the patch before bedtime -- this should help with sleep, anxiety and energy issues -- and it's what worked for me, so I guess I'm partial to the approach.
You would think that the increase in dosage would add to the sense of anxiety and overrstimulation, but in my experience, the effect of raising the dose is just the opposite -- it could be that the higher dose potentiates the serotonergic aspects of the drug, while the lower doses primarily impact dopamine and norepinepherine. Personally, I'm not entirely sure that 6mg is an effective dose for the treatment of major depression -- anything less that 6mg may provide added pep, but I doubt that it will have a true antidepressant effect (much like the 5mg selegiline pills.) Just based on reading past posts, it seems that people who take the higher dosage levels succeed at a far higher rate than those who stay at 6mg.
That's my 2 cents -- Good Luck!
> I appreciate all the great advice I've received.
>
> I am currently taking the 6mg patch and taking it off at night (over the last 3 nights) but I don't seem to be getting the same energy boost as when I left the patch on all day. I'm worried that the 4 or so mgs I am getting isn't enought to pull me out of depression. Taking the patch off at night has helped some with the anxiety the patch caused.
>
> I am thinking of two choices:
>
> 1. Cut the 6mg in half and put one half on in the morning and then the other half 12 hours later. This way I get 6mg during the day and the 3mg dosages doesn't whack me as hard as one 6mg patch.
>
> 2. Leave the 6mg patch on the full 24 hours.
> Taking the patch off at night has lessened my anxiety some... or maybe I am just getting used to the patch when I put it on in the morning.
>
> My goal is to stay on the patch as I think it will help me but I somehow need to manage the anxiety syptoms.
>
> Any thoughts?
Posted by JohnSky on July 23, 2007, at 15:21:26
In reply to Re: Patch decision - What to do?, posted by dewdropinn on July 19, 2007, at 12:41:33
Thank you for the idea about going up to 9mg. At that dose I believe the dietary constraints come into play? That is the strategy I may need to go.
I need to do something as I feel anxious and my mood is down. Over the last few days I just feel tired and "strange". Sort of a "out of touch feeling". This may be from feeling anxious alot of the time from the medication. Or from being over-medicated as I am also on Lithium and Seroquel. I just feel scared and that the EMSAM is making me worse. I have been on it 24 days. I will give it until Wednesday and then discontinue if I still feel so out of sorts.
John
Posted by dewdropinn on July 24, 2007, at 0:20:04
In reply to Re: Patch decision - What to do?, posted by JohnSky on July 23, 2007, at 15:21:26
The dietary issues are largely theoretical. Bristol-Meyers worked very hard to induce tyramine reactions during initial clinical studies without any luck. They have lobbied with the FDA to get the black box warning removed, because all of their research suggests that the dietary precautions are unnecessary. The dietary risks are miniscule at best, but they are worth knowing about because of the severity of the possible side effect. Does this make sense?
Raising the dose may prove beneficial -- it made a huge difference for me. If bipolarity is an issue, it may make sense to try reducing the dose -- you can easily cut the patch and assess your response -- this would seem to be the most readily testable option. I wish that I could give you more definitive direction. Best of luck, and please let me know how everything goes.
Drew
> Thank you for the idea about going up to 9mg. At that dose I believe the dietary constraints come into play? That is the strategy I may need to go.
>
> I need to do something as I feel anxious and my mood is down. Over the last few days I just feel tired and "strange". Sort of a "out of touch feeling". This may be from feeling anxious alot of the time from the medication. Or from being over-medicated as I am also on Lithium and Seroquel. I just feel scared and that the EMSAM is making me worse. I have been on it 24 days. I will give it until Wednesday and then discontinue if I still feel so out of sorts.
>
> John
Posted by JohnSky on July 24, 2007, at 10:25:34
In reply to Re: Patch decision - What to do?, posted by dewdropinn on July 24, 2007, at 0:20:04
Thanks for the info. Why do you mention bi-polar and using a lower dose of EMSAM if so? I have recently been diagnosed bi-polar because Effexor caused a major manic reaction in me a year ago and my doc said I must be bi-polar because of the reaction. No other medication has caused that reaction in me and I have never had a manic reaction in my 49 years.
I read an FDA report that listed a manic reaction as possibility when taking Effexor.John
Posted by dewdropinn on July 24, 2007, at 12:33:00
In reply to Re: Patch decision - What to do?, posted by JohnSky on July 24, 2007, at 10:25:34
It sounds like we're in a very similar boat.
As you may know, there's a trend towards expanding the bipolar spectrum to include individuals who have never experience a true manic episode -- or whose manic episodes are purely medication induced. It's almost as if there's an underlying pattern that influences the overall course of the disease without manifesting overt symptoms. Among bipolar specialists, it is generally agreed that all antidepressants pose a risk of inducing mania -- SSRIs are the worst, MAOIs are arguably the best along with Wellbutrin, but all antidepressants have the potential to induce cycling, mania, etc.
When these specialists decide to use antidepressants, they typically select the drugs that pose the least risk -- e.g. EMSAM or Wellbutrin -- and they administer them at the lowest possible dose, so as to minimize the risk of exacerbating the bipolar features of the mood disorder. That's the theory, and that would be my reasoning for saying "lower the dose." But it sounds like you're really on the soft side of the bipolar spectrum which means that a more conventional approach to antidepressant dosing may work so long as you have a mood stabilizer on-board.
I actually assumed that you were classic bipolar 1 -- lithium is the bipolar 1 gold standard, and seroquel is the add-on for people who still have insomnia and anxiety in spite of being on a potent mood stabilizer. If you aren't bipolar 1, I could definitely see how this combo could cloud things up considerably.
Here's a snapshot of my history with bipolarity. I have taken any number of different drugs and combos of drugs -- some have worked for a time and then pooped out and at least one combo induced something that resembled a manic episode (freewheeling spending and a lot of partying.) My doctor at the time was a research psychiatrist who has been involved with major NIMH studies, and he's something of an expert on bipolar spectrum disorders. Based on my poop-out and hypomanic response to certain antidepressants, I was slapped with a bipolar diagnosis, and began one of the most excruciating phases of my psychopharmacological treatment. The doctor first determined that antidepressants were only an option of last resort, and that we would work to find an effective mood stabilizer and/or atypical anti-psychotic. We started with Lithium, and that was pretty brutal -- somewhat calming, but it made me dumber and number, and my job requires clarity -- it ultimately induced akathesia which ended that experiment; I then moved on to Depakote which was vicious in every respect; then Trileptal which was better than Lithium and Depakote but sent me into near suicidal depression; then Tegretol which was better than Trileptal, but still induced depression. Along the way, I took Seroquel, which resolved my insomnia but redered me incapable of functioning, regardless of the dose (I literally took crumbs of the stuff and it still made me instantly retarded.) To make a very long story a little bit shorter, I eventually consulted with another NIMH doctor -- one of the legendary research psychiatrists from back in the 70's -- and he was of the opinion that, while I had some bipolar features, I really wasn't truly bipolar and that my treatment would never succeed if it followed the strict guidelines proscribed for the treatment of bipolar disorders. Fortunately, he provided me with a pharmacological plan that proved effective. He suggested taking Lamictal and pushing the dose above 200mg -- at the higher levels it acts as a mood stabilizer but it also has true antidepressant qualities -- if Lamictal alone did not work, then he recommended adding Wellbutrin or an MAOI. I started on Lamictal, titrated up the dose, started feeling better around 300mg, and reached maximum benefits at 400mg -- I still had residual depression and cognitive problems. Because I had some success with selegiline in the past, my doctor selected EMSAM as the add-on. The 6mg patch increased my energy levels almost immediately, but it also induced anxiety and insomnia -- I tried cutting the patch, but it resulted in an increase of the depression and a decrease of energy, so I knew reducing the dose wasn't the answer for me. My doctor then raised the dose to 9mg, and I experienced almost total remission for the first time in ages.
So, if you were in fact bipolar 1, a reduction in dosage would seem to correspond with the prevailing theories of the day. If you are on the softer side of the bipolar spectrum, you almost certainly need some kind of mood stabilizer -- but your current combo may simply be too powerful -- great for classic bipolar, but the proverbial emotional and cognitive hammer for less severe varieties. Lamictal is becoming the gold standard for bipolar 2, 3, atypical bipolar and atypical depression. It is not as potent a mood stabilizer as Lithium or Depakote or Seroquel, but it is effective in this capacity none-the-less and it can also be an effective antidepressant if taken at high enough doses. In my experience, it's the kindest and gentlest of the available mood stabilizers -- so this may be worth exploring. Many psychopharmacologist like to resolve the mood stabilizer situation before adding antidepressants -- it's almost like the mood stabilizer lays the foundation for antidepressant therapy.
Once you find a livable mood stabilizer and/or mood stabilizing combo, then you can explore adding antidepressants. EMSAM @ 9mg would be my choice just based on my own experience -- there are other antidepressants and atypical anti-psychotics that may work as well -- most of them posed problems for me, but that doesn't mean they won't be effective for you.So that's my story -- your reactions may be totally different from mine, so I don't know if there are any definitive answers in this narrative -- but at the very least, there's a precedent. Hopefully this is helpful -- and let me know if you have any other questions.
Drew
> Thanks for the info. Why do you mention bi-polar and using a lower dose of EMSAM if so? I have recently been diagnosed bi-polar because Effexor caused a major manic reaction in me a year ago and my doc said I must be bi-polar because of the reaction. No other medication has caused that reaction in me and I have never had a manic reaction in my 49 years.
> I read an FDA report that listed a manic reaction as possibility when taking Effexor.
>
> John
Posted by aegle on July 25, 2007, at 2:39:13
In reply to Re: Patch decision - What to do?, posted by dewdropinn on July 24, 2007, at 12:33:00
<snipped>
Drew, thank you for your particularly cogent replay. Our histories have some substantive similariites and the description of your experience has been mimicked my own in some surprising ways.
I dislike putting you on the spot in a public forum such as this, but I must ask, may I babblemail you? I have some questions not addressed in your post.
Regardless of your answer, thank you for your participation here.
Regards,
aegle
Posted by aegle on July 25, 2007, at 3:45:26
In reply to Re: Patch decision - What to do?, posted by JohnSky on July 24, 2007, at 10:25:34
JohnSky, for what it's worth, I've found little value in a diagnosis reached by a psychiatrist backing into one based simply on your response to a specific medication. There are far too many uncontrollable environmental variables to slap a label of soft or Bipolar II on you if you've been asymptomactic for your 49 years simply because of your response to one medication.
I'd caution you to accept the foregoing as my personal perspective only. A simple Google search would help you find some quick and dirty diagnostic tools to help you evaluate your response to several bipolar II tests; if you have that "A ha!" response after relecting upon your response in an unmedicated state, you'll have quite useful information.
Again, FWIW, I was took Effexor ER at a dose of 375mg per day for 11 years. My own psychiatrist dabbled with the soft Bipolar diagnosis based on my reaction to that medication, though I'd been previously diagnosed as an Atypical Depressive (which includes the component of reactivity, a symptom frequently associated with Bipolar II.) I went through trials of Tegretol, Neurontin and Lamictal and others whose names I don't immediately recall to stabilize my moods while on Effexor.
Lamictal provided the best relief (a floor for depression and a cap for those rare times when the inability to sleep and wildly optimistic moods prevailed) for the longest period; the others had intolerable side effects. My point: even if you have no legitimate diagnosis of BP II, a mood stabilizer could be held in reserve as a useful adjunct to your medication regime. I'd wait until you see how you respond to the 9mg dose of Emsam, however.
I've been away from this group for the last two weeks due to outside commitments, but based on what I've read here over the last eight months and my own experience, there appears to be an inverse relationship between Emsam dosage and anxiety/agitation. An increase to the 9mg patch is certainly something worth trying to see if the anxiety is reduced.
Wishing you well with your decision.
Regards,
aegle
> Thanks for the info. Why do you mention bi-polar and using a lower dose of EMSAM if so? I have recently been diagnosed bi-polar because Effexor caused a major manic reaction in me a year ago and my doc said I must be bi-polar because of the reaction. No other medication has caused that reaction in me and I have never had a manic reaction in my 49 years.
> I read an FDA report that listed a manic reaction as possibility when taking Effexor.
>
> John
Posted by JohnSky on July 26, 2007, at 10:15:26
In reply to Re: Patch decision - What to do?, posted by dewdropinn on July 24, 2007, at 12:33:00
Thank you Drew for your very detailed reply and history. It helps. After talking with my Doc I have decided to stay with the 6mg patch but not cut it in half at night.. thus I will have the full 6mg throughout the day. I slept Ok this way last night. My doc felt with me cutting the patch at night to help with sleep I was ending up with say 4.5mg for the day which was just not a high enough dose to help me. I have decided to see if I can handle the anxiety at this dose until this Sunday. If not I will likely try the 9mg patch for a week. The anxiety I have felt has been very tough to deal with and it wears me down so much and makes me feel so hopeless. Two days ago was the most I've felt depressed in some time. Scared me as the dark thoughts came quickly and I thought the very worst.
I am on a medium dose of Lithium and Seroquel. Sometimes I wonder if the Lithium is depressing me.
Posted by JohnSky on July 26, 2007, at 10:27:38
In reply to Re: Patch decision - What to do?, posted by JohnSky on July 26, 2007, at 10:15:26
Forgot to ask. If I go up to 9mg does the preferred method seem to be to take it off at night? Also, Are most people abiding by the dietary restrictions or are they "soft".
John
Go forward in thread:
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.