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Dr. Bob is Robert Hsiung, MD,
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Posted by Bob on September 27, 2008, at 21:45:09
In reply to Re: Exotic Meds for Treatment Resistant Depression, posted by SLS on September 27, 2008, at 5:48:43
> > I have treatment-resistant depression and am interested in hearing about experiences with the more exotic medications such as opiates, ghb, ketamine, alzheimers meds, etc. Please share your experiences if you have them.
>
> Have you tried an MAO inhibitor yet? What were the results?
>
> My regime comprises the following:
>
> Parnate
> nortriptyline
> Lamictal
> Abilify
> NAC
>
>
> - ScottWow. You've made some major changes to your drug regimen. As for the Nardil induced weight gain, don't you think Nortriptyline would cause weight gain in the long run also? I thought pretty much all tricyclics were known for that.
- Bob
Posted by Tony P on September 28, 2008, at 1:46:37
In reply to Exotic Meds for Treatment Resistant Depression, posted by glenni on September 27, 2008, at 5:11:48
> I have treatment-resistant depression and am interested in hearing about experiences with the more exotic medications such as opiates, ghb, ketamine, alzheimers meds, etc.
===========
Well, I'm either treatment-resistant, atypical, or both, and probably fit somewhere on a Bipolar III effect spectrum. Or else I'm just a hard guy to please. I don't do well with SSRI's, at least by themselves -- I get more side effects than benefit, with the possible exception of Lexapro. Down the years, I've tried quite a few odd meds, and found a few that worked for me. Some of the following probably belong on the Alternative board, but since you asked, it's convenient to summarize my experience with both Rx and "alternative" remedies in one place.The Alzheimer's meds and supposed GABA enhancers that I've tried (mostly non-Rx or European so-called nootropics) have been a total washout as far as I'm concerned. Other people swear by them; YMMV. I've tried GABA, GABOB, Piracetam, Pramiracetam, Galantamine, DMAE and Picamolon. None of them had an effect that I could _feel_, but perhaps an objective measurement would have showed some improvement. I certainly would not consider them antidepresssants by themselves.
I've tried Tianeptine (atypical Serotonin booster), and found it a moderately effective antidepressant with very few side effects, but in the long run not powerful enough or broad-spectrum enough to do the job for me. Also, not available in North America.
I tried Trivastal and bromocryptine (both dopamine enhancers) and found them essentially harmless but not very effective, so if you're treatment-resistant, they may not do much for you, at least by themselves. On the other hand, you never know 'til you try; YMMV.
Yohimbine, or yohimbe bark (taken as tea) is an effective aphrodisiac and can help with the sexual side-effects of SSRI's. However, I haven't found it works as an antidepressant for me; on the contrary, it makes me very anxious in high doses, and I crash the next day and have a mini-depression.
Dextromethorphan (DM or DXM), which has some pharmacolgical similarities to ketamine, has occasionally been proposed as an antidepressant. In doses higher than you would normally take in cough mixture, it has some short-term stimulant properties, but I found it likewise had a long hangover period (12-48 hrs depending on dose) which was very depressive. There may be some risk of permanent brain damage (there definitely is with ketamine) with high doses on a regular basis.
The following HAVE worked for me. They're not really exotic, but they're not quite main-line either: Selegeline, Requip, Buspar, Modafinil, Adrafinil, Reboxetine.
Selegeline was very effective at a low dose (5-10 mg/day) _combined_ with other antidepressants (mainly Remeron in my case). There's a significant risk in combining an MAOI with almost anything else, but with selegeline IMHO it can be managed with cautious dosing and careful monitoring, especially BP. It made me anxious & physically shaky, though; Inderal helped with that & helped keep my blood pressure down.
I take Requip (ropinirole) as part of my regime, and have for about 2 years now. It was originally developed for treatment of Parkinson's, but was also approved a couple of years ago for Restless Leg Syndrome. A small pilot study in the Can. J. Psych. a year or two before that found that people on a wide variety of anti-depressants and mood stabilizers almost all improved when ropinirole was _added_ to their medication. I haven't seen a follow-up, but there ought to be one by now.
It's hard for me to judge, since I've never really experimented with going off & on it again, how much it contributes to my sense of well-being, but it's my impression that it has a small but significant mood-brightening effect. It enhances dopamine, which few antidepressants do directly, although the sites at which it acts tend to be sedating rather than stimulating ones, but I am sure there is some positive effect that spills over, as it were, to the mood-enhancing receptors.
The other reason I take it is that the first time I tried Remeron I got RLS so bad it involved my whole body and drove me close to suicidal. With Requip added, I can take Remeron and some other meds such as Seroquel that otherwise give me severe RLS or akathisia.
Remeron works for me but it's not enough by itself. I'm currently taking: Remeron, Cymbalta, Requip, Buspar, clonazepam, Seroquel if I need it at night, and modafinil (Provigil/Alertec) &/or adrafinil if I need them during the day. I suspect some of these may be fighting with each other to some extent, but I hate to mess with the mix if it's working, which for the most part it is.
Buspar works well for me, again in combination with major ADs, although about 4 out of 5 people say they don't get any benefit from it. For me, it enhances mood and activity level, and helps prevent anger and depression as a reaction to stress.
Modafinil (Provigil/Alertec) & adrafinil I find are primarily helpful in promoting daytime alertness if you suffer from hypersomnia (like sleeping 10-15 hrs. a day) as part of your depression, or if you have sleep apnea. They do also have a mild energizing and mood-brightening effect.
And let me not forget to mention coffee, which (I've read) also boosts dopamine. A triple latte with my other morning meds and I'm set for the day. But seriously, I think coffee (or tea if it's good strong English-style) is a much neglected antidepressant, or at least adjuvant. Techically caffeine's addicting, but I find it's self-limiting because of the unpleasant side effects of too much. I seldom want more than my morning 2-3 cups, and I even cut that back for a while when I started on Selegeline, and again when I switched to Cymbalta, and found I was getting anxiety attacks (surprise, surprise) half an hour after my morning coffee. I don't suppose a coffee regime by itself has ever cured anyone of major depression, but -- in moderation -- it sure helps!
I, too, am curious about GHB, ketamine and the like, but there are
a) some very high medical risks involved (like permanent brain damage & death, especially combined with other things, including alcohol)
b) legal issues
c) questionable purity if obtained from an illegal source,
so I'm staying away from them. And I'm pretty sure opiates are a blind alley, offering only very temporary relief, as well as being mostly illegal or highly controlled. Moreover, there is growing evidence that depression and a predisposition to addiction are closely linked (quite likely they have genes in common), so opiates are doubly risky to those of us with depression.
TP
Posted by SLS on September 28, 2008, at 6:41:44
In reply to Re: Exotic Meds for Treatment Resistant Depression » SLS, posted by Bob on September 27, 2008, at 21:45:09
> > My regime comprises the following:
> >
> > Parnate
> > nortriptyline
> > Lamictal
> > Abilify
> > NAC
> >
> >
> > - Scott> Wow. You've made some major changes to your drug regimen.
I consider it to be a no-lose move. If I don't respond as well to Parnate as I expect to, I might even give Marplan a whirl before returning to Nardil.
> As for the Nardil induced weight gain, don't you think Nortriptyline would cause weight gain in the long run also?
It does, and has. However, I find that I have success at managing my weight through diet with nortriptyline. I have lost 10 pounds in less than two weeks. Nardil is much more stubborn for me.
> I thought pretty much all tricyclics were known for that.
Pretty much. I think amitriptyline is probably the worst. However, I don't think they are universally worse than SSRIs. Desipramine is relatively weight-neutral. The problem with desipramine is that it tends to leave me with residual anhedonia. A pinch of serotonin is probably helpful to me.
Where are you at with things?
- Scott
Posted by greywolf on September 28, 2008, at 9:04:37
In reply to Exotic Meds for Treatment Resistant Depression, posted by glenni on September 27, 2008, at 5:11:48
I've given up on "exotic" medications for treatment resistant depression. I am currently awaiting VNS implantation on October 14th and will work that with Remeron, Abilify, Xanax, and Deplin.
Posted by SLS on September 28, 2008, at 9:24:36
In reply to Re: Exotic Meds for Treatment Resistant Depression, posted by greywolf on September 28, 2008, at 9:04:37
> I've given up on "exotic" medications for treatment resistant depression.
Understandable.
> I am currently awaiting VNS implantation on October 14th and will work that with Remeron, Abilify, Xanax, and Deplin.
A year ago, I would never have thought VNS had much potential. However, after corresponding with people who have tried it, I am impressed with the antidepressant response it is capable of producing.
GOOD LUCK!
- Scott
Posted by greywolf on September 28, 2008, at 19:39:27
In reply to Re: Exotic Meds for Treatment Resistant Depression » greywolf, posted by SLS on September 28, 2008, at 9:24:36
Thanks, Scott. It's encouraging to hear about other people's positive results with VNS.
Greywolf
Posted by dbc on September 28, 2008, at 20:44:11
In reply to Re: Exotic Meds for Treatment Resistant Depression » SLS, posted by greywolf on September 28, 2008, at 19:39:27
Poppy pod tea (as in the pods with all the good alkaloids)works amazingly and is in the grey legal area to purchase (check ebay). Yes good old P. Somniferum is still totally legal to buy for flower arranging but strangely enough retailers sell organic ones in incredibly large lots. Clearly people are doing lots of flower arranging. You should all know the danger of ingesting morphine and codeine and know that addiction is an ever looming evil associated with imbibing such a tea.
But saying that opiates are good for depression is a long the same line as saying amphetamine is good for depression.
Lamictal works for me but in a weird way.
Posted by Bob on September 28, 2008, at 23:45:39
In reply to Re: Exotic Meds for Treatment Resistant Depression » Bob, posted by SLS on September 28, 2008, at 6:41:44
> > > My regime comprises the following:
> > >
> > > Parnate
> > > nortriptyline
> > > Lamictal
> > > Abilify
> > > NAC
> > >
> > >
> > > - Scott
>
> > Wow. You've made some major changes to your drug regimen.
>
> I consider it to be a no-lose move. If I don't respond as well to Parnate as I expect to, I might even give Marplan a whirl before returning to Nardil.
>
> > As for the Nardil induced weight gain, don't you think Nortriptyline would cause weight gain in the long run also?
>
> It does, and has. However, I find that I have success at managing my weight through diet with nortriptyline. I have lost 10 pounds in less than two weeks. Nardil is much more stubborn for me.
>
> > I thought pretty much all tricyclics were known for that.
>
> Pretty much. I think amitriptyline is probably the worst. However, I don't think they are universally worse than SSRIs. Desipramine is relatively weight-neutral. The problem with desipramine is that it tends to leave me with residual anhedonia. A pinch of serotonin is probably helpful to me.
>
> Where are you at with things?
>
>
> - Scott
I'm now taking relatively small amounts of Citalopram, Lithium, and Nortriptyline, along with a tiny pinch of Risperdal. I will eventually have to find something to add to this cocktail since I'm not getting a real robust response, but I am getting decent anxiolytic effects.Why do you combine Nortriptyline with the MAOIs? Did your doctor come up with this strategy way back in the first go-'round, or was that your idea? Wouldn't a sufficiently high dose of one or the other alone be sufficient, or is there something special about the combo of both? It seems like a quite unorthodox strategy.
Was the weight gain the only major thing that led you away from Nardil?
One last question... are you able to function sexually on your cocktails? I for one am mostly not able to, especially at fully accepted therapeutic doses.
- Bob
Posted by SLS on September 29, 2008, at 7:46:19
In reply to Re: Exotic Meds for Treatment Resistant Depression » SLS, posted by Bob on September 28, 2008, at 23:45:39
Hi Bob.
I was first place on a combination of MAOI + TCA in 1983 by the research team at Columbia University. Unfortunately, they were too sheepish to increase the dosage of Nardil beyond 45mg. I responded briefly. Subsequently, another doctor tried Parnate 60mg + desipramine 150mg. It worked.
It took some effort to have my current doctor combine MAOIs and TCAs. This time it would be nortriptyline that I was to use as the TCA. I chose it because it produced a better response when combined with Effexor than did desipramine.
My switch from Nardil to Parnate was motivated by my not maintaining a full remission with Nardil, although I was still making progress. It was just happening too slowly. I have nothing to lose except for 50 pounds, as long as nortriptyline doesn't put up too much of a fight.
> One last question... are you able to function sexually on your cocktails?
Yes, although my "performance" has been somewhat diminished, and reaching orgasm difficult. For the times I have been on Nardil, I found that the ability to reach orgasm returns after a few months - even at 90mg.
What dosages of medication are you taking?
- Scott
Posted by Bob on September 29, 2008, at 21:33:51
In reply to Re: Exotic Meds for Treatment Resistant Depression » Bob, posted by SLS on September 29, 2008, at 7:46:19
> Hi Bob.
>
> I was first place on a combination of MAOI + TCA in 1983 by the research team at Columbia University. Unfortunately, they were too sheepish to increase the dosage of Nardil beyond 45mg. I responded briefly. Subsequently, another doctor tried Parnate 60mg + desipramine 150mg. It worked.
>
> It took some effort to have my current doctor combine MAOIs and TCAs. This time it would be nortriptyline that I was to use as the TCA. I chose it because it produced a better response when combined with Effexor than did desipramine.I did a little research about MAOI's mixed with tricyclics, and couldn't find anything newer than the early eighties. What is the theory behind why these combinations would be advantageous? A couple articles did mention certain combos that seemed to be quite toxic.
Why did you stop the trial of Effexor with Desipramine?
>
> My switch from Nardil to Parnate was motivated by my not maintaining a full remission with Nardil, although I was still making progress. It was just happening too slowly. I have nothing to lose except for 50 pounds, as long as nortriptyline doesn't put up too much of a fight.
>
Is Parnate weight neutral?
> > One last question... are you able to function sexually on your cocktails?
>
> Yes, although my "performance" has been somewhat diminished, and reaching orgasm difficult. For the times I have been on Nardil, I found that the ability to reach orgasm returns after a few months - even at 90mg.
>
> What dosages of medication are you taking?
I'm on low doses of everything as I've had a history of extreme sensitivity to meds, which was greatly exacerbated by ECT a few years ago. Anyway... Notriptyline 30mg, Citalopram 20mg, Eskalith CR 225mg, and .25mg Risperdal.>
>
> - Scott
Posted by NewQuestions on September 30, 2008, at 13:12:06
In reply to Re: Exotic Meds for Treatment Resistant Depression, posted by dbc on September 28, 2008, at 20:44:11
Were you always treatment resistent or did something work for a while and then stop?
Posted by bleauberry on September 30, 2008, at 17:17:23
In reply to Exotic Meds for Treatment Resistant Depression, posted by glenni on September 27, 2008, at 5:11:48
Exotic meds for depression? Ok. How about the antibiotic Doxycycline. How about the lead/mercury chelator DMSA. I think too often we look only at the brain and fail to consider there is something else going on in the body that is impacting the brain. Like a chronic critter infection or low level metal toxicity. The absolute best I've ever felt was when on either of the above meds. They were short bursts and maybe a hint of better things to come, but certainly blew away any of the 30+ psych meds I've ever tried.
Other than that, look at stuff that doesn't make sense. Really. Not kidding. If all the stuff that makes sense doesn't work, then logic says you gotta look somewhere else because there is something else going on that you haven't identified yet.
And of course combinations abound. Maybe someone did not do well with zoloft or remeron, but did great when they tried them together? Prozac lousy, zyprexa lousy, but both together great? Ya know? Those kinds of things happen all the time. How about the guy who was bedridden for two years, was on prozac and ritalin, and then was woken from the dead to a brand new life as soon as memantine was added. Stuff happens like that.
Posted by Ant-Rock on September 30, 2008, at 19:40:15
In reply to Exotic Meds for Treatment Resistant Depression, posted by glenni on September 27, 2008, at 5:11:48
Exotic Meds you ask?
Have had TRD since 1990. Iv'e tried many many meds as well as Transcranial magnetic stimulation.
Not to mention therapy.The only time I've felt real relief has been from the following: GHB, Parnate(the first time briefly worked), Vicodin, Amisulpride, Ritalin/adderal briefly worked.
GHB when used responsibly was a wonderful temporary solution to my depression. Of course, it's not available any more.
I started coming and registered to this board in 1998-99,at the very beginning. I don't see most of the original posters names anymore, and I sometimes wonder if they have found a solution and moved on, or just accepted the situation and got tired of waiting for a new novel med that actually works.
My2cents.Anthony
Posted by theo on September 30, 2008, at 20:03:02
In reply to Re: Exotic Meds for Treatment Resistant Depression, posted by SLS on September 27, 2008, at 5:48:43
I didn't see Deplin. Did your retrial result in nightmares again?
> My regime comprises the following:
>
> Parnate
> nortriptyline
> Lamictal
> Abilify
> NAC
>
>
> - Scott
Posted by Phillipa on September 30, 2008, at 20:23:36
In reply to Re: Exotic Meds for Treatment Resistant Depression, posted by Ant-Rock on September 30, 2008, at 19:40:15
I know quite a few I e-mail with who either got better going off meds, or are just working with docs and improving. Phillipa
Posted by Phillipa on September 30, 2008, at 20:24:42
In reply to Re: Exotic Meds for Treatment Resistant Depression » SLS, posted by theo on September 30, 2008, at 20:03:02
Neither does Ron Hills. Phillipa
Posted by azalea on September 30, 2008, at 20:49:00
In reply to Re: Exotic Meds for Treatment Resistant Depression, posted by Ant-Rock on September 30, 2008, at 19:40:15
Xyrem (trade name for GHB) is currently marketed in the US by Jazz Pharmaceuticals.
>
> GHB when used responsibly was a wonderful temporary solution to my depression. Of course, it's not available any more.
>
Posted by SLS on October 1, 2008, at 7:21:18
In reply to Re: Exotic Meds for Treatment Resistant Depression » SLS, posted by Bob on September 29, 2008, at 21:33:51
Hi Bob.
> Why did you stop the trial of Effexor with Desipramine?
I responded only partially to it ~ 25% improvement.
> Is Parnate weight neutral?
I lose weight on it. I'm down over 10 pounds in 2 weeks.
> I'm on low doses of everything as I've had a history of extreme sensitivity to meds, which was greatly exacerbated by ECT a few years ago.
Very interesting. I think I encountered someone else who experienced the same thing.
> Notriptyline 30mg, Citalopram 20mg, Eskalith CR 225mg, and .25mg Risperdal.
You might want to try to sneak the nortriptyline up 10mg at a time. Most people need 75mg.
- Scott
Posted by SLS on October 1, 2008, at 7:23:13
In reply to Re: Exotic Meds for Treatment Resistant Depression, posted by NewQuestions on September 30, 2008, at 13:12:06
> Were you always treatment resistent or did something work for a while and then stop?
I have a history of responding to medications for no more than 3 days before abruptly relapsing.
- Scott
Posted by SLS on October 1, 2008, at 7:26:02
In reply to Re: Exotic Meds for Treatment Resistant Depression, posted by bleauberry on September 30, 2008, at 17:17:23
Hi BB.
> Exotic meds for depression? Ok. How about the antibiotic Doxycycline.
I tried doxycycline. I was interested in its anti-inflammatory properties along with its antibiotic properties. You need to be on it for quite awhile, but my doctor has had success with it.
- Scott
Posted by SLS on October 1, 2008, at 7:31:52
In reply to Re: Exotic Meds for Treatment Resistant Depression » SLS, posted by theo on September 30, 2008, at 20:03:02
> I didn't see Deplin. Did your retrial result in nightmares again?
Yes. It is a fascinating phenomenon that I and a few other people have such violent content to our dreams with Deplin. Why not vivid dreams of picking daisies?
For me, Deplin worked great early in treatment, but it very gradually lost its effect. It is often hard to know if something is still helping when it fades so slowly. The test for me was to discontinue Deplin to evaluate my response to it. I felt no different off of it than I did on it.
- Scott
Posted by uncouth on October 1, 2008, at 10:38:15
In reply to Re: Exotic Meds for Treatment Resistant Depression » theo, posted by SLS on October 1, 2008, at 7:31:52
Scott,
was wondering if you could talk about the Abilify and how you settled on 20mg. What sort of experimentation did you do?
im currently on 40mg Parnate, 5mg abilify, 450 Lithobid, and Lunesta/Xanax for sleep.I know abilify is tricky and works differently at different doseages, but are you using it as an a/d adjunct or a mood stabilizer? Did you test different dosages, and how did your subjective experience change as a function of that?
Thanks
uncouth
Posted by Bob on October 1, 2008, at 12:05:00
In reply to Re: Exotic Meds for Treatment Resistant Depression » Bob, posted by SLS on October 1, 2008, at 7:21:18
the same thing.
>
> > Notriptyline 30mg, Citalopram 20mg, Eskalith CR 225mg, and .25mg Risperdal.
>
> You might want to try to sneak the nortriptyline up 10mg at a time. Most people need 75mg.
>
>
> - Scott
>Actually, that is what I'm doing.
Posted by Ant-Rock on October 1, 2008, at 20:17:34
In reply to Re: Exotic Meds for Treatment Resistant Depression » Ant-Rock, posted by azalea on September 30, 2008, at 20:49:00
> Xyrem (trade name for GHB) is currently marketed in the US by Jazz Pharmaceuticals.
>
Thank you for that info Azalea.I think you need a diagnosis of narcolepsy to get a script.
It's a great band-aid anti-depressant, but not a long term solution. It got me through a whole summer of hell a few years back, with no withdrawal of any kind.Thank you again for responding.
Anthony
Posted by SLS on October 4, 2008, at 19:02:39
In reply to Re: Exotic Meds for Treatment Resistant Depression » SLS, posted by uncouth on October 1, 2008, at 10:38:15
Hi.
I tapered the dosage until I relapsed, then titrated back up to the dosage that I felt best at. For me, Abilify serves as both an adjunct antidepressant and an anti-manic mood stabilizer. Once I attain remission, I might try to back off to 10mg.
- Scott
> Scott,
> was wondering if you could talk about the Abilify and how you settled on 20mg. What sort of experimentation did you do?
> im currently on 40mg Parnate, 5mg abilify, 450 Lithobid, and Lunesta/Xanax for sleep.
>
> I know abilify is tricky and works differently at different doseages, but are you using it as an a/d adjunct or a mood stabilizer? Did you test different dosages, and how did your subjective experience change as a function of that?
>
> Thanks
> uncouth
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Dr. Bob is Robert Hsiung, MD,
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