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Dr. Bob is Robert Hsiung, MD,
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Posted by bulldog2 on May 18, 2009, at 12:28:37
In reply to Breaking through the wall., posted by SLS on May 18, 2009, at 6:59:44
> Hi folks.
>
> I did very well for over a year using a combination of drugs that included Nardil. When I began to relapse (Nardil poop-out), I decided to switch to Parnate. I have been feeling improved, but far from being in remission. I am about 35% improved relative to my baseline unmedicated depression.
>
> I seem to always reach a wall of some sort, beyond which my brain will just not respond further to continued treatment. It is a response plateau. I will need to do something different if I am to break through the wall and reach my goal of remission.
>
>
> Currently:
>
> Parnate 80mg
> nortriptyline 150mg
> Lamictal 200mg
> Abilify 20mg
>
>
> Thanks for reading.
>
> I would be grateful to receive feedback.
>
>
> - Scott
>
>Maybe toggle between things that have worked. Go back and retry nardil. Retry deplin with an maoi.
Posted by shasling on May 18, 2009, at 13:12:18
In reply to Breaking through the wall., posted by SLS on May 18, 2009, at 6:59:44
Scott you helped so many including myself alone,think about that in hopes it ads a little light.
Parnate is a double edged sword,nice a few days,then dead and drab the next,but it for me does give the days of remission,somthing no other med has done,but like you and many i feel it a drug that must be augmented.
I read you meds,and they sound good,i will say this and you might not agree,or others but,
LAMICTAL in my case totaly killed parnte,like a grey cloud over it making almost impossable to work.
I quickly removed it and added gabpentin instead.
Posted by ricker on May 18, 2009, at 14:42:29
In reply to Breaking through the wall., posted by SLS on May 18, 2009, at 6:59:44
Hi Scott, sorry to hear you have regressed with your treatment.
How would you describe your symptoms?
Is your depression such that you lose all desire/motivation?
How often, and long do you sink into the depression?
Do you, or have you in past, suffered with anxiety/panic?
Don't mean to sound nosy, but it would help me in understanding your pattern and maybe offering proactive advise.
Yes, I know, the wall can seem quite thick at times, but we will continue to fight, if not through it, then up and over it!
Please keep well, Rick
Posted by Sigismund on May 18, 2009, at 15:54:43
In reply to Breaking through the wall., posted by SLS on May 18, 2009, at 6:59:44
Well, 35 is better than 15 which is where you were years ago. I felt at the time that you had to work damn hard for that 15%, so it's better that you have had to work damn hard for 35. It was the Lamictal and Abilify that made the extra improvement. I dunno anything about those drugs.
Posted by bleauberry on May 18, 2009, at 17:02:28
In reply to Breaking through the wall., posted by SLS on May 18, 2009, at 6:59:44
I am sure you know, Scott, that the antipsychotics combined with antidepressants can have some magic. Not by themselves, but in combination. Who knows why. It is probably some intricate mechanisms involved with the 5ht antagonism and to a lesser degree the DA antagonism.
So, if you have not already tried them, I thought I would mention the two that seem to do best (at a non-scientific scan) in pubmed studies. Zyprexa and Risperdal.
And I certainly would not rule out any of the conditions that cause depression. Where the brain is not the primary problem, but some unseen unsuspected assault on the brain is. I know you've had thorough testing, but those aren't the kind of tests I'm thinking of. Too unreliable and too vague. They miss a lot. They often pronounce someone normal when in fact they are quite ill.
But that's a different topic.
Posted by desolationrower on May 18, 2009, at 17:09:12
In reply to Re: Breaking through the wall., posted by shasling on May 18, 2009, at 13:12:18
scott you're bipolar right. perhaps you're trying to get to a level of hyperthymia you associate with normal?
-d/r
Posted by jedi on May 18, 2009, at 20:29:25
In reply to Breaking through the wall., posted by SLS on May 18, 2009, at 6:59:44
Hi Scott,
How is your anxiety level? I tapered off clonazepam over three months, then dropped 90mg of Nardil in about 1.5 months.Lately I've felt my depression start to return which is normal for me after several weeks off Nardil. This time I'm going to add back in the clonazepam and try to stay off Nardil for as long as I can. I'm hoping that by increasing GABA I may be able to hold off the major depression, since anxiety is a major trigger of my depression.
Does the Lamictal increase GABA for you enough to help with anxiety? I've never used Lamictal but I have used gabapentin in the past. Any ideas for me on how to increase GABA without going back to the benzos on a daily basis? There were times, while coming off clonazepam where it got pretty dicey. If it were not for the memory impairment, I would just go on high dose clonazepam and relax.
I'm not bipolar, but I have had hypomanic episodes when first starting Nardil. My depression is atypical and IMHO this disease lies somewhere on the bipolar spectrum. Maybe a mood stabililer such as Lamictal would be good for me. Thoughts?
Good Luck Scott,
Jedi
> Hi folks.
>
> I did very well for over a year using a combination of drugs that included Nardil. When I began to relapse (Nardil poop-out), I decided to switch to Parnate. I have been feeling improved, but far from being in remission. I am about 35% improved relative to my baseline unmedicated depression.
>
> I seem to always reach a wall of some sort, beyond which my brain will just not respond further to continued treatment. It is a response plateau. I will need to do something different if I am to break through the wall and reach my goal of remission.
>
>
> Currently:
>
> Parnate 80mg
> nortriptyline 150mg
> Lamictal 200mg
> Abilify 20mg
>
>
> Thanks for reading.
>
> I would be grateful to receive feedback.
>
>
> - Scott
>
>
Posted by greywolf on May 18, 2009, at 20:41:28
In reply to Re: Breaking through the wall., posted by desolationrower on May 18, 2009, at 17:09:12
Scott:
Have you tried augmenting with Cytomel? Thyroid hormone has been shown to be effective in some people.
Greywolf
Posted by Elanor Roosevelt on May 18, 2009, at 21:51:40
In reply to Breaking through the wall., posted by SLS on May 18, 2009, at 6:59:44
I can't offer any advice
But wanted to thank you for reminding me to return to my hope for remissionhang in there
Posted by desolationrower on May 19, 2009, at 0:15:49
In reply to Re: Breaking through the wall., posted by Elanor Roosevelt on May 18, 2009, at 21:51:40
i think creatine would be a helpful addition, btw.
-d/r
Posted by Zana on May 19, 2009, at 14:32:44
In reply to Re: Breaking through the wall., posted by desolationrower on May 19, 2009, at 0:15:49
So where does all this leave you?
Zana
Posted by SLS on May 19, 2009, at 15:12:22
In reply to Breaking through the wall., posted by SLS on May 18, 2009, at 6:59:44
I just wanted to thank all of you for your thoughtful replies. I will try to answer each post individually later. Right now, I am short on energy and time.
I am still feeling "stuck", but I am doing better now than I had been while taking the memantine (Namenda) at 20mg. I may perform a quick experiment and try taking a small dose of memantine to see if there is a therapeutic window in my case.
Thanks again.
- Scott
Posted by floatingbridge on May 20, 2009, at 21:52:32
In reply to Breaking through the wall., posted by SLS on May 18, 2009, at 6:59:44
Scott,
Higher doses of abilify tanked me. Other than that, I want to offer you but my best wishes for remission.
Candace
Posted by SLS on May 21, 2009, at 5:19:13
In reply to Re: Breaking through the wall., posted by Zana on May 18, 2009, at 8:53:03
> Can you describe your mood? How can you tell you are not quite "there" yet?
1. Anergy - a lack of energy both psychic and physical.
2. Lack of interest to do anything. Content to stare into space.
3. Cognitive slowing.
4. Impaired memory - short term and long-term potentiation.
5. Amotivation - can't get started doing anything.
6. Flat affect - not animated.
> I'm wondering if adding a stimulant like provigilI reacted badly to Provigil. It made my depression worse and more painful. Your suggestion of using a stimulant of some sort is a good one. Thanks.
> You give so much to others. I hope you get a lot of good imput.
Thanks. I sometimes forget to take care of me. I am very happy to see so many helpful replies.
- Scott
Posted by SLS on May 21, 2009, at 5:23:04
In reply to Re: Breaking through the wall., posted by Phillipa on May 18, 2009, at 10:46:37
> Scott I don't know. What haven't you tried?
maprotiline (Ludiomil)
mianserin (related to Remeron)
fluvoxamine (Luvox)
pramepexole (Mirapex)
milnacipran
agomelatineThere aren't too many others.
> What do your docs suggest?
His last suggestion was to revisit memantine (Namenda). It helped a little at first, then hurt a lot as time progressed.
> I sincerely wish I had to knowledge to help.
I know you do, Jan. Thank you.
- Scott
Posted by SLS on May 21, 2009, at 5:33:21
In reply to Re: Breaking through the wall., posted by Relapse on May 18, 2009, at 11:52:32
Hi.
> I know this is not new news. Also, you may have already have tried this (not sure because I've only been here a few months). Last but not least, I am on the lower end concerning technical knowledge of the meds.
A little knowledge can go a long way if used judiciously and the intelligence to be found in the uncommon use of common sense. The most brilliant of ideas can come from anyone, and I appreciate your kind input.
> But I still wanted to mention this because it's a big strategy with my pdoc. He augmented 600 mg to my 150 of Zoloft.
Unfortunately, lithium hurts me more than it helps. I feel worse on it, plus the added flattening of affect, increased passivity, and lack of creativeness. Just blah.
> I've read some good success stories concerning MAOI's and lithium
Yes. Adding lithium to Parnate had been a frequently used strategy before the SSRIs came along.
I'm glad you are responding to treatment again. The choice of lithium shows some very good clinical practice.
- Scott
Posted by SLS on May 21, 2009, at 5:42:54
In reply to Re: Breaking through the wall., posted by uncouth on May 18, 2009, at 11:55:35
> my thinking is just to push up the parnate as far as it will go...
I have been as high as 150mg. It definitely feels like a different drug in this high dosage range. It provided moderate improvement, but not for long. I added desipramine, amphetamine, bromocriptine, and T4 together with Parnate 120mg.
> there is articles on psychotropical.com from a doctor who uses parnate who seems to think it's teh best a/d by far as long as your not afraid of pushing the dose higher.
Interesting. I have always found Parnate to provide me with a more stable improvement than Nardil. It probably has much to do with the fact that I am bipolar.
> either that or adding namenda to fight poop out which supposedly (i don't have experience myself) it does.This seems to be a notion that is becoming more popular. Memantine produced a nice "kick" during the first week. Thereafter, it made me feel worse and, I believe, PREVENTED any further improvement. In a way, perhaps memantine makes things "stick" better. I wonder how it would affect me had I waited to respond more fully first before adding it.
It's obvious that I really extend myself to produce some pretty silly ideas. It breeds hope for me, though, that there are alternatives to be found in uncertainty. I can't be certain that memantine wouldn't work in such away as to prevent poop-out.
Good thinking. Thanks.
Can you tell me more about your experience with agomelatine?
- Scott
Posted by SLS on May 21, 2009, at 5:44:59
In reply to Re: Breaking through the wall., posted by bulldog2 on May 18, 2009, at 12:28:37
> Maybe toggle between things that have worked. Go back and retry nardil. Retry deplin with an maoi.This is a brilliant idea that has been supported by some doctors whom are not petrified to play with MAOIs. One doctor I know used to cycle one of his patients between Parnate and Nardil. It was the only thing that kept him well.
Thanks.
- Scott
Posted by SLS on May 21, 2009, at 5:54:14
In reply to Re: Breaking through the wall., posted by shasling on May 18, 2009, at 13:12:18
> Parnate is a double edged sword,nice a few days,then dead and drab the next
I react exactly this way to Parnate when I am not combining it with other drugs.
> but it for me does give the days of remission,somthing no other med has done.
How precious is a single day of remission. I try to keep close to me the memories of being in remission so that I am that much sure of the biological nature of my condition, and that life is worth living when one emerges from the depths.
> many i feel it a drug that must be augmented.
Definitely.
> I read you meds,and they sound good,i will say this and you might not agree,or others but,Agreement is irrelevant. Your offering alternative suggestions and descriptions of personal anecdotes is precious.
> LAMICTAL in my case totaly killed parnte,like a grey cloud over it making almost impossable to work.
I will keep this in mind. It sounds like what memantine did to me for the 6 weeks I took it.
> I quickly removed it and added gabpentin instead.
Sounds good to me. How do you feel that gabapentin is helping? If you experience an inadequate response to it, don't forget about pregabalin (Lyrica). It operates on the same calcium channel receptor subsection (alpha-2-delta).
The exchange of information and ideas on Psycho-Babble is invaluable.
Thanks.
- Scott
Posted by SLS on May 21, 2009, at 6:04:21
In reply to Re: Breaking through the wall. » SLS, posted by ricker on May 18, 2009, at 14:42:29
> Hi Scott, sorry to hear you have regressed with your treatment.
> How would you describe your symptoms?1. Anergia
2. Loss of interest
3. Amotivation
4. Cognitive slowing
5. Memory impairments
6. Flat affect
7. Heavy sighing
8. Dysautomia (imbalance in autonomic system)
> Is your depression such that you lose all desire/motivation?Totally.
> How often, and long do you sink into the depression?
Although I had brief bouts of moderate depression after age 10, it became SEVERE by age 17. Since that time, I have only spent a few days at a time in remission due to treatment, and one 9 month period of stable full remission at age 27. In other words, my depression never remits spontaneously. I have been depressed for decades with no relent.
> Do you, or have you in past, suffered with anxiety/panic?
Yes. Social anxiety/phobia was a major part of what I experienced earlier in my history.
> Don't mean to sound nosy, but it would help me in understanding your pattern and maybe offering proactive advise.
Much appreciated.
> Yes, I know, the wall can seem quite thick at times, but we will continue to fight, if not through it, then up and over it!God damned right.
> Please keep well, Rick
You do the same, Scott
Posted by SLS on May 21, 2009, at 6:11:05
In reply to Re: Breaking through the wall., posted by Sigismund on May 18, 2009, at 15:54:43
> Well, 35 is better than 15 which is where you were years ago.
I cannot believe that you would take so much interest in me as to remember that.
> I felt at the time that you had to work damn hard for that 15%, so it's better that you have had to work damn hard for 35. It was the Lamictal and Abilify that made the extra improvement.
Yes. Thank you again!
> I dunno anything about those drugs.
Neuroscientists sometimes feel the same way about these drugs. There is an overwhelming amount of data coming from investigation so far, but little understanding. The jigsaw puzzles has very few pieces that fit together so far.
Thanks for your thoughtful reply.
- Scott
Posted by SLS on May 21, 2009, at 6:14:33
In reply to Re: Breaking through the wall., posted by bleauberry on May 18, 2009, at 17:02:28
> I am sure you know, Scott, that the antipsychotics combined with antidepressants can have some magic. Not by themselves, but in combination. Who knows why. It is probably some intricate mechanisms involved with the 5ht antagonism and to a lesser degree the DA antagonism.
>
> So, if you have not already tried them, I thought I would mention the two that seem to do best (at a non-scientific scan) in pubmed studies. Zyprexa and Risperdal.I reacted to both drugs wonderfully for about a week. Thereafter, nothing good enough to justify their continuation.
Abilify is the one that is helping at the moment. It is a stable response, thank God.
> And I certainly would not rule out any of the conditions that cause depression. Where the brain is not the primary problem, but some unseen unsuspected assault on the brain is. I know you've had thorough testing, but those aren't the kind of tests I'm thinking of. Too unreliable and too vague. They miss a lot. They often pronounce someone normal when in fact they are quite ill.
>
> But that's a different topic.
Understood.:-)
Valid and valuable ideas.
Thanks.
- Scott
Posted by SLS on May 21, 2009, at 6:21:27
In reply to Re: Breaking through the wall., posted by desolationrower on May 18, 2009, at 17:09:12
> scott you're bipolar right. perhaps you're trying to get to a level of hyperthymia you associate with normal
You brough a smile to my face. This has been suggested to me numerous times. It is a very valid concern, and I would say that some of the time I spent on Nardil 20 years ago qualifies. However, I am sure of what remission feels like without hyperthymia, as I spent 6 months in a normothymic state 22 years ago while being treated with Parnate + desipramine.
Thanks. Great question.
- Scott
Posted by SLS on May 21, 2009, at 6:41:14
In reply to Re: Breaking through the wall. » SLS, posted by jedi on May 18, 2009, at 20:29:25
> Hi Scott,
> How is your anxiety level?
Pretty low. Most of the health care professionals have a hard time believing it. To make a long story short, after I was informed by one of my more brilliant doctors that anxiety would prevent me from responding well to treatment and increase the liability for relapse, I have been using CBT to keep stress to a minimum. It took a few years of practice, but CBT really did the trick.
> Lately I've felt my depression start to return which is normal for me after several weeks off Nardil. This time I'm going to add back in the clonazepam and try to stay off Nardil for as long as I can. I'm hoping that by increasing GABA I may be able to hold off the major depression, since anxiety is a major trigger of my depression.
What about Xanax (alprazolam)? It has proven antidepressant properties. A sister drug, adinazolam is used specifically for anxious depression. I tried this during an open label investigation. It is a very "clean" drug. I felt like I was taking nothing. Unfortunately, my depression felt the same way, but a significant number of people are helped by this drug.
> Does the Lamictal increase GABA for you enough to help with anxiety?
It is hard to say. It does more for depression than anxiety. Lamictal seems to work by inhibiting the release of glutamate rather than act directly on GABAergic neurons. I guess GABA is potentiated because Lamictal is also a sodium channel blocker.
> I've never used Lamictal but I have used gabapentin in the past. Any ideas for me on how to increase GABA without going back to the benzos on a daily basis?
1. Depakote - some people find this drug mildly depressing.
2. Lyrica - a variant of Neurontin.* TCAs - doxepin, trimipramine, amitriptyline don't work on GABA directly, but are known to reduce anxiety along with depression.
* Seroquel
> There were times, while coming off clonazepam where it got pretty dicey.
I can imagine. I've been there myself. I particularly hated the brain "lightning" that I experienced. They felt different from SRI withdrawal brain "zaps".
> If it were not for the memory impairment, I would just go on high dose clonazepam and relax.
Hmm. Does Xanax do the same thing?
> I'm not bipolar, but I have had hypomanic episodes when first starting Nardil. My depression is atypical and IMHO this disease lies somewhere on the bipolar spectrum.
I agree.
> maybe a mood stabililer such as Lamictal would be good for me. Thoughts?
Definitely. It is a personal theory of mine that Lamictal works to increase dopaminergic activity downstream in the nucleus accumbens through a process known as disinhibition. I guess I do find Lamictal calming. It helps take away the anxious part of an agitated depression.
> Good Luck Scott,
Much appreciated, Jedi.
- Scott
Posted by SLS on May 21, 2009, at 6:43:56
In reply to Re: Breaking through the wall., posted by greywolf on May 18, 2009, at 20:41:28
> Scott:
>
> Have you tried augmenting with Cytomel? Thyroid hormone has been shown to be effective in some people.Yes. I know it is frustrating to hear, but Cytomel (T3) was tried on me in 1982. It made me feel much worse. We rechallenged me twice just to make sure. I find thyroxine (T4) mildly helpful. Now that you got me thinking about it, I'll remember to tell my doctor.
Thanks.
- Scott
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