![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 27. This is the beginning of the thread.
Posted by g_g_g_unit on February 4, 2012, at 22:03:45
So my psychiatrist and I decided to go with Parnate in the end. I'll be starting at 20mg tomorrow, before moving up to 30mg after a week. He consulted Stahl's prescribing manual and is willing to go up to at least 60mg.
I asked if he would prescribe clonidine for insomnia, given that benzos given me the worst rebound depression, but he said he needs to look into its interaction with MAOIs. His suggestion (based on Stahl) was Trazodone, though I just googled and it doesn't seem to be available in Australia.
Posted by tensor on February 5, 2012, at 4:49:37
In reply to starting Parnate tomorrow, posted by g_g_g_unit on February 4, 2012, at 22:03:45
> So my psychiatrist and I decided to go with Parnate in the end. I'll be starting at 20mg tomorrow, before moving up to 30mg after a week.
Good luck!
>He consulted Stahl's prescribing manual
I wish my pdoc did that, love his books.
> I asked if he would prescribe clonidine for insomnia, given that benzos given me the worst rebound depression, but he said he needs to look into its interaction with MAOIs. His suggestion (based on Stahl) was Trazodone, though I just googled and it doesn't seem to be available in Australia.
A low dose of Seroquel?
Posted by SLS on February 5, 2012, at 6:35:18
In reply to starting Parnate tomorrow, posted by g_g_g_unit on February 4, 2012, at 22:03:45
> So my psychiatrist and I decided to go with Parnate in the end. I'll be starting at 20mg tomorrow, before moving up to 30mg after a week. He consulted Stahl's prescribing manual and is willing to go up to at least 60mg.
Good plan.
> I asked if he would prescribe clonidine for insomnia,
Clonidine can produce depression in people who have no mental illness. I would be wary of this if you should go ahead with it.
The low-dose (25-100 mg) Seroquel is a valid alternative for treating insomnia. There is even a chance that it will make the Parnate work better. The major metabolite of Seroquel (norquetiapine) inhibits the reuptake of norepinephrine (NE). I haven't investigated this well enough to know what dosages of Seroquel are necessary for this mechanism to have the best clinical effect. However, I have seen the addition of Seroquel produce a dramatic antidepressant effect in a young woman at 50 mg. She was taking Risperdal at the time.
DO NOT give up on Parnate just because insomnia becomes a problem. You might have to treat the insomnia with the save aggressiveness with which you are treating the depression.
Trazodone is a yucky drug. It almost always produces a hangover effect the next day. It does work, though.
Can you list the specific drugs you have tried to treat insomnia and what were the results?
- Scott
Posted by bleauberry on February 5, 2012, at 6:40:16
In reply to starting Parnate tomorrow, posted by g_g_g_unit on February 4, 2012, at 22:03:45
If you have any trouble at the start, lower the dose. Some people need to be in the 2.5mg-5mg range at the beginning. Others can go right straight to big doses. I think Parnate is an excellent choice, but the dosing strategy can make it or break it. I believe a customized approach for each patient is much better than a preconceived blind blanket approach. That just requires paying attention to clues and side effects and then making necessary adjustments.
Posted by ed_uk2010 on February 5, 2012, at 15:53:17
In reply to starting Parnate tomorrow, posted by g_g_g_unit on February 4, 2012, at 22:03:45
>I'll be starting at 20mg tomorrow, before moving up to 30mg after a week.
I'd be tempted to increase the dose according to response and adverse effects, rather than after a fixed one week interval. Go with 10mg twice a day initially and see how you feel. If you have any problematic side effects you could reduce to 10mg once daily for a few days. If there are no adverse effects you can increase up to 30mg after one week but if you are having problems you might want to wait a few more days before increasing. In order to make psych meds more tolerable, think it's important to be flexible.
Posted by emmanuel98 on February 5, 2012, at 19:27:44
In reply to Re: starting Parnate tomorrow, posted by ed_uk2010 on February 5, 2012, at 15:53:17
I take parnate, 30mg. It has worked for me, but the insomnia is terrible. I have been taking 100mg trazadone plus 2mg ativan. But I recently ran out of ativan a week before my appt with p-doc. I didn't sleep at all or well for a week. My p-doc will not do ativan over the phone because I have a history of drug abuse and he wants to keep careful written records. I thought I had enough until our next appt (tomorrow), but I didn't. I had forgotten how bad the insomnia could be. Trazadone alone didn't help. I also tried seroquel ( had some left over from another trial) and it didn't help at all.
Posted by g_g_g_unit on February 6, 2012, at 3:35:29
In reply to Re: starting Parnate tomorrow » g_g_g_unit, posted by SLS on February 5, 2012, at 6:35:18
> > The low-dose (25-100 mg) Seroquel is a valid alternative for treating insomnia. There is even a chance that it will make the Parnate work better. The major metabolite of Seroquel (norquetiapine) inhibits the reuptake of norepinephrine (NE). I haven't investigated this well enough to know what dosages of Seroquel are necessary for this mechanism to have the best clinical effect. However, I have seen the addition of Seroquel produce a dramatic antidepressant effect in a young woman at 50 mg. She was taking Risperdal at the time.Strange. I replied to you last night, but it doesn't seem to have gone through. I noted that Seroquel, unfortunately, causes intolerable RLS in me, which makes it counter-productive as a sleep aid. I also experience a hangover effect.
>
> DO NOT give up on Parnate just because insomnia becomes a problem. You might have to treat the insomnia with the save aggressiveness with which you are treating the depression.Yes, the insomnia is what I'm dreading the most, to be honest. Loss of sleep - and the effects it has on cognition - kinda negates any benefits the drug might otherwise have, IMO.
>
> Trazodone is a yucky drug. It almost always produces a hangover effect the next day. It does work, though.
>
> Can you list the specific drugs you have tried to treat insomnia and what were the results?
>I've tried the "Z-drugs" like Ambien etc., which allowed me to sleep rather restfully, but produced hallucinations.
I've tried Seroquel, which caused RLS.
I've tried Xanax, Temazepam, Lorazepam - none of which allowed me to sleep restfully, with all producing rebound depression (agitation, suicidal ideation) the next day.
Posted by SLS on February 6, 2012, at 5:55:17
In reply to Re: starting Parnate tomorrow » SLS, posted by g_g_g_unit on February 6, 2012, at 3:35:29
> I've tried the "Z-drugs" like Ambien etc., which allowed me to sleep rather restfully, but produced hallucinations.
>
> I've tried Seroquel, which caused RLS.
>
> I've tried Xanax, Temazepam, Lorazepam - none of which allowed me to sleep restfully, with all producing rebound depression (agitation, suicidal ideation) the next day.I see. All of the things that you describe are consistent with what each of those drugs are capable of. Trazodone may, indeed, represent a reasonable alternative. It has been a common practice to use it with Parnate for over 20 years. Finding the lowest effective dosage is important to help prevent a "hangover" sedation the next day. There are the antihistamines (hydroxyzine, cyproheptadine, diphenhydramine). It might be an option to combine one of these drugs with trazodone if trazodone by itself is insufficient. Cyproheptadine adds some serotoninergic properties that may be helpful and that may actually guard against serotonin syndrome. Certain tricyclics can be combined safely with Parnate. Amitriptyline, trimipramine, and doxepin are all sedating and useful to treat insomnia. Mirtazapine would be a nice tool to work with, but I am not convinced that it is safe when combined with Parnate. One would think so. Sonata (zaleplon), a "Z" drug, might be worth a try. It is rather gentle, and works well to initiate sleep. Again, you could add an antihistamine to it in order to help keep you asleep. One should not generalize to all of the "Z" drugs the amnestic or hallucinatory effects of Ambien (zolpidem). Prazosin can help with sleep, but might be too mild. Melatonin might be helpful. You would have to experiment with it to discover what time is best for you to take it. Many people take it about an hour before bed. Others have more success with two hours. Infrequently, taking melatonin in the afternoon works and helps align one's circadian rhythms.
If I were you, I would probably opt to try trazodone first, possibly to be combined with an antihistamine. Linkadge has had success using cyproheptadine.
- Scott
Posted by g_g_g_unit on February 6, 2012, at 6:34:56
In reply to Re: starting Parnate tomorrow » g_g_g_unit, posted by SLS on February 6, 2012, at 5:55:17
Thanks for the tip! I find cyproheptadine to be a useful tool to combat insomnia, but unfortunately the half-life is too long for my liking; I notice a hang-over effect, as well as a rather flat/anhedonic mood the next day.
I've taken a tiny dose of melatonin combined with 25mg of Doxylamine tonight. I'll see how I fare. Given how much more urgent remission feels at this point, I'm determined to combat the insomnia by any means possible. Sonata was actually something that came up in my research which interested me. When I was travelling, a friend I was staying with had access to Hypnovel (Midazolam), which I liked, though his doctor was exceedingly liberal with the prescription pad, so I'm not sure how easy it would be to access here in Australia.
I really wish I could get my hands on some Xyrem.
>
> I see. All of the things that you describe are consistent with what each of those drugs are capable of. Trazodone may, indeed, represent a reasonable alternative. It has been a common practice to use it with Parnate for over 20 years. Finding the lowest effective dosage is important to help prevent a "hangover" sedation the next day. There are the antihistamines (hydroxyzine, cyproheptadine, diphenhydramine). It might be an option to combine one of these drugs with trazodone if trazodone by itself is insufficient. Cyproheptadine adds some serotoninergic properties that may be helpful and that may actually guard against serotonin syndrome. Certain tricyclics can be combined safely with Parnate. Amitriptyline, trimipramine, and doxepin are all sedating and useful to treat insomnia. Mirtazapine would be a nice tool to work with, but I am not convinced that it is safe when combined with Parnate. One would think so. Sonata (zaleplon), a "Z" drug, might be worth a try. It is rather gentle, and works well to initiate sleep. Again, you could add an antihistamine to it in order to help keep you asleep. One should not generalize to all of the "Z" drugs the amnestic or hallucinatory effects of Ambien (zolpidem). Prazosin can help with sleep, but might be too mild. Melatonin might be helpful. You would have to experiment with it to discover what time is best for you to take it. Many people take it about an hour before bed. Others have more success with two hours. Infrequently, taking melatonin in the afternoon works and helps align one's circadian rhythms.
>
> If I were you, I would probably opt to try trazodone first, possibly to be combined with an antihistamine. Linkadge has had success using cyproheptadine.
>
>
> - Scott
Posted by ed_uk2010 on February 6, 2012, at 7:48:20
In reply to Re: starting Parnate tomorrow » SLS, posted by g_g_g_unit on February 6, 2012, at 6:34:56
Have you tried zopiclone (Imovane/Zimovane) for your insomnia?
Posted by g_g_g_unit on February 7, 2012, at 1:40:34
In reply to Re: starting Parnate tomorrow » g_g_g_unit, posted by ed_uk2010 on February 6, 2012, at 7:48:20
Well, it's day#2 on 20mg. I take 10mg upon waking, and 10mg at noon. So far I've noticed some slight euphoria, aggression and increase in energy/alertness after each dose, which dissipates after 2-3 hours. Adding caffeine to the mix creates a rather nasty effect. I'm a little disappointed with the stimulant effect - it's too abrasive to help much with concentration.
In the afternoons, I'm hit by incredible fatigue/apathy and brain fog, and can barely keep my eyes open.
Last night, I took 50mg of doxylamine to sleep, which did the trick but left me with a bad hangover. I'm going to get a z-drug prescription from my doctor tomorrow and will probably alernate between that, doxylamine and Benadryl until I can find a sustainable solution.
Any of this sound out-of-the-ordinary?
Posted by g_g_g_unit on February 7, 2012, at 4:06:34
In reply to update, posted by g_g_g_unit on February 7, 2012, at 1:40:34
ugh. I'm feeling so depressed and flat and apathetic this evening. this is bringing back bad memories of my last trial. I'm wondering if I should just increase the dose as fast as possible.
Posted by SLS on February 7, 2012, at 4:45:43
In reply to update, posted by g_g_g_unit on February 7, 2012, at 1:40:34
> Well, it's day#2 on 20mg. I take 10mg upon waking, and 10mg at noon. So far I've noticed some slight euphoria, aggression and increase in energy/alertness after each dose, which dissipates after 2-3 hours. Adding caffeine to the mix creates a rather nasty effect. I'm a little disappointed with the stimulant effect - it's too abrasive to help much with concentration.
The stimulant effect of Parnate often subsides substantially with continued treatment.
> In the afternoons, I'm hit by incredible fatigue/apathy and brain fog, and can barely keep my eyes open.
Unfortunately, this is a common complaint. It can be persistent. I have never experienced this with Parnate. Let's hope if resolves. If it doesn't resolve, but Parnate produces a significant improvement in depression, you can use caffeine or methylphenidate to help get you through this period of fatigue.
- Scott
Posted by sigismund on February 7, 2012, at 4:45:57
In reply to update, posted by g_g_g_unit on February 7, 2012, at 1:40:34
>Any of this sound out-of-the-ordinary?
Nope
Posted by SLS on February 7, 2012, at 5:09:29
In reply to Re: update, posted by g_g_g_unit on February 7, 2012, at 4:06:34
> ugh. I'm feeling so depressed and flat and apathetic this evening. this is bringing back bad memories of my last trial. I'm wondering if I should just increase the dose as fast as possible.
You might be "using up" your neurotransmitter stores as you experience a stimulant effect without first having established MAO inhibition.
People are variable in their tolerance of rapid titration of Parnate. Hypotension is usually the limiting side-effect.
Parnate usually does not help with more severe depressions until a dosage of 40 mg is reached. I take 80 mg. 60 mg is usually sufficient.
The following drugs, once considered high-risk, can be safely combined with a MAOI. The last three drugs can help with sleep.
methylphenidate
d-amphetamine
Wellbutrin
desipramine
nortriptyline
amitriptyline
trimipramine
doxepinThe real danger with mixing drugs with Parnate is serotonin rather than norepinephrine or dopamine. Any drug that inhibits the reuptake of serotonin can produce serotonin syndrome, a potentially fatal reaction. Geodon is the one AP that should probably be avoided.
Lithium, Lamictal, and Abilify make good adjuncts to Parnate in bipolar depression, and should not be a cause for concern for any doctor. I just so happen to be taking all of these. Each serves a different purpose. When I attempt to discontinue any one of these, I deteriorate.
- Scott
Posted by g_g_g_unit on February 7, 2012, at 5:21:27
In reply to Re: update » g_g_g_unit, posted by SLS on February 7, 2012, at 5:09:29
> > ugh. I'm feeling so depressed and flat and apathetic this evening. this is bringing back bad memories of my last trial. I'm wondering if I should just increase the dose as fast as possible.
>
> You might be "using up" your neurotransmitter stores as you experience a stimulant effect without first having established MAO inhibition.Yes, the crash is very similar to that which I experience on Dexedrine. Does Parnate release DA/NE at lower doses? Would MAO inhibition help bolster against this effect? I think I remember the 'crash' improving after raising to 30mg last time.
>
> People are variable in their tolerance of rapid titration of Parnate. Hypotension is usually the limiting side-effect.
>
> Parnate usually does not help with more severe depressions until a dosage of 40 mg is reached. I take 80 mg. 60 mg is usually sufficient.Thanks. I think I'm just scared right now. There's quite a few reports of people feeling very flat/apathetic on Parnate. I was hoping it might relieve my apathy and anhedonia, though last time at 30-40mg I recall feeling quite flat.
The problem is I was worried my psychiatrist would grow weary of me if he'd known I had already trialed both MAOI's. This is probably an unreasonable fear, but regardless, I know lower doses don't help, so would like to reach 60mg as soon as possible; I hope I don't get stuck spending weeks titrating. Serves me right though I suppose.
Posted by g_g_g_unit on February 7, 2012, at 5:25:33
In reply to Re: update » g_g_g_unit, posted by SLS on February 7, 2012, at 5:09:29
I know it sounds silly, but I met someone (I posted about it in psychology) and, after 3 years of major depression, I suddenly expect to remit overnight. I don't know why, but I feel this intense pressure to get well, lest she abandon me. It's making SEs etc. way more threatening. I wish I could just 'live for myself' for once . .
Posted by SLS on February 7, 2012, at 6:01:24
In reply to Re: update » SLS, posted by g_g_g_unit on February 7, 2012, at 5:21:27
> > > ugh. I'm feeling so depressed and flat and apathetic this evening. this is bringing back bad memories of my last trial. I'm wondering if I should just increase the dose as fast as possible.
> >
> > You might be "using up" your neurotransmitter stores as you experience a stimulant effect without first having established MAO inhibition.
>
> Yes, the crash is very similar to that which I experience on Dexedrine. Does Parnate release DA/NE at lower doses?Whatever it does, it probably does it at all dosages. I don't know what the current thought is regarding the mechanisms involved with the stimulant-like effects of Parnate. After all of these years, there are still people searching for an amphetamine metabolite.
> Would MAO inhibition help bolster against this
effect?If one were to entertain the hastily-drafted idea that I proposed, the answer would be yes. I think you should look forward to things getting better.
> I think I remember the 'crash' improving after raising to 30mg last time.
Good guess on my part, perhaps?
> Thanks. I think I'm just scared right now.
I know. I would be, too. You desperately need something to work, and you don't want there to be any complicating negative side-effects with Parnate.
> There's quite a few reports of people feeling very flat/apathetic on Parnate.
I cannot report that.
> I was hoping it might relieve my apathy and anhedonia,
Parnate does improve these things for me, although I find Nardil to do this more so.
> though last time at 30-40mg I recall feeling quite flat.
That is interesting. However, if you had not achieved sufficient MAO inhibition, you cannot come to any conclusions.
> The problem is I was worried my psychiatrist would grow weary of me if he'd known I had already trialed both MAOI's. This is probably an unreasonable fear, but regardless, I know lower doses don't help, so would like to reach 60mg as soon as possible;Go for it. Don't titrate too fast, though. You don't want to get turned-off to Parnate because of the side-effects it might provoke.
> I hope I don't get stuck spending weeks titrating.
That should not be necessary. You can probably reach 60 mg by the end of week 3. I don't think that this is particularly aggressive.
> Serves me right though I suppose.
I don't know what you are referring to, but I bet that this is the depression talking.
Good luck.
- Scott
Posted by g_g_g_unit on February 7, 2012, at 6:17:29
In reply to Re: update » g_g_g_unit, posted by SLS on February 7, 2012, at 6:01:24
> Whatever it does, it probably does it at all dosages. I don't know what the current thought is regarding the mechanisms involved with the stimulant-like effects of Parnate. After all of these years, there are still people searching for an amphetamine metabolite.
>I'm thinking of taking 5mg at a time to see if I can get a smoother stimulant effect. The Australian GoldShield tabs are enteric-coated. Do you know if it's okay to split them? Also, this would mean 20mg = 4 doses, so the last should be no later than 3pm, right?
> > I think I remember the 'crash' improving after raising to 30mg last time.
>
> Good guess on my part, perhaps?Yes. I think that was the point where my anxiety started improving.
>
> > Thanks. I think I'm just scared right now.
>
> I know. I would be, too. You desperately need something to work, and you don't want there to be any complicating negative side-effects with Parnate.Yeah, I think it's that and, as I alluded to in my last post, trying to maintain a new relationship with someone who's far more functional than I am.
>
> > I was hoping it might relieve my apathy and anhedonia,
>
> Parnate does improve these things for me, although I find Nardil to do this more so.Hmm, yeah the mood-boost on Nardil was great, but I'm hoping for some ADD relief from Parnate.
> > though last time at 30-40mg I recall feeling quite flat.
>
> That is interesting. However, if you had not achieved sufficient MAO inhibition, you cannot come to any conclusions.
>
> > The problem is I was worried my psychiatrist would grow weary of me if he'd known I had already trialed both MAOI's. This is probably an unreasonable fear, but regardless, I know lower doses don't help, so would like to reach 60mg as soon as possible;
>
> Go for it. Don't titrate too fast, though. You don't want to get turned-off to Parnate because of the side-effects it might provoke.Well, that's the thing - since he doesn't know I've been on it before, I'm sure he'll want to see how I'm doing at each dose before titrating. The recommended dose here is in fact 30mg, but I (or rather Stahl) talked him into 60mg.
>
> > I hope I don't get stuck spending weeks titrating.
>
> That should not be necessary. You can probably reach 60 mg by the end of week 3. I don't think that this is particularly aggressive.
>
> > Serves me right though I suppose.
>
> I don't know what you are referring to, but I bet that this is the depression talking.
>
I meant serves me right for not telling my psychiatrist I'd already tried Parnate, because now I might have to wait around on ineffective doses for longer than necessary.> Good luck.
Thanks!
>
> - Scott
>
Posted by SLS on February 7, 2012, at 6:53:16
In reply to Re: update » SLS, posted by g_g_g_unit on February 7, 2012, at 6:17:29
I understand the relationship thing. I'm resistant to even look while I remain depressed. A new issue has arisen. Now that I appear to be on my way towards a robust improvement, I am afraid that, despite my feeling better now, I would not be able to guarantee someone that it would continue. Who would want to invest in a roulette wheel? I need six drugs to be able to function. I am afraid that no one with a future would want to take a chance on someone who had none for over 3 decades, and for whom there is a history of treatment refractoriness. I have my eye on an attractive doctor whom I have recently started using as a PCP. I don't even want to bother asking her out for the rejection it would surely end up in. Even if she didn't like the way I wear my hair, I would blame it on her knowing about my medical history. I won't even try to describe the demoralization of having gained so much weight due to the drugs that I must take. I know that this extra weight is a turn-off. I am just not marketable.
This whole depression thing sucks.
- Scott
Posted by ed_uk2010 on February 7, 2012, at 11:25:04
In reply to update, posted by g_g_g_unit on February 7, 2012, at 1:40:34
>I'm going to get a z-drug prescription from my doctor tomorrow and will probably alternate between that, doxylamine and Benadryl until I can find a sustainable solution.
Doxylamine and diphenhydramine are closely related. I don't think it would be valuable to alternate between those two.
Posted by g_g_g_unit on February 7, 2012, at 21:38:42
In reply to Re: update » SLS, posted by g_g_g_unit on February 7, 2012, at 6:17:29
Hmm. So I decided to take 4x5mg today, rather than 2x10mg. The stimulant effect is a lot smoother, thought it leaves me feeling a little stuporous, akin to sub-therapeutic Dexedrine doses.
I'm just concerned about the half-life. To avoid insomnia, I dosed 9am, 11am, 1pm, 3pm, but I do feel there's an overlap in the stimulant effect, so am wondering if I should just cut down to 2x5mg, until I can tolerate taking a whole 10mg tab, and then resume 2x10mg.
Posted by SLS on February 7, 2012, at 23:06:20
In reply to Re: day#3, posted by g_g_g_unit on February 7, 2012, at 21:38:42
> Hmm. So I decided to take 4x5mg today, rather than 2x10mg. The stimulant effect is a lot smoother, thought it leaves me feeling a little stuporous, akin to sub-therapeutic Dexedrine doses.
>
> I'm just concerned about the half-life. To avoid insomnia, I dosed 9am, 11am, 1pm, 3pm, but I do feel there's an overlap in the stimulant effect, so am wondering if I should just cut down to 2x5mg, until I can tolerate taking a whole 10mg tab, and then resume 2x10mg.The half-life of Parnate is about 2 hours. At 80 mg/day, you can take 40 mg in the morning and 40 mg six hours later. As long as your last dose is taken before 3:00 PM, you won't be making your insomnia worse. You might still experience it, though. I know of no way to predict. Of course, you can dose more frequently if that helps mitigate hypotension.
- Scott
Posted by g_g_g_unit on February 7, 2012, at 23:19:12
In reply to Re: day#3 » g_g_g_unit, posted by SLS on February 7, 2012, at 23:06:20
> The half-life of Parnate is about 2 hours. At 80 mg/day, you can take 40 mg in the morning and 40 mg six hours later. As long as your last dose is taken before 3:00 PM, you won't be making your insomnia worse. You might still experience it, though. I know of no way to predict. Of course, you can dose more frequently if that helps mitigate hypotension.
>Thanks for the tip. In that case, I'll probably cut down to 2x5mg tomorrow.
>
> - Scott
Posted by g_g_g_unit on February 8, 2012, at 3:59:41
In reply to Re: day#3, posted by g_g_g_unit on February 7, 2012, at 23:19:12
Hmm, I spoke to Dr Gillman and his belief was that the agitation etc. would not get worse at higher doses, and would probably improve, so I suppose I can just push through and raise the dose to 30mg in several days, or back down. The only reason I would want to lower it is to make some use of the psychostimulant effect for reading etc., but given tolerance grows to that property, maybe it would just be best to pursue a true AD response.
Decisions, decision ..
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