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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 57. This is the beginning of the thread.
Posted by phidippus on November 25, 2017, at 14:39:32
My mania has been well controlled. My OCD is in remission. My ADHD is well managed. The only thing I haven't been able to get under control is my depression. It is characterized by anhedonia, feelings of hopelessness and suicidal ideation. I've been on every SSRI, Clomipramine, Trintellix and now Mirtazapine. In the past ADs have destabilized my mood. What do I do?
Lithium - 900 mg
Invega - 6 mg
Vyvanse - 60 mg
Mirtazapine - 15 mg
Keppra - 1500 mgEric
Posted by rjlockhart37 on November 25, 2017, at 18:38:19
In reply to Everything is good, except for depression, posted by phidippus on November 25, 2017, at 14:39:32
lamotragine, or gabapentin, there both good at controlling some forms of mood fluctuations, but there not as potent as lithium, more for depressive symptoms rather than manic, topamax also could be a option, but i've read topamax causes clouded thinking, also known street "dopamax" cloud thinking, but it is used in off label depression/bipolar
Posted by phidippus on November 25, 2017, at 18:59:28
In reply to Re: Everything is good, except for depression, posted by rjlockhart37 on November 25, 2017, at 18:38:19
Unfortunately, Gabapentin gives me a drug rash and lamotrogine makes me balls out manic.
Eric
Posted by SLS on November 25, 2017, at 22:34:31
In reply to Everything is good, except for depression, posted by phidippus on November 25, 2017, at 14:39:32
If you are using mirtazapine for depression rather than sleep, I suggest that therapeutic antidepressant dosages fall between 45 and 90 mg/day.
- Scott
Posted by linkadge on November 26, 2017, at 14:12:00
In reply to Everything is good, except for depression, posted by phidippus on November 25, 2017, at 14:39:32
I find that mirtazapine is one medication that I can take for anxiety / sleep that doesn't cause mood destabilization. In fact, I feel it does the opposite (can act as a mood stabilizer).
However, it may not have the same AD umph that other meds have.
Not sure what to recommend. Have you tried Wellbutrin?
Linkadge
Posted by phidippus on November 26, 2017, at 14:29:31
In reply to Re: Everything is good, except for depression, posted by linkadge on November 26, 2017, at 14:12:00
Wellbutrin works well for me, but takes the pizazz out of my cigarette breaks. I know I should quit, but I prize my nicotine buzz.
I've been on every SSRI and SNRI, Trazadone, Clomipramine and evrything inbetween. Some TCAs I have not tried and Trintellix I didn't give a fair trial.
Eric
Posted by SLS on November 26, 2017, at 16:44:36
In reply to Everything is good, except for depression, posted by phidippus on November 25, 2017, at 14:39:32
> My mania has been well controlled. My OCD is in remission. My ADHD is well managed. The only thing I haven't been able to get under control is my depression. It is characterized by anhedonia, feelings of hopelessness and suicidal ideation. I've been on every SSRI, Clomipramine, Trintellix and now Mirtazapine. In the past ADs have destabilized my mood. What do I do?
>
> Lithium - 900 mg
> Invega - 6 mg
> Vyvanse - 60 mg
> Mirtazapine - 15 mg
> Keppra - 1500 mg
>
> EricYou might consider adding Saphris. It would be an interesting choice if paranoia is a prominent feature of your illness. If adding Saphris works magic for your depression, you might, at some point, test your need to take Invega. It is no crime to take two antipsychotics at the same time.
- Scott
Posted by linkadge on November 26, 2017, at 16:45:41
In reply to Everything is good, except for depression, posted by phidippus on November 25, 2017, at 14:39:32
Hmm. Have you tried Seroquel? It has a metabolite which acts as an antidepressant.
Mirtazpine is one of the meds which I almost found acted like a mood stabilizer. But, as SLS mentioned, you might need higher doses for depression.
The TCA surmontil may be less likely to induce mania, but it is VERY sedating (more so than mirtazapine, or doxepin). I don't know how good it is for depression, but it has a different mechanism (no monoamine reuptake).
Another med that might be worth looking into is amoxapine. It is an antidepressant with antipsychotic qualities:
https://en.wikipedia.org/wiki/Amoxapine
In theory (just guessing here) the d2 antagonism might provide some protection against mania (and may allow reduction of other antipsychotics).
I get help from vitamin D, omega-3 folic acid, niacin & magnesium, coffee, green tea and cocoa powder.
Linkadge
Posted by SLS on November 26, 2017, at 16:46:41
In reply to Re: Everything is good, except for depression » linkadge, posted by phidippus on November 26, 2017, at 14:29:31
> Wellbutrin works well for me, but takes the pizazz out of my cigarette breaks.
You gotta be kidding me.
-bScott
Posted by phidippus on November 26, 2017, at 18:42:52
In reply to Re: Everything is good, except for depression » phidippus, posted by SLS on November 26, 2017, at 16:44:36
Unfortunately, I am allergic to Saphris.
Eric
Posted by phidippus on November 26, 2017, at 20:27:16
In reply to Re: Everything is good, except for depression » phidippus, posted by SLS on November 26, 2017, at 16:46:41
I thought you might get a kick out of that :)
Eric
Posted by SLS on November 27, 2017, at 19:45:35
In reply to Re: Everything is good, except for depression » SLS, posted by phidippus on November 26, 2017, at 18:42:52
> Unfortunately, I am allergic to Saphris.
That sucks. :(
I can't imagine that you wouldn't have tried desipramine yet. It is better for ADHD than is nortriptyline. Do you think it possible that there is some sort of link to your ADHD with depression such that you would respond to desipramine?
- Scott
Posted by phidippus on November 27, 2017, at 19:55:30
In reply to Re: Everything is good, except for depression » phidippus, posted by SLS on November 27, 2017, at 19:45:35
There is a link between my mood and my ADHD. When I take my Vyvanse, my depression remits about 50%. Instead of a traffic jam of negative thoughts I experience one negative thought at a time. I'll think about desipramine...
Eric
Posted by linkadge on November 28, 2017, at 19:52:01
In reply to Re: Everything is good, except for depression » SLS, posted by phidippus on November 27, 2017, at 19:55:30
Hey SLS,
desipramine seems to have a lower cardiac safety index than the other TCAs. I (personally) would be cautious about using it with lithium. I have been getting some weird cardiac effects from lithium and nortriptyline.
Linkadge
Posted by SLS on November 28, 2017, at 21:28:35
In reply to Re: Everything is good, except for depression, posted by linkadge on November 28, 2017, at 19:52:01
> Hey SLS,
>
> desipramine seems to have a lower cardiac safety index than the other TCAs. I (personally) would be cautious about using it with lithium. I have been getting some weird cardiac effects from lithium and nortriptyline.
>
> Linkadge
Bundle-branch block?When I first started taking desipramine, I experienced rapid heartbeat and palpitations. There was also a sort of "edginess" that disappeared over time. After a few weeks, palpitations disappeared completely, but rapid heartbeat only partially mitigated. I don't think there is anything wrong with having a moderately elevated heart rate, though. I've been on TCAs for over 30 years. I'll let you know after my first stress-test. My EKGs are normal. All I can say is that combining Parnate + desipramine sure packed a wallop the first time they were used together in me. My autonomic nervous system felt like it was being fried. Good stuff. I reached remission within a few months (1987). To keep a long story from becoming longer, I never responded to that treatment again.
It is a matter of risk/cost/benefit.
I hope you are doing reasonably well. It is relative, I guess. When someone asks me how I am doing, I usually answer that I could be doing worse - knowing that I could be doing a hell of a lot better.
- Scott
Posted by Phillipa on November 28, 2017, at 22:26:54
In reply to Re: Everything is good, except for depression, posted by SLS on November 28, 2017, at 21:28:35
Bundle Branch Block is serious. Let me find a link on it quickly. Phillipa
Posted by Phillipa on November 28, 2017, at 22:37:17
In reply to Re: Everything is good, except for depression » SLS, posted by Phillipa on November 28, 2017, at 22:26:54
It's complicated so best to google it yourself. Not sure why that was posted. But TCA are known to be not that great for the heart
Posted by SLS on November 29, 2017, at 7:14:54
In reply to Re: Everything is good, except for depression, posted by Phillipa on November 28, 2017, at 22:37:17
> It's complicated so best to google it yourself. Not sure why that was posted. But TCA are known to be not that great for the heart
Neither is untreated depression.
If desipramine brought me into remission, I would not worry about bundle-branch block unless it actually appeared early in treatment. Some doctors will take a baseline ECG and compare it to one taken after treatment is initiated. I am not very afraid of tricyclics because I have been on and off of them since 1982. It was a time when SSRIs were not yet available. I didn't have much choice. I have no statistics to offer, as they are so variable in the medical literature. Heart block seems to be a rather uncommon event in the absence of preexisting CVD. Personally, I have yet to see or hear of a case in real life when desipramine is used at therapeutic dosaages. Still, as with so many unrelated drugs used for a variety of conditions, TCAs must be used judiciously and monitored by someone who knows their side effect profiles.
- Scott
Posted by Phillipa on November 29, 2017, at 9:14:55
In reply to Re: Everything is good, except for depression » Phillipa, posted by SLS on November 29, 2017, at 7:14:54
I agree with you about TCA's being only available AD's for many years. Now even the SSRI's are being found to have serious side effects. But taken as a one or two combo in low doses I don't fear them. Actually with the new studies in my RN newsletter I don't trust any meds. Even motrin can cause so many side effects. And the TV a neighbor and I were talking and she said the advertisements with all the side effects she won't take a med. And she's older like me. I guess at this point I just try to keep cutting down on any meds and excercising more. This why I suggested googling on own. Personally I'm not pleased with any meds. Sorry to be so negative. Phillipa ps you know ECG can only diagnosis if one has had a heart attack in the past?
Posted by linkadge on November 30, 2017, at 15:09:22
In reply to Re: Everything is good, except for depression, posted by SLS on November 28, 2017, at 21:28:35
I'm not sure of the specific effect, but desipramine appears to have risks beyond what normal NRI would seem to indicate.
For example, there is apparently a high rate of sudden cardiac death in children taking it for ADHD. The risk is above that of other NRIs like stimulants.
I suppose some of the intracellular effects of the drug may be at play (sodium channels?).
Linkadge
Posted by linkadge on November 30, 2017, at 15:11:40
In reply to Re: Everything is good, except for depression » SLS, posted by Phillipa on November 29, 2017, at 9:14:55
Exactly. It must be kept in perspective. Even Lexapro has cardiac effects (in higher doses).
For some reason, however, desipramine pops up quite a bit in my pubmed searches in terms of cardiac concerns. I don't see this with nortriptyline, protriptyline etc.
Linkadge
Posted by SLS on November 30, 2017, at 15:24:53
In reply to Re: Everything is good, except for depression » SLS, posted by linkadge on November 30, 2017, at 15:09:22
> I suppose some of the intracellular effects of the drug may be at play (sodium channels?).
That's a good thought.
- Scott
Posted by Phillipa on November 30, 2017, at 15:56:58
In reply to Re: Everything is good, except for depression, posted by linkadge on November 30, 2017, at 15:11:40
Link this is where I found so much about despramine. So the comment best to gogle on own. Pub med is full or right vs left bundle branch blocks, and having also worked in CCU cardiac care saw plenty with BBB so gets complicated. Phillipa
Posted by SLS on November 30, 2017, at 19:10:30
In reply to Re: Everything is good, except for depression » linkadge, posted by Phillipa on November 30, 2017, at 15:56:58
Would you ever take desipramine?
Would you tell everyone else not to take it?
- Scott
Posted by linkadge on December 1, 2017, at 15:18:24
In reply to Re: Everything is good, except for depression » Phillipa, posted by SLS on November 30, 2017, at 19:10:30
Hi SLS,
As you mentioned, many people take desipramine without apparent significant cardiac effects.
I suppose if there was a compelling reason that desipramine would provide a benefit that other medicaitons wouldn't then it would be worth a shot, with monitoring.
I do know that some health orginaziations discourage the use of desipramine for ADHD because of an apparent excess incidence of cardiac side effects.
I would (personallay) look to explore other NRI's such as fetzima and/or nortriptyline.
But hey, who knows.
Linkadge
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