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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 66. This is the beginning of the thread.
Posted by Clearskies on March 14, 2018, at 4:00:17
**TRIGGER** suicidal ideation
Hello all, Im discouraged to see Babble so quiet, but if we dont post, it wont be used. So. After my stay in a psych unit in October due to suicidal intentions and a plan to carry it out. None of this was a normal state of mind for me.
I started with my new pdoc in January, having been held in stasis medwise by my GP. She was all keyed up that I might not get a pdoc and saddle her with my psychiatric care. Um, no, I said, I know its a specialized area and is usually referred out to a specialist. I might have heard a warning growl.
My dx has changed slightly. Its gone from major depressive disorder, anxiety, PTSD, and panic attacks, to depression and PTSD, which will emcompass the anxiety features. I dont believe it makes a difference to me.
I mostly live from week to week with my plans and activities; appointments, classes, events, marches, rallies, looting. You know, the usual story.
Peace out.
Posted by ed_uk2010 on March 14, 2018, at 6:58:47
In reply to **TRIGGER** Current meds and question, posted by Clearskies on March 14, 2018, at 4:00:17
Hi Clear,
I hope you are feeling better now. Have any changes been made to meds which you found useful?
Posted by Clearskies on March 15, 2018, at 18:48:39
In reply to Re: **TRIGGER** Current meds and question » Clearskies, posted by ed_uk2010 on March 14, 2018, at 6:58:47
> Hi Clear,
>
> I hope you are feeling better now. Have any changes been made to meds which you found useful?Hi Ed,
I neglected that part, didnt I? Lol, Im still flaky.
Im currently on nortriptyline at night, as well as prazosin; sertraline, bupropion xl,propanol, and I went down to .5mg from 2.0 of clonazepam.Its quite the cocktail. The sertraline made the biggest impact on the depression. Honestly, my anxiety is as worse as ever, although I have tricks and strategies to get around it in order to live day to day.
Nice to see you.
Posted by SLS on March 16, 2018, at 7:53:55
In reply to Re: **TRIGGER** Current meds and question » ed_uk2010, posted by Clearskies on March 15, 2018, at 18:48:39
> Im currently on nortriptyline at night, as well as prazosin; sertraline, bupropion xl,propanol, and I went down to .5mg from 2.0 of clonazepam.
>
> Its quite the cocktail. The sertraline made the biggest impact on the depression. Honestly, my anxiety is as worse as ever, although I have tricks and strategies to get around it in order to live day to day.Perhaps Ed can comment.
I think Zoloft and Prozac are the worst SSRIs for treating anxiety. Paxil is the best, but comes with more robust side effects. Have you tried adding Effexor or Cymbalta to nortriptyline? Effexor is almost as effective for anxiety as is Paxil. Paxil, Effexor, and Cymbalta are all indicated in the treatment of generalized anxiety disorder (GAD). Pristiq doesn't seem to be as effective.
I take prazosin for depression. It works very well, and I wouldn't want to be without it. My childhood history is one of chronic trauma (adversity). The following three terms are used to describe the resulting condition.
1. Developmental PTSD.
2. Complex PTSD (C-PTSD)
3. Complex trauma disorder.What dosage of prazosin are you taking? Most doctors under-dose their patients when treating PTSD or trauma disorders. I take 20 mg/day. You can go up to 40 mg/day. I was taking 30 mg/day for a long time. However, I discovered that this dosage caused some dysphoria and memory/cognitive impairments. 20 mg/day seems to be the best dosage for me. Prazosin should be dosed 3 times a day.
- Scott
Posted by ed_uk2010 on March 16, 2018, at 8:20:11
In reply to Re: **TRIGGER** Current meds and question » ed_uk2010, posted by Clearskies on March 15, 2018, at 18:48:39
Hi!
Nice to see you too.
>I neglected that part, didnt I? Lol
Haha yes :) I thought - the meds bit is missing :)
My impression of sertraline in anxiety is that although it can feel stimulating initially, often more so than paroxetine (Paxil), I do think it helps in the long run.
An advantage of sertraline for you is its relative lack of drug interactions, and its cardiac safety. Paroxetine can interact with some of the other meds you take, which makes it more awkward to use as part of your combination. Citalopram and escitalopram (Celexa and Lexapro) are often used in anxiety + depression too, but they aren't normally recommended in combination with nortriptyline due to rare cardiac side effects.
How do you feel with the reduced clonazepam?
Posted by SLS on March 16, 2018, at 15:23:14
In reply to Re: **TRIGGER** Current meds and question » Clearskies, posted by ed_uk2010 on March 16, 2018, at 8:20:11
Hi, Ed.
Paxil and Wellbutrin are both CYP450 2D6 inhibitors as I remember. What kinetic interactions would one expect when combining these two drugs? Would you need to reduce the dosage of both, or just one?
In my estimation, combining the following drugs would address both anxiety and depression (unless Wellbutrin has already demonstrated anxiogenesis).
1. Effexor
2. Wellbutrin
3. NortriptylinePeople don't seem to like suggesting Effexor these days. Is it the withdrawal that is the problem? I have seen it work magic.
How long must someone take Effexor before withdrawal becomes an issue? I have taken Effexor for months without suffering too badly when I discontinued it using a rapid, but flexible taper. I may be unusual in this regard. I have speculated in the past that some anticonvulsants might reduce the magnitude of SSRI / SNRI / BZD withdrawal effects. I am most interested in oxcarbazepine for this.
How would you compare citalopram with escitalopram when it comes to treating comorbid MDD and GAD?
How would you rate the withdrawal syndromes produced by discontinuing sertraline and citalopram?
- Scott
Posted by ed_uk2010 on March 16, 2018, at 18:11:12
In reply to Re: **TRIGGER** Current meds and question » ed_uk2010, posted by SLS on March 16, 2018, at 15:23:14
Hi Scott,
>Would you need to reduce the dosage of both, or just one?
I'm unsure about that. To be honest, I've not known people to take bupropion with paroxetine.
>In my estimation, combining the following drugs would address both anxiety and depression
I suppose I was thinking.... for someone on nortriptyline, would venlafaxine generally be any more useful than sertraline?
>How would you compare citalopram with escitalopram when it comes to treating comorbid MDD and GAD?
I have a slight preference for escitalopram.
>How would you rate the withdrawal syndromes produced by discontinuing sertraline and citalopram?
I'd say they are very similar.
Posted by Clearskies on March 17, 2018, at 1:47:25
In reply to Re: **TRIGGER** Current meds and question » SLS, posted by ed_uk2010 on March 16, 2018, at 18:11:12
Both Effexor and Cymbalta pooped out on me in spectacular, gut wrenching ways. Both times I tried them. Gaaah.
Posted by ed_uk2010 on March 17, 2018, at 10:32:13
In reply to Re:Current meds and question EDIT title, posted by Clearskies on March 17, 2018, at 1:47:25
> Both Effexor and Cymbalta pooped out on me in spectacular, gut wrenching ways. Both times I tried them. Gaaah.
So, are you feeling like you want to stick with sertraline? How much do you take?
Posted by Clearskies on March 17, 2018, at 19:10:21
In reply to Re:Current meds and question EDIT title » Clearskies, posted by ed_uk2010 on March 17, 2018, at 10:32:13
Im on a fairly low dose, 100mg.
Posted by SLS on March 17, 2018, at 23:05:52
In reply to Re:Current meds and question EDIT title, posted by Clearskies on March 17, 2018, at 1:47:25
> Both Effexor and Cymbalta pooped out on me in spectacular, gut wrenching ways. Both times I tried them. Gaaah.
I'm sorry to hear that. How long did your improvements last for?
- Scott
Posted by Clearskies on March 17, 2018, at 23:19:43
In reply to Re:Current meds and question EDIT title » Clearskies, posted by SLS on March 17, 2018, at 23:05:52
> > Both Effexor and Cymbalta pooped out on me in spectacular, gut wrenching ways. Both times I tried them. Gaaah.
>
> I'm sorry to hear that. How long did your improvements last for?
>
>
> - ScottTwo short weeks. I still am less profoundly depressed, but simple things like bathing and dressing are beyond me until late in the day.
Posted by Clearskies on March 17, 2018, at 23:23:41
In reply to Re:Current meds and question EDIT title » SLS, posted by Clearskies on March 17, 2018, at 23:19:43
> > > Both Effexor and Cymbalta pooped out on me in spectacular, gut wrenching ways. Both times I tried them. Gaaah.
> >
> > I'm sorry to hear that. How long did your improvements last for?
> >
> >
> > - Scott
>
> Two short weeks. I still am less profoundly depressed, but simple things like bathing and dressing are beyond me until late in the day.
>
>I forgot to say how happy I am that you are here. Im actually having a very rough time atm. Highly emotional, Im 8 years post menopausal so thats out. I think that Im extremely underdeveloped, emotionally. Like to the age of 17 or so.
Posted by ed_uk2010 on March 18, 2018, at 6:40:30
In reply to Re:Current meds and question EDIT title » SLS, posted by Clearskies on March 17, 2018, at 23:19:43
>simple things like bathing and dressing are beyond me until late in the day.
Hi CS,
Is that what it's like at the moment? If you don't mind me asking, would you say any of these apply......
You feel exhausted early on but less tired later in the day.
You feel like hiding in the morning because you feel anxious or down. Later in the day, you feel less anxious or less depressed.
You feel like you don't have anything to get dressed and ready for. So you don't until late.
You want to go back to sleep in the morning, perhaps because it is comforting, and prefer not to get up. Or perhaps you get up but not ready?
.... Anyway, I was thinking it might be possible for someone to make a helpful suggestion if they have more insight into how you feel.
x
Posted by SLS on March 18, 2018, at 11:10:40
In reply to Re:Current meds and question EDIT title » SLS, posted by Clearskies on March 17, 2018, at 23:19:43
Hi Clearskies.
> > > Both Effexor and Cymbalta pooped out on me in spectacular, gut wrenching ways. Both times I tried them. Gaaah.
> > I'm sorry to hear that. How long did your improvements last for?
> Two short weeks. I still am less profoundly depressed, but simple things like bathing and dressing are beyond me until late in the day.What was the magnitude of your response? Was it close to remission? Did your anxiety improve when you were responding? What dosages did you take? Did you combine it with Wellbutrin 300 mg/day?
I feel better in the morning. This is consistent with "atypical" depression (and often bipolar depression). Feeling worse in the morning and better at night is consistent with "endogenous" or "melancholic" depression. Do you have anxiety revolving around feelings of doom? You might want to keep that in mind when choosing medications. Tricyclics and SNRIs are thought to be better for this type of depression than are SSRIs. Perhaps you should consider adding nortriptyline. Abilify is a drug worth taking a look at, too. As an augmenter, it can enhance a partial antidepressant response. I've had luck with both Abilify and Lamictal as augmenters.
Regarding your conclusion that your mental or emotional age is 17 years, I don't think it is productive to evaluate such things until you are feeling better. Depression warps thoughts and feelings. It is a liar. Depression is an altered state of consciousness. How did you feel about these things while you were responding to Effexor and Cymbalta?
It would be helpful to know what are the dosages of the medications you take. I know you are taking Zoloft 100 mg/day. That is a moderate dosage. You can go up to 200 mg/day, as I'm sure you already know. I hope raising the dosage proves to be an answer for you. 300 mg/day is the dosage most often chosen for Wellbutrin. Why are you taking prazosin? Is it helping? What dosage? For depression, I suggest looking at 15 mg/day (5 mg t.i.d). I take 20 mg/day. 40 mg/day is the maximum.
I plan to switch from Parnate to Trintellix (vortioxetine) in a few months. It is a drug substantially different from what I have taken before. It is part SSRI and part serotonin receptor modulator. I would continue taking the other drugs in my regime. I don't think it is a good idea to take Zoloft or any other serotonin reuptake inhibitor in combination with Trintellix. There is a possibility of precipitating a state of serotonin toxicity - serotonin syndrome.
I can't predict what you will ultimately respond to, but it is reasonable to increase the dosage of Zoloft before moving on. Be sure that your dosage of Wellbutrin is high enough - usually 300 mg/day. The questions that Ed_UK asked will help you to refine your diagnosis and possibly suggest which drugs to consider. The treatments I mentioned represent alternatives. I feel that knowing that there are untried treatments can bring hope. The brain is not quite a black box anymore, but it is still difficult to know which drugs will bring the desired result for any one individual. For instance, a person can feel worse on one SSRI but feel better on another. It is interesting that you had the same response to Cymbalta and Effexor.
- Scott
Posted by Clearskies on March 18, 2018, at 13:10:12
In reply to Re:Current meds and question EDIT title » Clearskies, posted by ed_uk2010 on March 18, 2018, at 6:40:30
> >simple things like bathing and dressing are beyond me until late in the day.
>
> Hi CS,
>
> Is that what it's like at the moment? If you don't mind me asking, would you say any of these apply......
>
> You feel exhausted early on but less tired later in the day.
>
Yes> You feel like hiding in the morning because you feel anxious or down. Later in the day, you feel less anxious or less depressed.
>
Yes> You feel like you don't have anything to get dressed and ready for. So you don't until late.
>
Yes> You want to go back to sleep in the morning, perhaps because it is comforting, and prefer not to get up. Or perhaps you get up but not ready?
>
I prefer not to get up and have to bargain with myself. If I am miserable an hour later, Ill allow myself to return to bed,> .... Anyway, I was thinking it might be possible for someone to make a helpful suggestion if they have more insight into how you feel.
>
> x
>
>Ok.
Posted by ed_uk2010 on March 18, 2018, at 14:10:20
In reply to Re:Current meds and question EDIT title » ed_uk2010, posted by Clearskies on March 18, 2018, at 13:10:12
Hi CS,
It sounds like most of your symptoms are worse in the morning, rather than anything specific. Would you say that's right? Although I'm currently doing OK, I'm very much the same. I am a definite 'evening person'.
I forgot to ask before, how do you sleep at night?
I was also wondering whether it might help to move some of your medication timing around. Just as an example... if you currently take clonazepam at night but sleep OK, it might help to move some of the dose to the morning to help with anxiety.
Posted by Clearskies on March 18, 2018, at 14:19:27
In reply to Re:Current meds and question EDIT title » Clearskies, posted by ed_uk2010 on March 18, 2018, at 14:10:20
> Hi CS,
>
> It sounds like most of your symptoms are worse in the morning, rather than anything specific. Would you say that's right? Although I'm currently doing OK, I'm very much the same. I am a definite 'evening person'.
>
Most definitely.> I forgot to ask before, how do you sleep at night?
>
It is taking me about 2 hours to fall asleep each night after I go to bed.> I was also wondering whether it might help to move some of your medication timing around. Just as an example... if you currently take clonazepam at night but sleep OK, it might help to move some of the dose to the morning to help with anxiety.
>Ive tried moving that dose all over the day - including taking it at bedtime - but theres no relief.
>
>
>Im working with a new pdoc. Im not even certain were on the same page yet. Suicidal thoughts are never far away any more. But I have zero plans to do anything.
I know my thinking is disordered. I dont even want to type the horrible things I think about myself, they are just repetitions of previous depressive dives I have made before.
Posted by ed_uk2010 on March 18, 2018, at 14:45:24
In reply to Re:Current meds and question EDIT title » ed_uk2010, posted by Clearskies on March 18, 2018, at 14:19:27
>I dont even want to type the horrible things I think about myself...
Well I'm thinking it's good to see your familiar name on the board, even though it's sad that you're not doing well lately. Not everyone here will remember your previous posting name, and the one before that. Talking about old times, I successfully got my original posting name 'ed_uk' back... then I realised I couldn't activate Babblemail. I guess I will have to stick with this one, from when I lost my password in 2010.
New psychiatrists can be difficult. It can be really hard to start over and get to know each other. On the other hand, a new doctor can eventually come up with valuable new ideas.
Has s/he suggested any meds changes or 'therapeutic interventions' so far?
Posted by Clearskies on March 18, 2018, at 14:54:04
In reply to Re:Current meds and question EDIT title » Clearskies, posted by ed_uk2010 on March 18, 2018, at 14:45:24
>
> Has s/he suggested any meds changes or 'therapeutic interventions' so far?Putting me on Zoloft and nortriptyline were changes she suggested. Shes kind of flaky- not very organized - but she knows what drug does what. My previous pdoc got to the point where she was switching my meds every week, trying to get me stable but not letting me adjust to anything before changing again. I was in very bad shape and she totally dropped the ball with me. Inexcusable.
Its funny about the user names... the weather has always been unsettled. Ive tried to describe my climate, ha ha, and now the state I want to be in. To be honest, my name right now should be Shitstorm.
Posted by ed_uk2010 on March 18, 2018, at 15:46:15
In reply to Re:Current meds and question EDIT title » ed_uk2010, posted by Clearskies on March 18, 2018, at 14:54:04
>my name right now should be Shitstorm.
Oh no! You need a classy weather name. Wuthering Heights, perhaps :) Definitely not Thunderbird or Shitstorm!
>Putting me on Zoloft and nortriptyline were changes she suggested.
That sounds positive. How long have you been on this combination?
Posted by Clearskies on March 18, 2018, at 16:16:01
In reply to Re:Current meds and question EDIT title » Clearskies, posted by ed_uk2010 on March 18, 2018, at 15:46:15
> >my name right now should be Shitstorm.
>
> Oh no! You need a classy weather name. Wuthering Heights, perhaps :) Definitely not Thunderbird or Shitstorm!
>
> >Putting me on Zoloft and nortriptyline were changes she suggested.
>
> That sounds positive. How long have you been on this combination?
>
>Its been about 2 1/2 months. I have some personal stuff going on thats brought my mood way down, too. I just cant seem to muster any confidence that I can raise myself up out of this quagmire.
CS
Posted by ed_uk2010 on March 18, 2018, at 16:48:38
In reply to Re:Current meds and question EDIT title » ed_uk2010, posted by Clearskies on March 18, 2018, at 16:16:01
But you've always been able to raise yourself up before, right? Eventually.
Posted by Clearskies on March 18, 2018, at 16:58:54
In reply to Re:Current meds and question EDIT title » Clearskies, posted by ed_uk2010 on March 18, 2018, at 16:48:38
> But you've always been able to raise yourself up before, right? Eventually.
Not to be fully operational. I have to budget my time and energy carefully or Im easily overwhelmed. Depression is always breathing down my neck.
Posted by ed_uk2010 on March 18, 2018, at 17:10:20
In reply to Re:Current meds and question EDIT title » ed_uk2010, posted by Clearskies on March 18, 2018, at 16:58:54
Not to be fully operational perhaps. But you got through, and that is something to be proud of.
When do you next see this new psychiatrist?
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