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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 30. This is the beginning of the thread.
Posted by Hordak on July 26, 2019, at 12:10:34
I am 31 years old, I live in Germany. I have been diagnosed with MDD & Social Anxiety Disorder in 2017, although the disorder(s) undoubtedly persisted since way before being diagnosed with it. Here a brief description of myself before diagnosis: skinny, pale, agitated, motorically restless, jumpy, ruminating and difficulty making decisions, with rather typical depressive symptoms (reduced affect display, apathy, anhedonia to some degree, low appetite, avoidance, low self-esteem etc.). I've also had many psychosomatic ailments: reoccurring gastritis, reflux, pains that were not explainable by any "tangible" medical cause. Social anxiety with emphasis on speech- and presentation anxiety. Since the diagnosis in spring 2017 I have been taking Sertraline 50mg. I've also been on 75mg and 100mg, but that caused me unbearable agitation & motor restlessness AND too much weight loss, so I cut it down to 50mg.
I have mixed views when it comes to Sertraline: on the one hand I am quite annoyed with it because it sapped my creativity and basically made me not want to do anything, not feel anything. I just sit at the computer and watch youtube-videos and occasionally walk around, or eat, or go to the bathroom. I just don't have any drive to really do very much of anything, except what is needed for continued basic survival. I don't even want to do things that I liked. To put it bluntly: I can't get my *ss up, it's just all "blah" and "meh". I get less things done on Sertraline than without. It seems to me that Sertraline induces overall emotional flattening - reduced sadness, but also reduced joy, reduced motivation & ambition, reduced desire to socialize, reduced interest in everything. It is really disconcerting, because things happen that should bother me, and I'd be thinking "this SHOULD piss me off, but, meh.. whatever..". I felt at ease with my situation and no longer care. Appartement could be on fire and I would be indifferent about it. I don't think this is a mentally healthy state, especially in the long term. I need to care about things... (It seems that this is quite common with SSRIs...**** knows why these things are marketed for depression when they cause or enhance the very symptoms people are trying to get rid of. The apathy / indifference itself is like an additional mental illness. I know that many people have it as part of their depression which is pretty bad, but when you get it as a side-effect to medication to treat depression & anxiety, it is just another unnecessary problem you have to deal with.). My father died last summer due to Parkinson's terminal stage (Aspiration pneumonia) and I couldn't cry. My mind just was blank. To not be able to cry if someone close dies just kills me. I want healthy emotions. Maybe too much empathy & emotions aren't a good thing but neither is total lack of it.
Some people on Internet-Forums (Socialanxietysupport, Dr-bob Babble...) have mentioned that this is due to diminished noradrenergic and dopaminergic signaling / transmission, possibly due to elevated 5HT2 receptor stimulation caused by strong SRIs. They suggest that possibly an NRI with 5HT2 antagonism as add-on might be helpful. Many have mentioned tricyclics (Amitriptyline, Clomipramine, Imipramine) as better alternative. But I am unsure as to what extend is is true or false.
But I don't want to be too negative about Sertraline, because on the other hand there are definitely some positive aspects to it: It's a rather good anxiolytic and it has helped me with my anxiety and fears. It was also good in relieving my diverse psychosomatic ailments. It also stopped my ruminations and derealization symptoms. It's also quite good for cognition. At the beginning of the treatment it induced horrible insomnia, but right now I sleep quite well, maybe even too much. It also made me more emotionally stable and even-tempered.
I would very much like to hear you opinion on the subject. Are there antidepressants and anxiolytics that help with depression and social anxiety, but do not cause the aforementioned SSRI-"zombification"? What is your experience? I've already talked it over with my psychiatrist, but he is unwilling to try other antidepressant classes. He only prescribes SSRIs & SSNRIs (Venlafaxine, Duloxetine), and is rather afraid of combination-therapy. I am somewhat desperate and don't know what to do. (I am on 25mg since April 2019)
One important note: I am quite an agitated person with lots of "motor restlessness" / psychomotor agitation, resembling forms of many "akathisia"-like symptoms: rocking back and forth, lips biting, checks biting, skin picking, bruxism, fidgeting, pacing, fist clenching, toes clenching... (moderate in severity). I've been this way since I can remember. I've never taken anti-psychotics. In my case it is most likely an inborn / innate condition(?). Some people mentioned that it might be some form of "hospitalism", but my early childhood was pretty much okay. Nothing extraordinary good or bad happened, al least that I can remember. Sertraline made it rather worse, but definitely not better. What would be potentially good medications (medication classes) to calm me down and lessen my psychomotor agitation? I would also like to gain some weight! I am a skinny bastard and Sertraline unfortunately did make me loose some pounds... (62kg @ 175cm right now).
One other annoying side effect of Sertraline is heat intolerance. I've always loved warm summers and sauna, but since I am on Sertraline, I cannot stand heat anymore. I feel like I am overheating...
btw: I have an appointment with a new psychiatrist in about a month.... ;=)
I thank you for all your help, advice(s) and suggestions!
Posted by Christ_empowered on July 26, 2019, at 14:01:41
In reply to I need some advice regarding my medication regimen, posted by Hordak on July 26, 2019, at 12:10:34
hi. sorry about your father and your ongoing struggles.
im on prozac and it covers a lot of the bases you've described...but i take it with abilify. maybe...prozac and gabapentin or lyrica?
remeron+effexor springs to mind. i read a small abstract in which remeron+cymbalta was used...worked well, but there was a warning about hypomania, etc. hmmm...
imipramine was OK for me, years ago...I tried it again, and it was too rough on me (dry mouth, weight gain). i have never been prescribed any other tca drugs, although a former psychiatrist mentioned amoxapine, which...is considered effective for agitated and/or psychotic depression, but it carried the nms, td, eps risks of the neuroleptics, plus prolactin elevation over the long haul, on top of the typical tca adverse effects.
i seem to recall reading that some doctors use phenergan to help with severe anxiety. i imagine it could be combined with an appropriate antidepressant, such as celexa, lexapro, or maybe paxil (?).
ok. clearly, these are just suggestions from some individual on the internet. i hope things get better for you, and i hope the appointment with the psychiatrist proves productive.
Posted by linkadge on July 26, 2019, at 17:23:40
In reply to Re: I need some advice regarding my medication regimen, posted by Christ_empowered on July 26, 2019, at 14:01:41
Augmenting sertraline with say nortriptyline or bupropion is common. I would describe to your doctor how you feel - that the SSRI helps anxiety and depression, but your energy and motivation is nonexistent. You may not need to change (if you don't want to).
Linkadge
Posted by Hordak on July 27, 2019, at 9:38:32
In reply to Re: I need some advice regarding my medication regimen, posted by Christ_empowered on July 26, 2019, at 14:01:41
> hi. sorry about your father and your ongoing struggles.
>
> im on prozac and it covers a lot of the bases you've described...but i take it with abilify. maybe...prozac and gabapentin or lyrica?
>
> remeron+effexor springs to mind. i read a small abstract in which remeron+cymbalta was used...worked well, but there was a warning about hypomania, etc. hmmm...
>
> imipramine was OK for me, years ago...I tried it again, and it was too rough on me (dry mouth, weight gain). i have never been prescribed any other tca drugs, although a former psychiatrist mentioned amoxapine, which...is considered effective for agitated and/or psychotic depression, but it carried the nms, td, eps risks of the neuroleptics, plus prolactin elevation over the long haul, on top of the typical tca adverse effects.
>Thanks for all the sympathy.
Prozac is probably too stimulating for me... I need something to put some weight on me and calm me down :=D ;=)
Lyrica is an interesting one. I would very much like to try it. Seems to work like a Benzo light or something....
I am avoiding effexor due to its short half life. Mirtazapine is an interesting one! Together with Nortriptyline the most interesting add-on.
Tricyclics... don't know. Weight gain wouldn't be a problem.... not sure how severe anticholinergic side effects are... maybe Amitriptyline or Clomipramine?
Posted by Hordak on July 27, 2019, at 9:50:24
In reply to Re: I need some advice regarding my medication regimen, posted by linkadge on July 26, 2019, at 17:23:40
> Augmenting sertraline with say nortriptyline or bupropion is common. I would describe to your doctor how you feel - that the SSRI helps anxiety and depression, but your energy and motivation is nonexistent. You may not need to change (if you don't want to).
>
> LinkadgeWhats your take on Mirtazapine?
Do you think that the combination of Escitalopram and Nortriptyline would be worth a try?
Not sure how Sertraline compares to Escitalopram...
Posted by linkadge on July 27, 2019, at 10:28:55
In reply to Re: I need some advice regarding my medication regimen, posted by Hordak on July 27, 2019, at 9:38:32
If you want something for weight gain and anxiety, mirtazapine would be a good option / adjunct.
However, it does have a long half life, and can leave you sedated during the day.
Linkadge
Posted by linkadge on July 27, 2019, at 10:31:30
In reply to Re: I need some advice regarding my medication regimen » linkadge, posted by Hordak on July 27, 2019, at 9:50:24
Escitalopram and sertraline are similar. Sertraline tends to be a bit more stimulating than escitalopram. If sertraline is sort of working, you might first try adding some mirtazapine or nortriptyline. Nortriptyline might be better in terms of motivation, but mirtazapine would probably be better for sleep / anxiety / appetite.
Personally, I like nortriptyline better than mirtazapine, BUT my sleep became increasingly fragmented on nortriptyline, so I switched back to mirtazapine.
Linkadge
Posted by ed_uk2010 on July 27, 2019, at 11:36:48
In reply to Re: I need some advice regarding my medication regimen » linkadge, posted by Hordak on July 27, 2019, at 9:50:24
>Do you think that the combination of Escitalopram and Nortriptyline would be worth a try?
Not sure whether doctor would agree to that due to potential ECG (EKG) changes. You'd need cardiac monitoring if you did it.
Posted by Hordak on July 27, 2019, at 13:13:36
In reply to Re: I need some advice regarding my medication regimen, posted by linkadge on July 27, 2019, at 10:28:55
> If you want something for weight gain and anxiety, mirtazapine would be a good option / adjunct.
>
> However, it does have a long half life, and can leave you sedated during the day.
>
> LinkadgeIs it true that tolerance builds fast? I have heard that the H1 receptor desensitizes fast...
Posted by Hordak on July 27, 2019, at 13:17:30
In reply to Re: I need some advice regarding my medication regimen, posted by linkadge on July 27, 2019, at 10:31:30
> Escitalopram and sertraline are similar. Sertraline tends to be a bit more stimulating than escitalopram. If sertraline is sort of working, you might first try adding some mirtazapine or nortriptyline. Nortriptyline might be better in terms of motivation, but mirtazapine would probably be better for sleep / anxiety / appetite.
>
> Personally, I like nortriptyline better than mirtazapine, BUT my sleep became increasingly fragmented on nortriptyline, so I switched back to mirtazapine.
>
> Linkadge
>maybe too much stimulation. I overheat on Sertraline.
So i think there are the possibilities:
1.) Sertraline + (Nortriptyline or Mirtazapine)
2.) Escitalopram + (Nortriptyline or Mirtazapine)
3.) TCA?btw.: What about Paroxetine?
Posted by Hordak on July 27, 2019, at 13:19:22
In reply to Re: I need some advice regarding my medication regimen » Hordak, posted by ed_uk2010 on July 27, 2019, at 11:36:48
> >Do you think that the combination of Escitalopram and Nortriptyline would be worth a try?
>
> Not sure whether doctor would agree to that due to potential ECG (EKG) changes. You'd need cardiac monitoring if you did it.You think that qt prolongation might potentiate when taking both drugs combined?
Posted by linkadge on July 27, 2019, at 15:10:41
In reply to Re: I need some advice regarding my medication regimen » linkadge, posted by Hordak on July 27, 2019, at 13:17:30
You build tolerance to the sedating effects (usually) of mirtazapine after a few weeks. I never had much success with paroxetine. I would say that escitalopram is much cleaner and probably more effective.
Posted by Hordak on July 27, 2019, at 17:32:07
In reply to Re: I need some advice regarding my medication regimen » Hordak, posted by linkadge on July 27, 2019, at 15:10:41
> You build tolerance to the sedating effects (usually) of mirtazapine after a few weeks. I never had much success with paroxetine. I would say that escitalopram is much cleaner and probably more effective.
What's your take on tricyclics, especially the classic ones: Amitriptyline, Clomipramine, Imipramine
Posted by Christ_empowered on July 28, 2019, at 12:20:29
In reply to Re: I need some advice regarding my medication regimen, posted by Hordak on July 27, 2019, at 17:32:07
hi. the tca drugs are...perhaps not surprisingly...rather toxic. remember; the original tca, imipramine, was supposed to be a rip off of Thorazine. when tested in hospitalized people, the 'schizophrenics' got worse, and the 'severe depressives' got a mood lift...and about 1/4 of them turned manic.
there is one...i've never taken it, i don't know if its available where you live....surmontil. it is sedating, a later developed tca that somehow helps get to sleep and then doesn't produce the artificial, not so refreshing sleep of most sedatives...
and i think its more closely related to clozapine...i forget the specifics, but its supposed to be helpful for the more agitated depressives among us, less cardio-toxicity, wide dosage range, etc. etc. etc.
it also dawned on me...remeron+wellbutrin. the remeron could possibly help improve appetite, the wellbutrin is a relatively mild stimulant, one of the less apathy-inducing drugs out there.
is gabapentin an option? even on an as needed basis, i would think it might be helpful, particularly during the antidepressant start up period.
just some random thoughts. i hope things get better for you.
Posted by Hordak on July 28, 2019, at 16:06:44
In reply to Re: I need some advice regarding my medication regimen, posted by Christ_empowered on July 28, 2019, at 12:20:29
> hi. the tca drugs are...perhaps not surprisingly...rather toxic. remember; the original tca, imipramine, was supposed to be a rip off of Thorazine. when tested in hospitalized people, the 'schizophrenics' got worse, and the 'severe depressives' got a mood lift...and about 1/4 of them turned manic.
>
> there is one...i've never taken it, i don't know if its available where you live....surmontil. it is sedating, a later developed tca that somehow helps get to sleep and then doesn't produce the artificial, not so refreshing sleep of most sedatives...
>
> and i think its more closely related to clozapine...i forget the specifics, but its supposed to be helpful for the more agitated depressives among us, less cardio-toxicity, wide dosage range, etc. etc. etc.
>
> it also dawned on me...remeron+wellbutrin. the remeron could possibly help improve appetite, the wellbutrin is a relatively mild stimulant, one of the less apathy-inducing drugs out there.
>
> is gabapentin an option? even on an as needed basis, i would think it might be helpful, particularly during the antidepressant start up period.
>
> just some random thoughts. i hope things get better for you.Thanks man!
surmontil is Trimipramine... we've got it in Germany. It is being used as a sedative, but has most probably no antidepressive effects!? Very strong H1 and strong HT2A & alpha1-adrenergic antagonism. Somewhat related to Mirtazapine when it comes to function.
My biggest fear when it comes to TCAs is constipation and orthostatic hypotension :=D
Wellbutrin is an interesting drug, BUT I have anxiety and weight gain issues, so I am not sure if it's wise to take it :=D
Gabapentin, Pregabalin are definitely an option, but in the end the psychiatrist has to decide... O_o
Posted by sigismund on July 29, 2019, at 11:21:42
In reply to Re: I need some advice regarding my medication regimen, posted by Christ_empowered on July 28, 2019, at 12:20:29
Surmontil (trimipamine) gave me a good refreshing sleep at low doses for a few years.
The TGA decided to discontinue it in Australia, though it is legal to buy it at high prices online.
It can also be acquired through a compassionate access program, sufficiently difficult to discourage every doctor and pharmacist to whom I spoke.
I could speculate about the motives of the TGA but it sounds paranoid.
Posted by sigismund on July 29, 2019, at 11:23:21
In reply to Re: I need some advice regarding my medication regimen » Christ_empowered, posted by Hordak on July 28, 2019, at 16:06:44
I like gabapentin and pregabalin except for the fact that my feet swell up.
Posted by linkadge on July 29, 2019, at 19:09:45
In reply to Re: I need some advice regarding my medication regimen, posted by Christ_empowered on July 28, 2019, at 12:20:29
I would disagree that the TCAs are 'toxic'.
It really depends on the TCA. Clomipramine is a very tolerable medication. Many docs don't even know that anafranil is a TCA. It is like a combination of a balanced SNRI (SSRI + NRI metabolite) and mirtazapine. It is still considered the 'gold standard' for OCD and is probably one of the most effective antidepressants. The anticholinergic side effects vary from TCA to TCA. Nortriptyline, for example, is less anticholingeric than amitriptyline.
Yes, the TCAs can induce mania. I haven't seen any conclusive evidence that TCAs are more likely to cause mania than SSRIs. However, if they do, it might be a sign of their superior antidepressant effects.
They are not selective and they hit a lot of targets. However, this may make them more effective in certain cases. Many of them can be taken at night, which can reduce daytime side effects and they tend to be much less disruptive on sleep than SSRIs.
Imipramine and amitriptyline are still a very effective antidepressants. They are (IMHO) much stronger for depression than any SSRI and the side effects are different (less sexual dysfunction, for example).
The SSRIs are safer in overdose, but this is a very poor rationale for selecting an antidepressant. Supposedly only a very (very) small portion of completed suicides are actually from antidepressant overdoses.
Linkadge
Posted by linkadge on July 29, 2019, at 19:14:31
In reply to Re: I need some advice regarding my medication regimen » Christ_empowered, posted by Hordak on July 28, 2019, at 16:06:44
Suposedly (in head to head trials) surmontil is as effective for depression as imipramine. This is hard for some to believe, but it may be evidence that there is an additional (yet undiscovered) common mechanism of the TCAs. I remember reading that a metabolite of trimipramine inhibits MAO-B and DAT. Also, like other TCAs is has an indirect effect on opioid systems. However, it is a VERY strong antihistamine (I took 25mg and slept till 4:00 pm the next day).
Honestly, if you were to try one TCA, I would highly recommend clomipramine.
Linkadge
Posted by mtom on July 30, 2019, at 10:38:04
In reply to Re: I need some advice regarding my medication regimen, posted by linkadge on July 29, 2019, at 19:14:31
Problem is, everyone reacts differently to each antidepressant.
Sertraline (Zoloft), tried many years ago, was horrifically activating for me. More recently Citalopram (Celexa) also made me very agitated and anxious along with other side effects. So switched to Escitalopram (Lexapro-Cipralex). Still made me very anxious, slightly less so than Celexa, and other side effects. But some people find it helps anxiety (!?).
So recently started decreasing Escitalopram while adding very low dose Mirtazapine (Remeron). Have been cross-titrating slowly for about 7 weeks, gradually decreasing Escitalopram while also gradually increasing Mirtazapine (I'm unusually sensitive to AD side effects).
I'm now taking very low dose Escitalopram and 7.5 gm Mirtazapine. And I have started to feel better for the first time in over a year. It's not consistent yet, buy my anxiety is definitely less on average, and I'm having some happier days. The Mirtazapine made me slightly groggy in mornings and after each dose increase, but this wore off. I'm also underweight - I've put on just a few pounds so far. The biggest downside has been an increase in Nightmares and Vivid dreams, but this also happened on higher doses of Escitalopram, and for the Mirtazapine, they increased upon starting and after dose-increases but gradually faded over a couple of weeks.
So, just sharing my experience. Mirtazapine is prescribed by some doctors as an add-on to SSRI's in addition to use on its own.
Posted by ed_uk2010 on July 31, 2019, at 6:29:21
In reply to Re: I need some advice regarding my medication regimen, posted by sigismund on July 29, 2019, at 11:21:42
>The TGA decided to discontinue it in Australia
Hi S,
Not just that the manufacturer discontinued it from the Australian market due to very low sales? That's what usually happens.
Posted by ed_uk2010 on July 31, 2019, at 6:31:06
In reply to Re: I need some advice regarding my medication regimen » ed_uk2010, posted by Hordak on July 27, 2019, at 13:19:22
> You think that qt prolongation might potentiate when taking both drugs combined?
It is a possibility to be aware of. Effects of drugs on cardiac conduction can be additive.
Posted by Hordak on August 5, 2019, at 19:23:22
In reply to Re: I need some advice regarding my medication regimen, posted by sigismund on July 29, 2019, at 11:21:42
> Surmontil (trimipamine) gave me a good refreshing sleep at low doses for a few years.
>
> The TGA decided to discontinue it in Australia, though it is legal to buy it at high prices online.
>
> It can also be acquired through a compassionate access program, sufficiently difficult to discourage every doctor and pharmacist to whom I spoke.
>
> I could speculate about the motives of the TGA but it sounds paranoid.
It's available where I live...
Posted by Hordak on August 5, 2019, at 19:24:28
In reply to Re: I need some advice regarding my medication regimen, posted by sigismund on July 29, 2019, at 11:23:21
> I like gabapentin and pregabalin except for the fact that my feet swell up.
I would like to try them. How do they feel?
Posted by Hordak on August 5, 2019, at 19:59:13
In reply to Re: I need some advice regarding my medication regimen, posted by linkadge on July 29, 2019, at 19:14:31
> Suposedly (in head to head trials) surmontil is as effective for depression as imipramine. This is hard for some to believe, but it may be evidence that there is an additional (yet undiscovered) common mechanism of the TCAs. I remember reading that a metabolite of trimipramine inhibits MAO-B and DAT. Also, like other TCAs is has an indirect effect on opioid systems. However, it is a VERY strong antihistamine (I took 25mg and slept till 4:00 pm the next day).
>
> Honestly, if you were to try one TCA, I would highly recommend clomipramine.
>
> Linkadge
>
>
>I would very much like to try Clomipramine.
I've been on Mirtazapine 15mg for two weeks (a friend of mine had some tablets and gave them to me). Appetite and metabolizm were insane: I gained 15 pounds in two weeks. Sleep felt like being hit by a hammer, strange dreams. I felt weak. Two weeks were probaby too short to assess its potential.
Escitalopram + Nortriptyline => good combo?
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