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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 9 of 9. This is the beginning of the thread.
Posted by dennison on April 1, 2002, at 14:22:44
Dr.Kramer hello --Appreciate your helping us!!!:):)........................ MY ? Ssri's and psychostimulant combinations!!! There exist many reports not necessarily double blind studies but, nonetheless a good deal of reports of individuals being treated with psychostimulants to help augment ssri's relieve residual anergia and daytime somnolence, that are pretty impressive. Yet here's the quandry, many laboratory studies have shown ssri's to negate the psychomotor aspects of psychostimulants. Release of dopamine into nucleus accumbens etc wasn't blunted, nonetheless psychomotor effects were reduced to baseline, no behavior effect was generated. The negation of the psychomotor enhancing effects therefore, was obviously somehow down stream of the dopamine post synaptic receptors --reciprocal diminution by enhanced serotonin functioning of some manner............................. Since I've been offerred the option to begin combination of any psychostimulant plus antidepressant, I'm somewhat speculative of just what is the most likely manifestation, psychomotor aspect will be negated or will it indeed be significant , as my greatest impairment currently concerns lethargy and day time drowsiness........................................ I'm currently taking parnate an maoi - thus the dreaded withdrawal and washout period awaits me--:). Thus I'm a bit weary of jumping off bridge before I know where I'm going to land,so to speak!! In otherwords, I don't want to deceive myself into thinking grass is greener on otherside off fence,if indeed that is unlikely to be the case. ....................... Tried effexor and prozac in past both made me extremely apathetic and very tired and constant lethargy, so the psychostimulant would be an essential aspect of the medication regiment. Wellbutrin tried as monotherapy - only produced some agitation but still fatique and somnolence "daytime" were very prominent. Cylert I've been on for quite some time it has little effect, but has prominent side effects,liver tests no big deal all ok -. Ritalin for a few days was not very effective, dexedrine though I tried, response was very good and experienced no side effects whatsoever............................. Guess my ? is dexedrine plus ssri, is this likely to work in your opinion, desimpramine is an option but I'm a bit reluctant to take a tricyclic because of prominent side effects . Ok thanks Dr. Kramer hope this presentation isn't too fragmented :) --probably a bit disorganized though:) but I figurred was best to get postup and not try to get wording perfect or I'd probably never get it done. :):)........... Thanks in advance DR. Kramer.............P.S. sorry about all the dots but my paragraphs always disappear so I use them as a spacer:)
Posted by dennison on April 1, 2002, at 14:54:03
In reply to dexedrine augmentation of ssri's , posted by dennison on April 1, 2002, at 14:22:44
> Dr.Kramer hello --Appreciate your helping us!!!:):)........................ MY ? Ssri's and psychostimulant combinations!!! There exist many reports not necessarily double blind studies but, nonetheless a good deal of reports of individuals being treated with psychostimulants to help augment ssri's relieve residual anergia and daytime somnolence, that are pretty impressive. Yet here's the quandry, many laboratory studies have shown ssri's to negate the psychomotor aspects of psychostimulants. Release of dopamine into nucleus accumbens etc wasn't blunted, nonetheless psychomotor effects were reduced to baseline, no behavior effect was generated. The negation of the psychomotor enhancing effects therefore, was obviously somehow down stream of the dopamine post synaptic receptors --reciprocal diminution by enhanced serotonin functioning of some manner............................. Since I've been offerred the option to begin combination of any psychostimulant plus antidepressant, I'm somewhat speculative of just what is the most likely manifestation, psychomotor aspect will be negated or will it indeed be significant , as my greatest impairment currently concerns lethargy and day time drowsiness........................................ I'm currently taking parnate an maoi - thus the dreaded withdrawal and washout period awaits me--:). Thus I'm a bit weary of jumping off bridge before I know where I'm going to land,so to speak!! In otherwords, I don't want to deceive myself into thinking grass is greener on otherside off fence,if indeed that is unlikely to be the case. ....................... Tried effexor and prozac in past both made me extremely apathetic and very tired and constant lethargy, so the psychostimulant would be an essential aspect of the medication regiment. Wellbutrin tried as monotherapy - only produced some agitation but still fatique and somnolence "daytime" were very prominent. Cylert I've been on for quite some time it has little effect, but has prominent side effects,liver tests no big deal all ok -. Ritalin for a few days was not very effective, dexedrine though I tried, response was very good and experienced no side effects whatsoever............................. Guess my ? is dexedrine plus ssri, is this likely to work in your opinion, desimpramine is an option but I'm a bit reluctant to take a tricyclic because of prominent side effects . Ok thanks Dr. Kramer hope this presentation isn't too fragmented :) --probably a bit disorganized though:) but I figurred was best to get postup and not try to get wording perfect or I'd probably never get it done. :):)........... Thanks in advance DR. Kramer.............P.S. sorry about all the dots but my paragraphs always disappear so I use them as a spacer:)
kramer above post thank you :)
Posted by Bekka H. on April 1, 2002, at 19:35:15
In reply to dexedrine augmentation of ssri's , posted by dennison on April 1, 2002, at 14:22:44
Yet here's the quandry, many laboratory studies have shown ssri's to negate the psychomotor aspects of psychostimulants. Release of dopamine into nucleus accumbens etc wasn't blunted, nonetheless psychomotor effects were reduced to baseline, no behavior effect was generated. The negation of the psychomotor enhancing effects therefore, was obviously somehow down stream of the dopamine post synaptic receptors --reciprocal diminution by enhanced serotonin functioning of some manner
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Hi Dennison, I was just about to ask Dr. Kramer a similar question, so I'll wait to see his response to yours. The reason I'm writing now is that I wonder whether you have a citation (or two) for the above studies you referred to. I've been on several SSRI plus stimulant combos, and I've experienced what your post describes. In fact, at times, it feels like nearly complete negation of the positive aspects of BOTH drugs. It feels as if they are counteracting each other. If you have references readily available, I'd like to read them. Thanks so much.
Bekka
Posted by dennison on April 1, 2002, at 22:28:04
In reply to dexedrine augmentation of ssri's - dennison , posted by Bekka H. on April 1, 2002, at 19:35:15
Hi Bekka - Hope Dr. kramer ventures down and takes alook at my post!!! :):).............................Bekka yes I have plenty studies showing psychostimulants being used to help augment ssri's or help alleviate anergic "lack of energy", hypersomnolence "daytime drowsiness" , apathy "frontal apathy--:) lol" ,all serious impediments to adequate restoring functional status,lethargy etc. etc........................................The response was dramatic and sustained,whereas before the addition of the psychostimulant functional status was essentially non-existent,thus any significant degree of recovery was severely hamperred. Psychostimulants also showed basic mood augmenting effects to the previous refractory ssri clients, thus as I stated earlier these reports, although not actual double blind studies -the improvement was definitely significant and was sustained, ritalin and dexedrine were both used in these situations. Some cases were followed for many months without loss of effect or tolerance,thus this strategy certainly merits at the very least a good honest consideration as a valid treatment ""ssri + psychostimulant" -- These were small groups of patients however nonetheless you can't argue with success..............................................................................................................................................Now as I stated previously laboratory studies have indeed shown ssri drugs, in these studies at least, to have the capability to totally block the psychomotor aspect of subsequent psychostimulant addition, though in some cases dopamine release into the critical areas(((((((((((( "nucleus accumbens" , of course being most important producing the "psychomotor-effect")))))))))))) was still just as significant and some times above psychostimulant alone.........................However, as earlier stated the subsequent stimulatory effect on psychomotor activity was totally abolished, thus implying a down stream effect of the actual dopamine receptors in the "nucleus accumbens" . Postulated theory was that some how the ssri enhanced neural functionality was reciprocally diminishing the dopamine effect, which of course we know happens with ssri's "sexual diminution" , "increase in extrapyramidal effects from neuroleptics" , ssri extrapyramidal effects from ssri's alone occassionally as well disinhibition of modualatory dopamine effects on skeletal musculature "" resulting in spasms, twitching and myoclonus". ................................................I've kinda just rehashed my previous post haven't I, rambling on again I guess, but In this little tiny text box lol - I kinda get stir crazy--, plus I'm doing this straight out of on spot thinking no preparation or outline.......................Anyway the issue of the studies. .......................................................Here's one #1 Methylphenidate Augmentation of Serotonin Selective Reuptake Inhibitors: A Case Series J Clinical Psychiatry 57:2, February 1996 ""AndrewL. Stroll, M.D., Srinivasan S. PIllay, M.D., Lisa Diamond, Susan B. workum, M.D., and Jonathan O.Cole, M.D. """ whew --take was kinda long - no cut n paste there :) !!!! I have several more similar to that but my typing is so atrocious I'm getting A bit fatiqued here. .............................................Ok another study of interest , more of theoretical nature,though demonstrating deleterious effect ssri's can have on dopamine function though!!!!! ""Flouxetine and Extrapyramidal Side Effects""" Am J psychiatry 146:10, October 1989 ---Roch Bouchard M.D., Emmanuelle Pourcher M. D., Pierre Vincent M.D..........................................................................................................................The main study which specifically showed ssri negation of psychomotor aspect of psychostimulants I have, but I'll need to dig it up - I remember it in detail though since the implication was very significant. I presume you only have pubmed abstract access, and not full medline access priviledges, I have the full reports but the abstracts sometimes aren't all that bad, though I definitely prefer the full complete full text article, perhaps if you could access a medical school library they of course would have all the journals. Bekka I'll supplement with more citations to literature, in near future, simply need to dig them up -- I have literally piles and piles---will take awhile. ..................................btw methylphenidate augmentation of desimpramine has been extensively studied and shown efficacy -- without inherent serotonin over-ride that ssri's potentially exhibit!!!!!!!
Posted by Bekka H. on April 1, 2002, at 23:42:51
In reply to Reply to Bekka !!! :) » Bekka H., posted by dennison on April 1, 2002, at 22:28:04
Hi Dennison,
Thank you, thank you, thank you! I certainly didn't anticipate that you would do all that work for me. I really appreciate it.
Have you ever read Joseph Glenmullen's PROZAC BACKLASH? He cites several studies in which SSRIs lowered dopamine levels by at least 50%!! When I read that, it confirmed what I had suspected all along. When I was on Wellbutrin and Zoloft, the Zoloft seemed to completely negate the motivation and energy that I'd gotten from WB alone. No matter how high I increased the WB dose (and I was up to the highest allowed dose), and no matter how low I kept the Zoloft, I just couldn't get back the drive and motivation I'd felt on WB alone. Then, later, when I was put on Dexedrine and Celexa, the SAME thing happened. I was on Dex first, and for a very long time, I was able to keep the Dex dose at 15 mg per day or lower. Within a few days after adding Celexa, however, I had to double the Dex dose, and within less than a month, all the benefits I'd gotten from Dex were gone. I had the WORST prostration and fatigue. I would slouch for hours and hours at a time. I developed the worst posture. I couldn't even stand up straight. I felt like a limp rag. I was very upset because I felt that Dexedrine had been very helpful to me. I probably would have developed a tolerance to it eventually anyway, but Celexa's adverse effects, and my attempt to counteract them by increasing Dex, hastened the development of Dex tolerance. I had to stay off of it for several months before I was able to benefit from it again. Consequently, I am very wary of these SSRI+stimulant combos. Not everyone responds the way I do to the combo; some do well on it, but I'd be careful. It's worth a try, but you really have to monitor yourself for ssri-induced apathy and wimpiness. I call ssri's "the wimpogenic drugs."
Posted by Bekka H. on April 2, 2002, at 1:39:48
In reply to Reply to Bekka !!! :) » Bekka H., posted by dennison on April 1, 2002, at 22:28:04
Hi again.
I just re-read my post to you, and I think I should mention that although I have had less-than-ideal responses to the ssri+stim combo, you might do very well on it. I think you just have to give it a try and do a lot of self-monitoring. You see, because of the very nature of the ssri problem of apathy, one is less likely to notice it or report it. If you have someone close to you who can help monitor you, that can be very helpful. Some time ago, I read an article by a physician about ssri-induced apathy. One phrase he used was "lack of appropriate anxiety." Granted, many of us here on PB would like to be LESS anxious, but there are some things we SHOULD be anxious about. A little bit of anxiety can be a good thing. It can motivate people to do things they need or want to do, and it can prevent us from engaging in careless or dangerous behavior. So, as long as you are on the lookout for the possible drawbacks, I think the combo is certainly worth a try.
Bekka
Posted by Dr. Kramer on April 2, 2002, at 8:20:51
In reply to dexedrine augmentation of ssri's , posted by dennison on April 1, 2002, at 14:22:44
> Dr.Kramer hello --Appreciate your helping us!!!:):)........................ MY ? Ssri's and psychostimulant combinations!!! There exist many reports not necessarily double blind studies but, nonetheless a good deal of reports of individuals being treated with psychostimulants to help augment ssri's relieve residual anergia and daytime somnolence, that are pretty impressive. Yet here's the quandry, many laboratory studies have shown ssri's to negate the psychomotor aspects of psychostimulants. Release of dopamine into nucleus accumbens etc wasn't blunted, nonetheless psychomotor effects were reduced to baseline, no behavior effect was generated. The negation of the psychomotor enhancing effects therefore, was obviously somehow down stream of the dopamine post synaptic receptors --reciprocal diminution by enhanced serotonin functioning of some manner............................. Since I've been offerred the option to begin combination of any psychostimulant plus antidepressant, I'm somewhat speculative of just what is the most likely manifestation, psychomotor aspect will be negated or will it indeed be significant , as my greatest impairment currently concerns lethargy and day time drowsiness........................................ I'm currently taking parnate an maoi - thus the dreaded withdrawal and washout period awaits me--:). Thus I'm a bit weary of jumping off bridge before I know where I'm going to land,so to speak!! In otherwords, I don't want to deceive myself into thinking grass is greener on otherside off fence,if indeed that is unlikely to be the case. ....................... Tried effexor and prozac in past both made me extremely apathetic and very tired and constant lethargy, so the psychostimulant would be an essential aspect of the medication regiment. Wellbutrin tried as monotherapy - only produced some agitation but still fatique and somnolence "daytime" were very prominent. Cylert I've been on for quite some time it has little effect, but has prominent side effects,liver tests no big deal all ok -. Ritalin for a few days was not very effective, dexedrine though I tried, response was very good and experienced no side effects whatsoever............................. Guess my ? is dexedrine plus ssri, is this likely to work in your opinion, desimpramine is an option but I'm a bit reluctant to take a tricyclic because of prominent side effects . Ok thanks Dr. Kramer hope this presentation isn't too fragmented :) --probably a bit disorganized though:) but I figurred was best to get postup and not try to get wording perfect or I'd probably never get it done. :):)........... Thanks in advance DR. Kramer.............P.S. sorry about all the dots but my paragraphs always disappear so I use them as a spacer:)
I think it's worth a try. Remember, the studies you are citing show no psychomotor deviation from BASELINE with the combination, and that's really all you want: to maintain normal psychomotor status. Hopefully the stimulant will put you back in the middle.
Posted by dennison on April 2, 2002, at 9:25:03
In reply to Re: dexedrine augmentation of ssri's , posted by Dr. Kramer on April 2, 2002, at 8:20:51
DR. Kramer thank you very much for responding-I agree totally!!!! :)............Anything that might work, is certainly worth a try.
Posted by Elizabeth on April 4, 2002, at 22:28:15
In reply to Re: dexedrine augmentation of ssri's , posted by Dr. Kramer on April 2, 2002, at 8:20:51
Hi Dr. Kramer.
I'm curious -- do you have an opinion as to what sort of particular symptoms of depression (other than fatigue, obviously) are likely to be improved by amphetamine?
More generally, it seems to me that the diagnosis of "major depressive disorder" doesn't help much in predicting what treatment will work, probably because the definition of major depression is so broad. I'm interested in whether there's a way to subdivide it usefully. I'm aware of the subtypes identified in DSM-IV and the evidence validating these subtypes. I'd like to know whether you've noticed or heard of any other characteristics which may be associated with response to a particular treatment.
-elizabeth
This is the end of the thread.
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