![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 15 of 15. This is the beginning of the thread.
Posted by jralphc on December 6, 2002, at 12:39:59
Over the past decade, I think I've tried almost every AD: Ludiomil, Nardil, Prozac, Paxil, Serzone, Trazodone, Wellbutrin, Celexa, Lexapro, Effexor.... Although I get partial response to SSRIs, taking them means giving up my sex life, which would make me even more depressed. The only drug that I get some response to that I can tolerate is Wellbutrin SR, and I take 300 mg. daily. The problem is that I remain apathetic, unmotivated, have hypersomnia (I could sleep 12 hrs. a day) and basically feel pretty blue. I am tired of feeling this way. My Dr. is now trying an "unconventional" approach--Adderall XR 20 mg. in the morning. If this doesn't work, the Dr. mentioned Ritalin, anticonvulsants, Buspar and Lithium as possible approaches.
Has anyone out there failed to respond, or had inadequate response, to nearly all meds, but found an unconventional one that works? Or does anyone have experience with Adderall? I'm a little concerned because when I was 41 (I'm now 44) I had a (relatively mild) heart attack and am on Toprol XL for mild hypertension, and Adderall is amphetamine/dextroamphetamine. a stimulant. But I also know there's a strong relation between depression and heart attacks, and I want to feel better emotionally.
Posted by SJMA on December 6, 2002, at 15:44:08
In reply to Stimulants for Refractory Depression?, posted by jralphc on December 6, 2002, at 12:39:59
> Over the past decade, I think I've tried almost every AD: Ludiomil, Nardil, Prozac, Paxil, Serzone, Trazodone, Wellbutrin, Celexa, Lexapro, Effexor.... Although I get partial response to SSRIs, taking them means giving up my sex life, which would make me even more depressed. The only drug that I get some response to that I can tolerate is Wellbutrin SR, and I take 300 mg. daily. The problem is that I remain apathetic, unmotivated, have hypersomnia (I could sleep 12 hrs. a day) and basically feel pretty blue. I am tired of feeling this way. My Dr. is now trying an "unconventional" approach--Adderall XR 20 mg. in the morning. If this doesn't work, the Dr. mentioned Ritalin, anticonvulsants, Buspar and Lithium as possible approaches.
>
> Has anyone out there failed to respond, or had inadequate response, to nearly all meds, but found an unconventional one that works? Or does anyone have experience with Adderall? I'm a little concerned because when I was 41 (I'm now 44) I had a (relatively mild) heart attack and am on Toprol XL for mild hypertension, and Adderall is amphetamine/dextroamphetamine. a stimulant. But I also know there's a strong relation between depression and heart attacks, and I want to feel better emotionally.
I have a friend who sounded exactly like what you're describing, who finally tried Topamax, and after YEARS of sluggishness, she is a changed woman! I have no idea what the side effects are, or whether it would be advised with your heart condition, but it is worth looking into if it's as successful treating intractable depression as she says! Good Luck!
Posted by BrittPark on December 6, 2002, at 16:20:21
In reply to Stimulants for Refractory Depression?, posted by jralphc on December 6, 2002, at 12:39:59
> Has anyone out there failed to respond, or had inadequate response, to nearly all meds, but found an unconventional one that works? Or does anyone have experience with Adderall? I'm a little concerned because when I was 41 (I'm now 44) I had a (relatively mild) heart attack and am on Toprol XL for mild hypertension, and Adderall is amphetamine/dextroamphetamine. a stimulant. But I also know there's a strong relation between depression and heart attacks, and I want to feel better emotionally.
There are a lot of people out there who have been helped by augmentation, with lithium, thyroid hormone, anticonvulsants, antipsychotics, stimulants, and others. For someone with hypersomnia a stimulant is a natural choice.
Best of luck,
Britt
Posted by Nala on December 6, 2002, at 16:48:56
In reply to Re: Stimulants for Refractory Depression?, posted by SJMA on December 6, 2002, at 15:44:08
I've been taking Adderall 5-10 mg bid for years in addition to my AD's (I've tried most SSRI's, Serzone, Wellbutrin, currently on Remeron). I believe the adderall helps with mental and physical energy. In addtition, I take a small dose of lithium (450mg) for my so-called bipolar 2. I don't think I'd have the drive or energy to leave my house without the Adderall in the equation
Posted by snood on December 6, 2002, at 20:58:05
In reply to Stimulants for Refractory Depression?, posted by jralphc on December 6, 2002, at 12:39:59
I also have hypersomnia, and have been very depressed at times. I have been taking Zoloft and Wellbutrin for the past 6 months or so. That has helped with the suicidal thoughts, but hasn't brought me out of depression completely. My pdoc added ritalin, and it doesn't really help much with the insomnia....it only seems to be helping my ADD.
Wish I could say ritalin helped keep me awake, but it doesn't. Maybe it will work for you.....meds effect everyone differently.
Posted by viridis on December 7, 2002, at 1:57:38
In reply to Stimulants for Refractory Depression?, posted by jralphc on December 6, 2002, at 12:39:59
I've experienced periodic episodes of moderate to very severe depression (several times a year) since childhood. The standard antidepressants I tried (SSRIs, Wellbutrin) caused major side effects and didn't help much, even after months of use. I also have anxiety problems, and when I started Klonopin for that, the worst of the depression and lack of motivation disappeared. But I still had frequent, less intense depression.
When I started taking Adderall (for ADD) almost a year ago, the remaining depression lifted and now I generally feel more energetic, focused, and enthusiastic. It also has an antianxiety effect for me, especially in combination with Klonopin. I commented to my pdoc that Adderall has a powerful antidepressant effect in addition to helping with ADD. He said that amphetamines often work that way, and seems quite happy with my response.
By the way, I take a very low dose of Adderall (5-10 mg/day) and haven't needed to increase it so far. I sometimes skip a day or two with no problem. It's a very good med for me.
I can't comment about the possible heart risks -- this is something to discuss with your doctor. My blood pressure is normal and doesn't go up the way it often used to when I was stressed out, but I've never had any heart problems.
Posted by medlib on December 7, 2002, at 2:13:28
In reply to Stimulants for Refractory Depression?, posted by jralphc on December 6, 2002, at 12:39:59
Hi jralphc--
Toprol XL is a beta blocker type of antihypertensive, and beta blockers have been known to cause or worsen depression in some (often enough that that SE is listed fairly prominently in the drug lit). A Beta blocker (Tenormin) made me suicidal within 5 days. So, before you try any more psych med alternatives, you might want to ask your cardiologist or internist about trying a different type of BP-lowering med, such as a calcium-channel blocker like Verapamil, or better yet, an ACE inhibitor like enalapril maleate. ACE inhibitors have far fewer SEs than other classes of antihypertensives and don't cause depression.
As far as stimulants go, you are wise to be concerned. All can raise resting pulse rate and BP; and while a modest increase isn't a problem for most, your cardiac history may make even a small increase problematic. I'd urge you to consult your cardiac doc about taking any stimulant, especially if you experience a l0 point or more rise in either resting PR or systolic BP after adding a stim. I think Adderall and dex more often raise BP than ritalin, but any are capable of that in the wrong person. You might want to look into Provigil. Another little caveat: Both Wellbutrin and ritalin act powerfully on dopamine receptors. I had to discontinue ritalin when I started Wellbutrin because of EPS (although I'm at higher risk for EPS than you would be, and I also take Effexor; so EPS might not be a relevant risk for you.)
Fortunately, or unfortunately depending on how you look at it, the same lifestyle changes which help your heart can help your depression--moderate, pulse-monitored exercise and a high fiber, low fat diet. Borrrring, I know, and a lot tougher than taking pills. On the other hand, the antidepressant effect of exercise, though modest, is a whole lot reliable any pill combo.
You've taken a lot of different meds, and that by itself is both depressing and exhausting. (I got off the musical meds merry-go-round 6 mo.s ago after a 3 year ride not because I found the right combo, but because I just couldn't handle the stress of constant change any longer.) That said, there are classes of meds you haven't tried--neuroleptics like Geodon, and ACs like lamictal come to mind.
Hang tough, but make your docs *talk* to one another! You shouldn't have to play moderator between them, or monitor your own drug interactions; that's part of what you're paying *them* for. Regards---medlib
Posted by jralphc on December 7, 2002, at 10:44:22
In reply to Re: Stimulants for Refractory Depression? » jralphc, posted by medlib on December 7, 2002, at 2:13:28
I'm a newcomer to this board. First off, I'd like to express my appreciation to all of you for your thoughtful responses. This seems like a great resource, and I'm really glad to hear from each of you.
All of the advice has been very helpful in one way or another. Today is the 3rd day taking Addrerall XL 20 mg. I am monitoring my BP and heart rate. So far, I've seen small increases in systolic BP and heart rate (from 77 to 82 on BP; pulse rate tends to be the same or sometimes it rises by 5 to 10 points for awhile). I don't know if it is the extended release formulation that causes this, but it seems like I have periods where I feel calm but focused, and other times when I'm more anxious/agitated.
Medlib--I've asked my cardiologist about ACE inhibitors or calcium channel blockers--mentioning to him the depression, too--but he seems pretty adamant that beta blockers are the best. I do think you are correct that they can worsen depression and make me feel fatigued. I will talk to him about Adderall when I see him (I only see him once or twice a year; I've gone 3 years now with no problems and a good result on my stress echocardiogram, plus my cholesterol is quite low--122 total, 67 LDL, but 31 HDL which isn't good so I take niacin and lipitor). Good advice about getting my 2 docs to consult--I may also need to get a 2nd opinion on my cardiac care. I think my cardiologist is good, but it is my life we are talking about so a 2nd opinion seems warranted.
Anyway, it is too early to judge things mentally I guess, but I certainly have more energy, get out of bed easily, sleep well and am not so lethargic during the day. So that's a big plus. But I will have to monitor BP and pulse closely, because I don't want to do anything to hurt my cardiovascular system. I am also trying to exercise more--the Adderall seems to help give me the extra boost I need to do that. The problem with my depression is I just don't have the desire to exercise when I'm blue, even though I know it could help a lot.
So, I'll give this a shot. I've read about modafinil/Provigil--do any of you have experience with that one? The reviews here seem pretty mixed, but I know from experience that it usually is that way with meds. As they say, "your mileage may vary." :-)
Thanks again.
Posted by viridis on December 7, 2002, at 12:35:29
In reply to Re: Stimulants for Refractory Depression? -, posted by jralphc on December 7, 2002, at 10:44:22
Provigil could be worth a try (if your doctor/cardiologist think it's appropriate given your heart condition). I took it for a short while, and it definitely was energizing without increasing anxiety, interfering with sleep, or affecting my blood pressure. As I've mentioned here before, my psychiatrist says he's found it a very useful drug for certain people (although he was talking mainly about ADD).
I changed to Adderall because it was better for my ADD, but I did get a boost from Provigil, and I think its "sister" drug, Adrafinil, is used quite a bit for depression in Europe. IsoM, who posts here often, has quite a bit of experience with this and related drugs -- maybe Iso could offer some advice?
Posted by SLS on December 8, 2002, at 15:23:21
In reply to Stimulants for Refractory Depression?, posted by jralphc on December 6, 2002, at 12:39:59
Hi.
Can you describe your experience with Ludiomil? It is once drug that I haven't tried yet. Like you, I have been resistant to drug treatment.
If Ludiomil produced even a mild response, you might do well with a combination of Effexor 300mg + Wellbutrin 300mg. It is worth trying psychostimulants, but I don't think it's a good bet if you are receiving little or no benefit from Wellbutrin. As far as being able to tolerate medication, you might be forced to start at very low dosages and raise the dosage very gradually so as not to "provoke" side-effects. Often, side-effects occur early in treatment and abate with time. However, it can take months for some side effects to improve. Effexor + Remeron is often suggested for treatment resistance.
Try not to think of yourself as being doomed. Some people have pursurvered for decades and finally find their magic pill. New drugs are coming out. You might want to try duloxetine (Cymbalta), which is supposed to be available within the next six months. It is a dual-action drug like Effexor. However, it inhibits the reuptake of both norepinephrine (NE) and serotonin (5-HT) nearly equally. Effexor is less balanced in this regard, and is much more skewed towards 5-HT.
Have you ever tried adding Lamictal? By itself, I don't think it can maintain a strong antidepressant effect, but it can make an excellent augmentor.
I think the caring people whom have contributed along this thread have offered you enough ideas to help you feel that you have plenty of new things to try before you can reach the conclusion that you are really doomed.
By the way, there is a VERY strong association between depression and heart disease.
- Scott
Posted by jralphc on December 9, 2002, at 10:37:06
In reply to Re: Stimulants for Refractory Depression? » jralphc, posted by SLS on December 8, 2002, at 15:23:21
Scott-
While it has been awhile since I took it, I recall that I did have some response to Ludiomil. I suspect it is because norepinephrine is more important to my depressive symptoms than is serotonin. It did cause me to gain some weight and feel tired. But you may want to give it a shot.
I do have some response to Wellbutrin, probably more than to any other "typical" AD drug, which is why I still take it. But I'm not really satisfied with a partial response, and I don't think I should be either. So I am looking for soemthing to augment the Wellbutrin and make me feel like a productive happy person again.
Although I don't have full-blown Seasonal Affective Disorder, I do have a worsening of my depression every year in October/November, and again in about April. Pretty curious thing. I'm hopeful that I can find something that is effective and maybe take the drug that augments Wellbutrin at those times of the year that I need it.
You are right about the very strong link between heart disease and depression--that is one reason why I really want to deal with this.
I've read a lot about Duloxetine. I hope it is available soon--my doc had wanted to try reboxetine when it became available, which isn't going to happen. But, I tried it from an overseas pharmacy and had a bad problem with urinary hesitancy. It was painful. I seem to be very sensitive to these drugs and if there's a side effect, I get it.
I've been on Adderall for 5 days now and so far it is helping, I think. But it's too soon to tell.
Thanks for the advice, and best of luck.
Jeff
Posted by Vanessa on December 17, 2002, at 2:28:26
In reply to Re: Stimulants for Refractory Depression? » SLS, posted by jralphc on December 9, 2002, at 10:37:06
Although I take several meds for depression, for years I couldn't find one (or a combo) that was stimulating enough. I tried dexedrine, ritalin, provigil, caffeine, parnate, wellbutrin, and others. Feeling lethargic so much of the time was really crippling. What finally worked for me was to add to the mix yohimbe, a stimulating herb, which I have used for 3 years now without a drop in effectiveness. (Do some research first; I know there are some meds (MAOIs) yohimbe should be combined with only cautiously) I am on an MAOI, and have had no problems whatsoever with also using yohimbe. My doctor is fine with this. I like the liquid version; it makes it easy to control the dosage, which you can vary according to your moods, and it works quickly.
Posted by Peter S. on December 17, 2002, at 15:47:50
In reply to Re: Stimulants for Refractory Depression?, posted by Vanessa on December 17, 2002, at 2:28:26
Hi Vanessa,
What brand of yohimbe do you use and how much? How often do you have to take it?
Your experience sounds very interesting since I've had low energy, lethargic depression for years and all the stimulants I've tried only work briefly.
Thanks!
Peter
> Although I take several meds for depression, for years I couldn't find one (or a combo) that was stimulating enough. I tried dexedrine, ritalin, provigil, caffeine, parnate, wellbutrin, and others. Feeling lethargic so much of the time was really crippling. What finally worked for me was to add to the mix yohimbe, a stimulating herb, which I have used for 3 years now without a drop in effectiveness. (Do some research first; I know there are some meds (MAOIs) yohimbe should be combined with only cautiously) I am on an MAOI, and have had no problems whatsoever with also using yohimbe. My doctor is fine with this. I like the liquid version; it makes it easy to control the dosage, which you can vary according to your moods, and it works quickly.
Posted by Christina on December 18, 2002, at 8:01:47
In reply to Re: Stimulants for Refractory Depression? » jralphc, posted by viridis on December 7, 2002, at 1:57:38
I was like you.. I tried several SSRIs, (as well as Wellbutrin, Lithium and Depakote) for depression. I found only minimal relief at best, and gained 40 pounds in the process.
Then i stopped all ADs and anti-psychotics, and started taking Adderall XR (30mgs), and it has done wonders for the depression... as well as taking the edge off my anxiety.
The problem is that the effects only last about 7 hours (less if I take it on a full stomach).
So when the Adderall wears off, I am depressed, lethargic and very irritable. My doc suggested addding another 10 mgs in the early evening, which I do if I've got a busy evening.
I've thought about taking a 30mg XR at about 8 am, and then another one at 3 pm, to get the full effects all day, but I'm afraid that dose is very high.
A 24-hour (or at least 18-hour) Adderall would be perfect for me.
My doc has suggested adding Serzone to the Adderall. Anyone have experience using this combination?
Posted by Vanessa on December 20, 2002, at 1:24:47
In reply to Vanessa-yohimbe?, posted by Peter S. on December 17, 2002, at 15:47:50
Hi Peter....
I use a brand of yohimbe made by Herbs Pharm.
I have used other brands too, and they also work. The main thing is to get the herb in liquid
form; that way you can vary dosages according to needs and the liquid starts working in a short period of time (i hr. or so)The more depressed I am, the more I take. My dose varies between 5 - 20 drops a day. I usually split the dose up. But using something I can gear to my body depending on its mood has been critical in my healing. Make sure to read the insructions for yohimbe because there are side efffects for some people. And talk to your Doc about it. If you try it, you may have to experiment with dosages, time to take the drug ,etc. Do not give up too soon. I am in an up cycle, and am not taking it. But two weeks ago I went real low, and took about 25 drops that day. And sometimes taking 3 drops is plenty; other times 20 drops barely help. It has definitely helped with my mild to moderate depressions. I vary the dose according to my needs. It does not make me feel drained and it does not make me feel too druggy. As with everything though, do some research and start slow. Vary doses, times of day to take them -- all the usual experiments that goes along with the start up of a new drug.Talk to your doctor about it.Yohimbe has been the most consistent "stimulant" I have tried (and I
tried a lot) Good luck, Stephanie
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.