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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 13 of 13. This is the beginning of the thread.
Posted by Squiggles on May 10, 2003, at 18:27:36
It's the weekend, the dose has been raised
from 15mg to 30mg;Results: Very promising, much better than
starting at 30mg where Miss X felt like she
was hit by a ton of bricks; no anxiety, sleep
very good, some sneezing, histaminic feeling
in the morning, increase in appetite.It has only been 2 weeks, so more developments
will be reported as they arise. Nevertheless,
the ability to sleep well after some 12-15 yrs.
is something to be grateful for. Had it been
in my power, i would have given a long-life benzo
with the imipramine from the beginning, but hey,
i'm not a doctor, just look like one on the net.My comments: the remarkable success of the older
drugs, such as lithium, imipramine and Remeron,
can only indicate the paucity of real scientific
research and advancement in the psychopharmacology
medicines.Indeed, the reason i chose Remeron as a suggestion
for this is among other things (i.e. anxiety and
depression target) that it was remarked that it is
not clearly known how the drug works, and it is very
old. Same with lithium - i guess i am a bit
biased, but there is something to this i think.Squiggles
Posted by SLS on May 10, 2003, at 19:02:25
In reply to Remeron rocks for treatment-resistant unipolar, posted by Squiggles on May 10, 2003, at 18:27:36
Hi Squiggles. (That's such a cool name)
> My comments: the remarkable success of the older
> drugs, such as lithium, imipramine and Remeron,
> can only indicate the paucity of real scientific
> research and advancement in the psychopharmacology
> medicines.Are you taking imipramine and Remeron together? How much imipramine are you taking, and how does it affect you?
So far, of all the drugs I have tried, a combination of imipramine 300mg + Lamictal 300mg is the only thing that enables me to function well enough to do things like participate on Psycho-Babble. Perhaps adding Remeron makes sense for me. I'm also taking Abilify and Lexapro, but I'll probably drop the Lexapro because it seems to do more harm than good.
- Scott
Posted by Squiggles on May 10, 2003, at 19:35:09
In reply to Re: Remeron rocks for treatment-resistant unipolar, posted by SLS on May 10, 2003, at 19:02:25
No, i'm sorry i did not make myself clear;
i meant that of the 18 or 20 drugs tried
by my friend - most of them new only,
imipramine and Remeron have worked; and in
my case - lithium;I am simply wondering if there has been any
real advance with the new drugs or if they
are just spin-offs.I'm glad yours work - are you under the care
of a psychopharmacologist?
Squiggles
Posted by SLS on May 10, 2003, at 21:08:56
In reply to Re: Remeron rocks for treatment-resistant unipolar » SLS, posted by Squiggles on May 10, 2003, at 19:35:09
Hey, Squiggles.
> No, i'm sorry i did not make myself clear;
> i meant that of the 18 or 20 drugs tried
> by my friend - most of them new only,
> imipramine and Remeron have worked; and in
> my case - lithium;Well then, I guess your lack of clarity has given me a potentially good idea. I could try adding Remeron to imipramine.
> I am simply wondering if there has been any
> real advance with the new drugs or if they
> are just spin-offs.I think the answer is probably "yes and no". All of the SSRIs are chemically distinct from each other and all offer alternatives to one another, exhibiting different efficacies for any one individual. I know someone who responds to Paxil and not to Celexa. There are plenty of people for whom the reverse is true. As someone else mentioned, it may be that too many resources are being spent to develop more SSRIs at the expense of more novel compounds. What I find encouraging is that it has become increasingly apparent (and reported in the media) that the available antidepressants are less effective than they were once portrayed. For example, the number 70% is reported to be the percentage of people who respond to any one antidepressant. However, "respond" does not mean "remission". It only means that 70% experienced at least a 50% reduction of measurable symptoms. Perhaps only 40% actually attain full remission. 30% respond to placebo.
> I'm glad yours work
Right now, I am improved by only 15% over my unmedicated baseline. That will not get me back to work.
> - are you under the care of a psychopharmacologist?
The doctor I'm seeing is primarily a psychopharmacologist. I just started seeing him, so I don't know the extent to which he offers psychotherapy.
- Scott
Posted by Squiggles on May 10, 2003, at 21:30:20
In reply to Re: Remeron rocks for treatment-resistant unipolar, posted by SLS on May 10, 2003, at 21:08:56
> Hey, Squiggles.
>
> > No, i'm sorry i did not make myself clear;
> > i meant that of the 18 or 20 drugs tried
> > by my friend - most of them new only,
> > imipramine and Remeron have worked; and in
> > my case - lithium;
>
> Well then, I guess your lack of clarity has given me a potentially good idea. I could try adding Remeron to imipramine.
* You sound well-informed about meds. Imipramine is an old tricyclic;
Remeron, just as old or older (used to be marketed by
Organon, a Dutch drug and dye co. by another name) tetracyclic;
just how they influence the brain hormones is something i would
have to look up in Stahl's little book, or search the net,
and even then, it mean little to me in terms of prediction.Why would you want to mix the two?
>
> > I am simply wondering if there has been any
> > real advance with the new drugs or if they
> > are just spin-offs.
>
> I think the answer is probably "yes and no". All of the SSRIs are chemically distinct from each other and all offer alternatives to one another, exhibiting different efficacies for any one individual. I know someone who responds to Paxil and not to Celexa. There are plenty of people for whom the reverse is true. As someone else mentioned, it may be that too many resources are being spent to develop more SSRIs at the expense of more novel compounds. What I find encouraging is that it has become increasingly apparent (and reported in the media) that the available antidepressants are less effective than they were once portrayed. For example, the number 70% is reported to be the percentage of people who respond to any one antidepressant. However, "respond" does not mean "remission". It only means that 70% experienced at least a 50% reduction of measurable symptoms. Perhaps only 40% actually attain full remission. 30% respond to placebo.
>
> > I'm glad yours work
>
> Right now, I am improved by only 15% over my unmedicated baseline. That will not get me back to work.Oh sorry. Whenever that sort of thing happens, i have
a knee-jerk reaction to ask about the initial diagnosis.
I know that lithium has good success as an adjunct with many
ADs of different types.
>
> > - are you under the care of a psychopharmacologist?
>
> The doctor I'm seeing is primarily a psychopharmacologist. I just started seeing him, so I don't know the extent to which he offers psychotherapy.I think they must be gods - i always wanted to marry one,
and if i couldn't seduce one of those, maybe settle
for an anaesthesiologist - i am a shameless hedonist,
i know :-)good luck
Squiggles
>
>
Posted by jrbecker on May 11, 2003, at 2:38:03
In reply to Re: Remeron rocks for treatment-resistant unipolar » SLS, posted by Squiggles on May 10, 2003, at 21:30:20
Scott,
remeron takes a bit of time to get comfortable with. It's probably the first med where I waited over a month and found eventual positive effects finally kick-in. This is a med with long-term payoff.
I really think you should give remeron another go, maybe even monotherapeutically. From reading your posts, it sounds like you have a high tolerance level for most meds. Maybe spend less time at 30mg and try to bump up to 45 mg as soon as possible.
Posted by SLS on May 11, 2003, at 9:15:00
In reply to Re: Remeron rocks for treatment-resistant unipolar » SLS, posted by Squiggles on May 10, 2003, at 21:30:20
Hi Squiggles.
> > Why would you want to mix the two?
My reasons are the following:
1. Imipramine continues to be partially effective and responsible for the few brief robust antidepressant responses (usually just a few days) I have experienced. The only long term remission I experienced (9 months) was with a combination of Parnate + desipramine. Desipramine is an active metabolite of imipramine.
2. Remeron is a particularly useful adjunct to other antidepressants because its actions are often complementary. Its NE alpha-2 antagonism might act synergistically with imipramine's NE reuptake inhibition. Perhaps its 5-HT2a and 5-HT3 antagonisms complement the 5-HT reuptake inhibition of imipramine.
3. I would not be able to function without imipramine (combined with Lamictal). I would not be able to manage my apartment and personal affairs. It would be easier on me to remain on imipramine as long as there are no major interactions with Remeron.
> > Oh sorry. Whenever that sort of thing happens, i have
a knee-jerk reaction to ask about the initial diagnosis.
I know that lithium has good success as an adjunct with many
ADs of different types.My initial diagnosis was ultra rapid-cycling atypical unipolar depression. I no longer cycle. I was later diagnosed as being bipolar when antidepressants precipitated severe mania, although I never had a manic episode in the absence of medication. I wish I could become manic again, as mania is easily treated for me using either Depakote or Zyprexa. I don't know what the hell I am other than a pain in my doctor's ass.
I have tried lithium in the past. In fact, it was responsible for abolishing my rapid-cycle (I wish it hadn't). Lithium tends to make me feel worse as it significantly flattens my affect. I still wouldn't exclude it among alternatives, but I would try it at dosages between 300-600mg.
Thanks for the input!
- Scott
Posted by SLS on May 11, 2003, at 9:24:35
In reply to Re: Remeron rocks for treatment-resistant unipolar, posted by jrbecker on May 11, 2003, at 2:38:03
Hi JB.
> remeron takes a bit of time to get comfortable with. It's probably the first med where I waited over a month and found eventual positive effects finally kick-in. This is a med with long-term payoff.
Thanks. It is good to know that.
> I really think you should give remeron another go, maybe even monotherapeutically. From reading your posts, it sounds like you have a high tolerance level for most meds. Maybe spend less time at 30mg and try to bump up to 45 mg as soon as possible.
I like that idea.
I am a bit shy about Remeron, although I have never been on it for more that a few days. When I was a patient at the NIMH, they had me take a drug known as idazoxan. It made my depression significantly worse, and I had to endure it for several months. Idazoxan, like Remeron, blocks NE alpha-2 receptors. When I felt worse 1-2 days after beginning Remeron, I attributed it to this shared property. Of course, it is sometimes silly to think we can predict with certainty what these chemicals will do within the milieu of our complex neurobiology.
Did Remeron make you feel worse in the beginning?
- Scott
Posted by Squiggles on May 11, 2003, at 9:36:54
In reply to Re: Remeron rocks for treatment-resistant unipolar » Squiggles, posted by SLS on May 11, 2003, at 9:15:00
Hi Scott,I wish i knew as much as you do about the
chemistry of these drugs and their effect -
this collage of interacting AD effects is
not something i can respond to - definitely
would ask a doc. or a pharmacist.I have been told that the reason Remeron is
so good for heavy depression is on account of
its effect on norepinephrine, which is not
as stimulated by imipramine (is that right?);
on the other hand, it is quite sedating, but
that is supposed to go away within a few months
after starting. My friend is doing ok so far -
better than ever.I recall with imipramine there
would be a cycle of slammerino sleep after taking
it, uneasy, tense, anxious days, with a 4 hr.
span of agressive, rage explosive tendencies
just before taking the nightly dose again. And that
was the best drug of all the consequent ones tried.
>
> My initial diagnosis was ultra rapid-cycling atypical unipolar depression. I no longer cycle. I was later diagnosed as being bipolar when antidepressants precipitated severe mania, although I never had a manic episode in the absence of medication. I wish I could become manic again, as mania is easily treated for me using either Depakote or Zyprexa. I don't know what the hell I am other than a pain in my doctor's ass.
>
> I have tried lithium in the past. In fact, it was responsible for abolishing my rapid-cycle (I wish it hadn't). Lithium tends to make me feel worse as it significantly flattens my affect. I still wouldn't exclude it among alternatives, but I would try it at dosages between 300-600mg.
>
> Thanks for the input!
>Ultra-rapid cycling unipolar? Wow! I've never heard
of that one before; sorry, exactly how did that
feel, without the mania? It sounds very unusual.
So what's the plan Scott - are you going to
recommend that soup to your doctor? I think you
should. As for being a pain in the ass, i have
a feeling that doctors hate psychiatry more than
brain tumour removal - i am sure it is the most
taxing and challenging area in their practice.I can only be grateful that my dr. has not thrown
me out the door after telling him exactly how he
is supposed to do things right, LOL.Squiggles
Posted by jrbecker on May 11, 2003, at 10:35:28
In reply to Re: Remeron rocks for treatment-resistant unipolar » jrbecker, posted by SLS on May 11, 2003, at 9:24:35
Remeron made me feel terrible at first. The sedation was so overwhelming, that depsite an underlying sense of mood lift, the sedation itself was almost too much to take. Thankfully, this passes relatively quickly in the first couple of days and continues to decrese longitudinally over time. There is some irritability at first as well, probably due the activity at the 5HT2 receptors. This passes relatively soon as well. Longterm, anybody that has the fortitude to try and stay on it more than two months will find that most of the sedation vanishes. This is probably a fairly subjective thing though.
As for alpha-2 antagonism as a possible depressant mechanism, you might have something there. Since having a great experience with effexor as my first NE drug, I've been trying to find a comfortable fit with a drug that modulates NE, but in a more "soft" way. It is my belief that NE reuptake (or 5HT reuptake for that matter) is a pretty rough way to increase NE. Those familiar with effexor and strattera can attest to that. It's my belief that alpha-2 antagonism is a much more fine-tuned way to modulate NE release (and you get a little dopamine out of it to boot). Consequently, I've experimented with a lot of supplements (pregnenolone, dhea, etc) that modulate alpha-2 antagonism. Tx success has had mixed results from this. Take DHEA for example, although it definitely helps my mood, motivation, and energy level, I walk a fine line before it makes me irritability, anxious, and rageful -- and this is at 1-5 mg doses. Could the alpha-2 antagonism be the culprit? Quite possibly. Experiments like this have lead me to believe that I have minor bipolar tendencies and that an acute sensitivity to dopamine is an important factor in my anhedonic depression (trials with stimulants, nicotine and other supplements seem to corroborate this).
What does this mean for taking remeron? Absolutely nothing. I have had really no issues at all with anger or anxiousness or a decrease in mood for that matter. And since remeron is doing so many things biochemically at once, it's really impossible to attribute any effect to just one thing its modulating. I just know it works.
As for bipolars trying remeron, my doc said that remeron can induce mania. But in reality, this is probably a more stable drug than the SSRIs to be on. I feel very focused and calm on it. Maybe it's b/c of the 5HT2A and C antagonism -- the latter being implicated in bipolarity and the former having some sort of weak antipsychotic effect. At high doses, it's possible that the alpha-2 antagonism could trigger mania, but I believe that this is somehow being kept in check at lower doses by the 5HT 2 & 3 antagonism (and possibly by the decrese in cortisol levels). Just my own speculation though.
Back to the alpha-2 discussion. I think it's only a matter of time before they figure out an even more specific mechanism to hit for more NE modulation. For instance, I've read about one company concetrating on alpha-2c antagonism for depression. Eventually, they're gonna provide a better roadmap for these subreceptors and we'll be all the better for it.
last thing on remeron. If you're going to try it, i think you really have to be ready to spend a month ready to acclimate to it. It can be a tough go and no picnic at first. That should definitely factor into your decision.
JB
Posted by McPac on May 11, 2003, at 13:56:45
In reply to Re: Remeron rocks for treatment-resistant unipolar, posted by jrbecker on May 11, 2003, at 10:35:28
I am trying to increase my Remeron so that I can DEcrease my Zoloft. Here is the problem. I've been taking Remeron for quite a while for insomnia (7.5 mg/night...very low dose). About a year ago, my doc raised the dose from 7.5 to 45 mg---IN ONE JUMP!!!!!! Extreme jitteriness, nervousness, Very rapid heartbeat...I could not handle that norepinephrine (adrenaline) effect! So, here I am now, about a year later, wanting to give the Remeron another shot BUT by gradually increasing the dose (and maybe not even needing 45mg). Well, I just increased the Remeron dose from 7.5mg to 22.5mg (half of a 45mg tablet) for the past 2 nights. Geez, already I feel more jittery and also MORE IRRITABLE. I just read a previous post by jr that mentioned, quote, "There is some irritability at first as well....This passes relatively soon as well". Okay, now here is where I could really use some advice---how long before this irritability is likely to last? Should I drop down to 15mg and take that for awhile (I've taken 15mg before and that did NOT make me jittery/irritable) AND THEN try the 22.5mg? Would it be best/make a difference to simply raise the dosage very slowly and very gradually rather than "jumping" in bigger increments? Based on my extreme jitters/nervousness at 45mg last year, I really don't know if I can handle 45mg...I hope I can at least handle 30mg....but first I've got to handle 22.5! IF I KNEW that this "jittery/irritable" effect would diminish or go away relatively soon (how long??) I would just stay on 22.5 and get this stage over with...and then try 30mg. (Do you guys think that even the 45mg EXTREME "jitters/nervousness" would go away eventually OR would that increased NE effect simply continue to be a problem for me as long as I kept taking the Remeron at that dose?) THANK YOU ALL!!!!
Posted by jrbecker on May 11, 2003, at 17:30:38
In reply to JR, SLS, Squiggles,observer, help. Remeron rocks , posted by McPac on May 11, 2003, at 13:56:45
I echo what squiggles and observer stated.
I have no experience with the jump from 15mg to 30mg since I started at 30 to begin with. As for the jump from 30mg to 45mg, it was slightly jarring for me. I would take the Soltabs before bed, and about an hour or so after taking it, I would wake up totally wired and fidgety, despite feeling slightly sedated. Usually having a small snack helped to calm me back down. Daytime agitation was minimal, although I definitely felt a little more revved. This transition period lasted about a week for me and then went much smoother.JB
Posted by Jack Smith on May 12, 2003, at 16:13:18
In reply to JR, SLS, Squiggles,observer, help. Remeron rocks , posted by McPac on May 11, 2003, at 13:56:45
Wondering what people think of this combo? I have seen just about nothing on it here or anywhere.
Wellbutrin has always been pretty neutral, energy wise with me. I know many find it activating. I wonder how the dopamine and norardrenaline effect of WB would interact with REmeron. Noone has ever been able to fully explain how WB works and I still think it is poorly understood. Anyone have experience with this combo?
This is the end of the thread.
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