![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 17 of 17. This is the beginning of the thread.
Posted by sundown on November 13, 2004, at 1:19:17
I seem to have chronic mild depression which anti-depressants do little to change. But I believe now that a more basic anhedonic tendency is the real problem. I have been anhedonic as long as I can remember.
Does anyone have any treatment suggestions. I am currently taking 20mg of Lexapro and it did give me more energy. But I still am unable to enjoy myself and feel good.
Posted by anxiety_free on November 13, 2004, at 2:32:35
In reply to Long-standing Anhedonia, posted by sundown on November 13, 2004, at 1:19:17
Hi! Sorry about your situation. I had a similar problem, which has vastly improved. In terms of meds, you might want to try a tricyclic. Yes, they're old,dirty drugs, but they can do wonders for endogenous depression. Secondly, see if your doc will provide you with a stimulant. Provigil helps some with depression; personally, I responded to Ritalin and later Adderall. Regulating the sleep/wake cycle helped me, too...if you have any insomnia at all, get a stash of sleeping pills. An anti-anxiety drug can help loosen you up a bit while smoothing out the edges of any stimulants...benzos are good, most docs will probably go the BuSpar route first. Exercise helped me as well, as did meditation, occasional fasting, etc. Back to your meds...lexapro is a great AD, but I still seriously recommend a TCA...one can probably be added to your current therapy. Good luck!
Posted by alexandra_k on November 13, 2004, at 3:30:47
In reply to anhedonia, posted by anxiety_free on November 13, 2004, at 2:32:35
Hi there. I have dysthymia (chronic low grade depression) and I am on Effexor (for anxiety / depression) and Olanzapine (for sleep and anxiety). What I have found to be most helpful for that, however (in combination with meds) is psychotherapy, and (much as I hate to admit it) things such as activity scheduling (Ugh).
I worry about meds as they can become a 'quick fix' and thus ultimately addicitve 'solution'. I have found that the meds that work well work too well, and the last thing I need is a new addiction.
I hope you feel better soon... :-)
Posted by jlbl2l on November 13, 2004, at 3:46:31
In reply to Long-standing Anhedonia, posted by sundown on November 13, 2004, at 1:19:17
I have another medicine you want to try and that is Lyrica (pregabalin). It should be literally on the shelves within a few months hopefuly in the USA, butits available in Europe. It has done wonders for my low grade depression. Until you can get it, you may want to try its predessor, Neurontin at the higher dose range.
As another poster suggested, Provigil works very well. 100-400mg range but you might have trobule sleeping unless you have sleep meds.
My final suggestion which is relavent to probably half the people here is that you have some sort of chronic infection or immune abnormality. I would get a very comprehensive panel for numerous diseases, + CBC/diff etc, Thyroid etc... Inflammation is a huge cause of low grade depression and anxiety that is not realized in the medical community.
A trial of the antibiotic minocycline sometimes is a cheap way of determining this.
All the best,
JLBl2l
Posted by King Vultan on November 13, 2004, at 11:21:13
In reply to Long-standing Anhedonia, posted by sundown on November 13, 2004, at 1:19:17
> I seem to have chronic mild depression which anti-depressants do little to change. But I believe now that a more basic anhedonic tendency is the real problem. I have been anhedonic as long as I can remember.
>
> Does anyone have any treatment suggestions. I am currently taking 20mg of Lexapro and it did give me more energy. But I still am unable to enjoy myself and feel good.
I've also suffered from anhedonia for years, with it perhaps being the major contributing cause to my depression. Typically, the more dopaminergic drugs seem to be indicated for what you are describing. While most of the antidepressants I've tried brightened by mood, only a few of them seemed to really be effective for my fundamental anhedonia. The two that I found to be the best in this area were Wellbutrin and Parnate, and Parnate is the med I am currently on and will likely be staying with for the forseeable future. As suggested, a tricyclic might also be worth trying. Nortriptyline has shown some efficacy in smoking cessation (as has Wellbutrin, which is the same thing as Zyban), indicating it may have some positive effects on dopamine transmission, and hence in relieving anhedonia. Nortriptyline also has fairly low side effects for a tricyclic. I think the Provigil that has been mentioned is also a good suggestion, as this also appears to be somewhat dopaminergic; although, precisely how it works does not seem to be particularly well understood.Todd
Posted by Shalom34Israel on November 13, 2004, at 14:29:05
In reply to Long-standing Anhedonia, posted by sundown on November 13, 2004, at 1:19:17
> I seem to have chronic mild depression which anti-depressants do little to change. But I believe now that a more basic anhedonic tendency is the real problem. I have been anhedonic as long as I can remember.
>
> Does anyone have any treatment suggestions. I am currently taking 20mg of Lexapro and it did give me more energy. But I still am unable to enjoy myself and feel good.anhedonia is relieved more by dopaminergic medications than serotonin drugs. But if you have been that way as long as you can remember, treatment maybe difficult.
Shalom
Posted by sundown on November 14, 2004, at 1:22:44
In reply to anhedonia, posted by anxiety_free on November 13, 2004, at 2:32:35
Thanks to all who posted information and suggestions. I now have several avenues to explore. I am really impressed with the posters on this board, your knowledge and thoughtfulness.
Patricia
Posted by robot on November 14, 2004, at 20:03:14
In reply to Re: Long-standing Anhedonia, posted by Shalom34Israel on November 13, 2004, at 14:29:05
"Many drugs are relatively selective for one of the monoaminergic systems—for example, serotonin for the SSRIs and norepinephrine for reboxetine and desipramine. However, before we assume that these agents are truly selective, it is important to keep in mind that there is considerable co-localization and "cross-talk" of monoamines in the central nervous system (54). That is, monoamines are mutually regulating. Norepinephrine itself as well as norepinephrine selective reuptake inhibitors (NSRIs) enhance the release of both dopamine and serotonin in the forebrain (55).
The effect of NSRIs on serotonin and dopamine may be explained by the observation that norepinephrine, acting through alpha1 receptors, can induce release of these transmitters (54). However, in addition, the norepinephrine transporter protein—the reuptake site—also has high affinity for the reuptake of dopamine (56). Thus NSRIs are, in effect, dopamine reuptake inhibitors as well. This concept is supported by Karson's finding (57) that spontaneous blink rates—as noted, a putative measure of forebrain dopamine activity—were elevated among depressed patients who were taking tricyclic antidepressants. Thus enhancement of norepinephrine transmission—by reuptake blockade or by a reduction in the metabolism of norepinephrine by inhibition of monoamine oxidase—would be expected to induce an enhancement of arousal via the norepinephrine mechanisms (58) but also to enhance reward acquisition—that is, motivation—through actions on dopaminergic systems.
The interplay of serotonin with norepinephrine and dopamine is more complicated because of the complexity of the serotonin receptor system relative to the catecholamines. For example, serotonin has been shown to both enhance and inhibit dopaminergic activity in the frontal cortex and nucleus accumbens, depending on the type of serotonin receptor subtype that is activated (21). The inhibition of dopamine by serotonin—primarily via 5-HT2C receptors (59,60,61)—may explain why highly selective SSRIs have been shown to reduce dopamine release in the frontal cortex or nucleus accumbens (62,63) and reward acquisition in animals (64,65,66).
This effect may parallel the mood-flattening effect of these agents among some patients and is consistent with the concept of a link between serotonin and constraint of dopaminergic systems as posited by Depue and colleagues (40). Clinically, it is important to keep in mind that not all patients who are treated with SSRIs will experience a flattening effect. However, it has been our observation that when a therapeutic failure occurs with one of these agents, it is often the result of a lack of improvement in the anhedonia experienced by many depressed patients."
http://ps.psychiatryonline.org/cgi/content/full/52/11/1469?
> > I seem to have chronic mild depression which anti-depressants do little to change. But I believe now that a more basic anhedonic tendency is the real problem. I have been anhedonic as long as I can remember.
> >
> > Does anyone have any treatment suggestions. I am currently taking 20mg of Lexapro and it did give me more energy. But I still am unable to enjoy myself and feel good.
>
> anhedonia is relieved more by dopaminergic medications than serotonin drugs. But if you have been that way as long as you can remember, treatment maybe difficult.
>
> Shalom
Posted by jujube on November 15, 2004, at 9:52:22
In reply to anhedonia, posted by anxiety_free on November 13, 2004, at 2:32:35
Would any of the TCAs be effective? I have just been prescribed Anafranil, and am hoping it will help with my anhedonia. I had actually hoped to get Nortryptiline, but my pdoc prefers Anafanil. Also, do you know if a TCA can be safey augmented with Provigil? I had asked my pdoc about Provigil, but he didn't want to put me on it. The next time I see him I may raise it again if I am not getting a sufficient response from the Anafranil.
Thanks.
Tamara
> Hi! Sorry about your situation. I had a similar problem, which has vastly improved. In terms of meds, you might want to try a tricyclic. Yes, they're old,dirty drugs, but they can do wonders for endogenous depression. Secondly, see if your doc will provide you with a stimulant. Provigil helps some with depression; personally, I responded to Ritalin and later Adderall. Regulating the sleep/wake cycle helped me, too...if you have any insomnia at all, get a stash of sleeping pills. An anti-anxiety drug can help loosen you up a bit while smoothing out the edges of any stimulants...benzos are good, most docs will probably go the BuSpar route first. Exercise helped me as well, as did meditation, occasional fasting, etc. Back to your meds...lexapro is a great AD, but I still seriously recommend a TCA...one can probably be added to your current therapy. Good luck!
Posted by anxiety_free on November 16, 2004, at 15:02:46
In reply to Re: anhedonia » anxiety_free, posted by jujube on November 15, 2004, at 9:52:22
Hey! I think Anafranil may very well help you, although its a kind of odd choice for anhedonia (its the official TCA for obsessive compulsive disorder). Anyway, if it doesn't, ask about Tofranil and/or Tofranil PM...most docs seem comfy with Tofranil, since it was the first tricyclic and has been around forever. The PM version is newer, its what I take...if your insurance will cover it, I'd whole-heartedly recommend the PM version. Tricyclics can be and have been augmented by stimulants..I personally take 60mgs of adderall a day, along with another AD. Some docs are a bit wary of this kind of combo, but its pretty common....I would think that, especially with Provigil, your doc would flexible. Other than that...if all else fails to ease your depression/anhedonia, you can try mood-stabilizers, maybe anti-psychotics...but personally I think more stimulation would help you more. What drug combos have you tried in the past? Did any help, even for a little while? Did any worsen the situation? I'm just curious. Good luck!
Posted by sundown on November 16, 2004, at 17:46:10
In reply to TCAs, posted by anxiety_free on November 16, 2004, at 15:02:46
What is it about tricyclics that makes then better for treating depression and anhedonia than the SSRI's? I take it that tricyclics are serotonin-norepinephrine reuptake inhibitors (maybe I'm wrong) but I'm not sure about the role of norepinephrine. I read somewhere that it enhances the release of both dopamine and serotonin. Is it the dopamine release that provides the relief of anhedonia?
Patricia
Posted by pablo1 on November 17, 2004, at 11:35:55
In reply to Re: Long-standing Anhedonia, posted by robot on November 14, 2004, at 20:03:14
What robot is saying is that norepenephrine meds like wellbutrin may increase dopamine also and some antidepressants (SSRI's) will decrease dopamine making the anhedonia worse. Effexor sucked all the dopamine out of me, I could tell because when I quit I had an amazing dopamine high for a couple weeks! Zoloft does not seem to be doing that to me in fact I think it increases doppamine slightly and I'm also taking some ritalin along with it.
I've also tried amisulpride and ameneptine for pure dopamine action and those were very effective against the anhedonia giving me a whole new sense of being able/interested in seeking pleasure in life. Unfortunately those are not available in the US, presumably because they feel good and we are a nation of prudes.
Posted by jujube on November 17, 2004, at 15:13:04
In reply to TCAs, posted by anxiety_free on November 16, 2004, at 15:02:46
Thanks for the response! I have only ever been on one antidepressant at a time. Actually, until the beginning of this year, Paxil had been my first and only antidepressant. I stopped Paxil a couple of years ago, and when I tried it again, it didn't work. I had raised Tofranil and Nortriptyline with the pdoc, but he seems to like Anafranil. I am going to give it a try. I took my first dose (25 mg) Sunday night, and will increase to 50 mg after 7 days at 25 mg. Unlike the other 4 ADs that I have tried since January, I think I am only going to give this one a 4 week trial, although my doc usually prefers 6 - 8 week trial. If I don't have a least a moderate response within a month, I will ask for Tofranil. I will also try to be more assertive about a stimulant, although I am thinking of trying some natural things in the meantime like Enada NADH, ALC and possibly DMAE or TMG.
Thanks again. Take care.
Tamara
> Hey! I think Anafranil may very well help you, although its a kind of odd choice for anhedonia (its the official TCA for obsessive compulsive disorder). Anyway, if it doesn't, ask about Tofranil and/or Tofranil PM...most docs seem comfy with Tofranil, since it was the first tricyclic and has been around forever. The PM version is newer, its what I take...if your insurance will cover it, I'd whole-heartedly recommend the PM version. Tricyclics can be and have been augmented by stimulants..I personally take 60mgs of adderall a day, along with another AD. Some docs are a bit wary of this kind of combo, but its pretty common....I would think that, especially with Provigil, your doc would flexible. Other than that...if all else fails to ease your depression/anhedonia, you can try mood-stabilizers, maybe anti-psychotics...but personally I think more stimulation would help you more. What drug combos have you tried in the past? Did any help, even for a little while? Did any worsen the situation? I'm just curious. Good luck!
Posted by gromit on November 17, 2004, at 19:36:19
In reply to Re: Long-standing Anhedonia » robot, posted by pablo1 on November 17, 2004, at 11:35:55
> I've also tried amisulpride and ameneptine for pure dopamine action and those were very effective against the anhedonia giving me a whole new sense of being able/interested in seeking pleasure in life. Unfortunately those are not available in the US, presumably because they feel good and we are a nation of prudes.
What is the approximate cost of amisulpride? Has anyone here imported it legally with a prescription?
Thanks
Rick
Posted by sundown on November 17, 2004, at 20:41:30
In reply to Re: Long-standing Anhedonia, posted by robot on November 14, 2004, at 20:03:14
Robot,
I tried this post once before and it got lost, so here it is again.
Just want to thank you for the excellent reference to that study on depression and anhedonia and their treatments. I'll insert it again here because I really recommend it to anyone who, like me, was lost in a sea of terminology.
http://ps.psychiatryonline.org/cgi/content/full/52/11/1469?
I understand so much more now, and I can approach my medication analytically instead of trial and error. This was a great contribution to my search. Thank you. Patricia
Posted by pablo1 on November 17, 2004, at 22:37:22
In reply to Re: Long-standing Anhedonia, posted by gromit on November 17, 2004, at 19:36:19
It is not legal to import thought it is not illegal to possess, the crime lies in the seller's hands as I understand. It used to be possible to send a US prescription to order from Europe but those days are over and it's all grey market now. I don't even have a source now, it came through canada but that was a short term availability.
Posted by gromit on November 19, 2004, at 19:37:18
In reply to Re: Long-standing Anhedonia, posted by pablo1 on November 17, 2004, at 22:37:22
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.