![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 6 to 30 of 30. Go back in thread:
Posted by SLS on January 21, 2009, at 6:59:23
In reply to Re: Desipramine vs Strattera for adult ADD., posted by linkadge on January 20, 2009, at 22:07:12
The key to understanding the risks involved are to compare the rate of observed cardiac related deaths reported from desipramine to those seen in the general public.
This piece claims that they are equal.
"Wayne H. Green, M.D., in 1995, published that "The American Academy of Child and Adolescent Psychiatry's Ad Hoc Committee on Desipramine and Sudden Death, established to investigate these concerns, reported at a members' forum at the 1992 Annual Convention that the risk of sudden death for children 5 to 14 years old who are treated with desipramine in therapeutic doses is approximately the same as the risk of sudden death for similarly aged children in the general population, between 1.5 and 4.2 [deaths per] million/year (P>0.23)."
http://www.addmtc.com/desipramine
- Scott
Posted by jrbecker76 on January 21, 2009, at 19:05:16
In reply to Re: Desipramine vs Strattera for adult ADD., posted by SLS on January 21, 2009, at 6:59:23
as an aside, i find it interesting that eli lilly is putting their money on a "second generation" norepinephrine reuptake inhibitor (LY 2216684) to eventually replace both Straterra for ADHD and Cymbalta for depression. The mechanism of noradrenergic reuptake inhibition for either depression or adhd indications has proven to be less than impressive though, so I'm curious to see just how much more efficacious a new compound can elevate itself above reboxetine or atomoxetine.
Posted by SLS on January 22, 2009, at 6:37:11
In reply to Re: Desipramine vs Strattera for adult ADD., posted by jrbecker76 on January 21, 2009, at 19:05:16
Two things occur to me:
1. I have personally seen Strattera work a miracle for a middle aged man with ADD who was originally diagnosed with depression. He went through drug after drug without success. He was unemployed and behaviorally challenged. Within a month of starting Strattera (atomoxetine), he reported feeling "normal" for the first time in his life. He found an apartment and a job. One drug. My point here is that statistically, it might be that atomoxetine does not help as many people as psychostimulants do - although I have seen no evidence that is true - but when it works, it can produce robust improvements in ADD.
2. A NE reuptake inhibitor is not a NE reuptake inhibitor, etc. Surely, atomoxetine, desipramine, reboxetine, viloxazine, and nisoxetine all have different clinical profiles. Preclinical studies demonstrated that they all had antidepressant properties during development. Clearly, atomoxetine and reboxetine are not as potent as desipramine when treating depression. So, different is different. Here, I suggest that it is not only what a drug does neurochemically that matters, but also where it does it. Atomoxetine accumulates in the prefrontal cortex more than it does elsewhere. This is probably why it is not an effective antidepressant for most people. Here, its inhibition of the NE transporter results in a simultaneous rise in diffused interstitial dopamine as it is taken up by the NE transporter there. I think one needs to look at the localization of drugs in the brain and the circuits they represent. Determining circuitry is equally important to determining what neurotransmitters and receptors facilitate those circuits.
- Scott
Posted by desolationrower on January 23, 2009, at 2:21:41
In reply to Re: Desipramine vs Strattera for adult ADD., posted by SLS on January 22, 2009, at 6:37:11
what makes you think attomoxetine accumlate preferentially in the pfc as compared to desip or whatever?
-d/r
Posted by SLS on January 23, 2009, at 3:10:01
In reply to Re: Desipramine vs Strattera for adult ADD., posted by desolationrower on January 23, 2009, at 2:21:41
> what makes you think attomoxetine accumlate preferentially in the pfc as compared to desip or whatever?
>
> -d/r
I thought I recalled reading that in one of Stephen Stahl's Brainstorm publications. Perhaps I am mistaken.
- Scott
Posted by SLS on January 23, 2009, at 3:17:40
In reply to Re: Desipramine vs Strattera for adult ADD. » desolationrower, posted by SLS on January 23, 2009, at 3:10:01
> > what makes you think attomoxetine accumlate preferentially in the pfc as compared to desip or whatever?
> >
> > -d/r
>
>
> I thought I recalled reading that in one of Stephen Stahl's Brainstorm publications. Perhaps I am mistaken.There is evidence that individual drugs accumulate differentially across different brain regions, and that this might explain the differences in clinical outcome between two NE reuptake inhibitors. I did find something on cocaine during a quick search on Google:
" Article
Cocaine disposition in discrete regions of rat brain
Dr J. I. Javaid *, J. M. Davis
Illinois State Psychiatric Institute and Department of Psychiatry, University of Illinois at Chicago*Correspondence to J. I. Javaid, Illinois State Psychiatric Institute, 1153 N. Lavergne Ave, Chicago, Il 60651, U.S.A.
Keywords
Cocaine levels Brain regions Serum Disposition KineticsAbstract
It has been proposed that various effects of psychoactive drugs on the central nervous system may be related to the capacity of the drug to selectively concentrate in specific regions of the brain. In rat brain, cocaine effects on striatal and nucleus accumbens dopaminergic systems show quantitative differences. However, the disposition of cocaine in various brain regions has not been reported. In the present studies we examined the cocaine concentrations over time in serum and discrete brain regions of the rat after single intraperitoneal (i.p.) injection. At different time points (5, 10, 20, 30, 60, 120, and 240 min) after i.p. injection of cocaine hydrochloride (10 mg kg-1, free base) the rats were decapitated and cocaine in serum and various brain regions was quantitated by a specific gas liquid chromatographic method. There was large inter-individual variability in different rats at each time-point. The disposition pattern of cocaine in rats after i.p. administration was similar to that observed in humans after intranasal administration. Initial absorption rate was rapid and, on average, the peak levels of cocaine were achieved in 10 min. The cocaine levels remained relatively high over the next 50 min indicating continual absorption, and then declined with a rate such that the levels 4 h after cocaine administration were undetectable in most of the animals. The overall changes in cocaine levels in various brain regions paralleled the serum concentrations. The area under the cocaine concentration-time curve (AUC) revealed more than three-fold differences in cocaine accumulation in various brain regions. This unequal disposition of cocaine may be responsible in part for differential biochemical effects in different brain regions.
Received: 14 May 1992; Revised: 30 September 1992"
http://www3.interscience.wiley.com/journal/112402840/abstract?CRETRY=1&SRETRY=0
- Scott
Posted by desolationrower on January 23, 2009, at 13:03:52
In reply to Re: Desipramine vs Strattera for adult ADD. » desolationrower, posted by SLS on January 23, 2009, at 3:10:01
Thanks; i guess it seems to me like backward rationlization; attomoxetine doesn't work as an antidepressant (KOR), so it was marketed as a 'non-stimulant' ADHD treatment, whereas desipramine is in a class of drugs known as antidepressants. So its tempting to think they each work differently.
also, i think NET occupancy is pretty high, its not like a AP or stimulant where you are aiming for a narrow range, i think reuptake inihibitors are usually dosed to the point where its becoming asymtotic with full occupancy
-d/r
Posted by SLS on January 23, 2009, at 20:10:51
In reply to Re: Desipramine vs Strattera for adult ADD., posted by desolationrower on January 23, 2009, at 13:03:52
> ...asymtotic...
Damn you. Make me go look up a word.
:-)
You make good points.
- Scott
Posted by psychobot5000 on January 23, 2009, at 22:11:59
In reply to Re: Desipramine vs Strattera for adult ADD., posted by Incubusfan on January 20, 2009, at 18:16:25
> I'm interested to see responses on this as well. I suffer from anxiety and ADD. What would be a good medication/cocktail for this? SSRIs don't help.
>
> Thanks.I'm tempted to suggest Agomelatine. It helps me pay attention at work, and is good for most of my anxiety.
Posted by psychobot5000 on January 23, 2009, at 22:23:52
In reply to Re: Desipramine vs Strattera for adult ADD., posted by SLS on January 22, 2009, at 6:37:11
>
>
> 2. A NE reuptake inhibitor is not a NE reuptake inhibitor, etc. Surely, atomoxetine, desipramine, reboxetine, viloxazine, and nisoxetine all have different clinical profiles. Preclinical studies demonstrated that they all had antidepressant properties during development. Clearly, atomoxetine and reboxetine are not as potent as desipramine when treating depression. So, different is different. Here, I suggest that it is not only what a drug does neurochemically that matters, but also where it does it. Atomoxetine accumulates in the prefrontal cortex more than it does elsewhere. This is probably why it is not an effective antidepressant for most people. Here, its inhibition of the NE transporter results in a simultaneous rise in diffused interstitial dopamine as it is taken up by the NE transporter there. I think one needs to look at the localization of drugs in the brain and the circuits they represent. Determining circuitry is equally important to determining what neurotransmitters and receptors facilitate those circuits.
>
>
> - Scott
>Thought my own experience might be slightly useful, at least in confirming this idea of differences among NRIs. I haven't taken Desipramine, but I've taken nortriptyline, Strattera, and Reboxetine, and they all felt very different. Nortrip felt like...a TCA, for the most part. Reboxetine made me unpleasantly wired, and did not noticeably help with attention. Strattera gave me very mild euphoria (or relative euphoria) combined with sleepiness during the first two days' treatment. Without that sleepiness, it might have been helpful for inattention. But in any case, the positive effects (the mild euphoria, mostly) disappeared completely within three days, leaving only the bizarre sedation. It was an odd experience.
Sorry I can't comment directly on Desipramine. But those NRIs felt qualitatively very different from each other.
Posted by SLS on January 24, 2009, at 8:50:12
In reply to Re: Desipramine vs Strattera for adult ADD. » Incubusfan, posted by psychobot5000 on January 23, 2009, at 22:11:59
> > I'm interested to see responses on this as well. I suffer from anxiety and ADD. What would be a good medication/cocktail for this? SSRIs don't help.
> >
> > Thanks.
>
> I'm tempted to suggest Agomelatine. It helps me pay attention at work, and is good for most of my anxiety.
>
I wish I knew how you guy got your hands on that stuff.Thanks for sharing your experiences. It is most helpful.
- Scott
Posted by SLS on January 24, 2009, at 10:09:09
In reply to Re: Desipramine vs Strattera for adult ADD. » SLS, posted by psychobot5000 on January 23, 2009, at 22:23:52
> > 2. A NE reuptake inhibitor is not a NE reuptake inhibitor, etc. Surely, atomoxetine, desipramine, reboxetine, viloxazine, and nisoxetine all have different clinical profiles. Preclinical studies demonstrated that they all had antidepressant properties during development. Clearly, atomoxetine and reboxetine are not as potent as desipramine when treating depression. So, different is different. Here, I suggest that it is not only what a drug does neurochemically that matters, but also where it does it. Atomoxetine accumulates in the prefrontal cortex more than it does elsewhere. This is probably why it is not an effective antidepressant for most people. Here, its inhibition of the NE transporter results in a simultaneous rise in diffused interstitial dopamine as it is taken up by the NE transporter there. I think one needs to look at the localization of drugs in the brain and the circuits they represent. Determining circuitry is equally important to determining what neurotransmitters and receptors facilitate those circuits.
> Thought my own experience might be slightly useful, at least in confirming this idea of differences among NRIs. I haven't taken Desipramine, but I've taken nortriptyline, Strattera, and Reboxetine, and they all felt very different. Nortrip felt like...a TCA, for the most part. Reboxetine made me unpleasantly wired, and did not noticeably help with attention. Strattera gave me very mild euphoria (or relative euphoria) combined with sleepiness during the first two days' treatment. Without that sleepiness, it might have been helpful for inattention. But in any case, the positive effects (the mild euphoria, mostly) disappeared completely within three days, leaving only the bizarre sedation. It was an odd experience.
>
> Sorry I can't comment directly on Desipramine. But those NRIs felt qualitatively very different from each other.Desipramine has always managed to make me feel better with more energy, even if only for a few days before pooping-out. It has never been noxious to me. I became suicidal on reboxetine. It came over me very quickly and included a disgusting type of anxiety. Suicidality resolved within 36 hours of discontinuing the drug. Strattera did nothing for me. Oh, wait a minute, yes it did. It made me feel tired, sleepy and fatigued.
- Scott
Posted by bulldog2 on January 24, 2009, at 11:21:41
In reply to Re: Desipramine vs Strattera for adult ADD. » psychobot5000, posted by SLS on January 24, 2009, at 10:09:09
> > > 2. A NE reuptake inhibitor is not a NE reuptake inhibitor, etc. Surely, atomoxetine, desipramine, reboxetine, viloxazine, and nisoxetine all have different clinical profiles. Preclinical studies demonstrated that they all had antidepressant properties during development. Clearly, atomoxetine and reboxetine are not as potent as desipramine when treating depression. So, different is different. Here, I suggest that it is not only what a drug does neurochemically that matters, but also where it does it. Atomoxetine accumulates in the prefrontal cortex more than it does elsewhere. This is probably why it is not an effective antidepressant for most people. Here, its inhibition of the NE transporter results in a simultaneous rise in diffused interstitial dopamine as it is taken up by the NE transporter there. I think one needs to look at the localization of drugs in the brain and the circuits they represent. Determining circuitry is equally important to determining what neurotransmitters and receptors facilitate those circuits.
>
> > Thought my own experience might be slightly useful, at least in confirming this idea of differences among NRIs. I haven't taken Desipramine, but I've taken nortriptyline, Strattera, and Reboxetine, and they all felt very different. Nortrip felt like...a TCA, for the most part. Reboxetine made me unpleasantly wired, and did not noticeably help with attention. Strattera gave me very mild euphoria (or relative euphoria) combined with sleepiness during the first two days' treatment. Without that sleepiness, it might have been helpful for inattention. But in any case, the positive effects (the mild euphoria, mostly) disappeared completely within three days, leaving only the bizarre sedation. It was an odd experience.
> >
> > Sorry I can't comment directly on Desipramine. But those NRIs felt qualitatively very different from each other.
>
> Desipramine has always managed to make me feel better with more energy, even if only for a few days before pooping-out. It has never been noxious to me. I became suicidal on reboxetine. It came over me very quickly and included a disgusting type of anxiety. Suicidality resolved within 36 hours of discontinuing the drug. Strattera did nothing for me. Oh, wait a minute, yes it did. It made me feel tired, sleepy and fatigued.
>
>
> - ScottHow about a time released version of ritalin. It's a reuptake inhibitor and I believe can be safely used with parnate.
Or go back to nortriptyline since it worked!
Posted by SLS on January 24, 2009, at 11:30:53
In reply to Re: Desipramine vs Strattera for adult ADD., posted by bulldog2 on January 24, 2009, at 11:21:41
Bulldog2:
> Or go back to nortriptyline since it worked!
Your concern is very, very much appreciated.
I may have given the wrong impression that I am not responding to desipramine. I am responding very well at 200mg, but 300mg is my sweet-spot. I am forced to follow my doctor's orders on this one. I might not feel great for a few weeks yet. I feel better on desipramine than I did on nortriptyline. I have more energy and motivation. Plus, my brain woke up to some extent. You know, I think nortriptyline made me feel too content and laid-back. I never felt a need to do anything but sit around. I'm sure it isn't like that for everyone.
> How about a time released version of ritalin. It's a reuptake inhibitor and I believe can be safely used with parnate.
That's a great idea. I am sure that it is safe, as I have been on that combination before. The thing that is different for me this time around is Abilify and Lamictal.
- Scott
Posted by theo on January 25, 2009, at 19:52:43
In reply to Re: Desipramine vs Strattera for adult ADD., posted by Incubusfan on January 20, 2009, at 18:16:25
I suffer from anxiety and ADD. What would be a good medication/cocktail for this? SSRIs don't help.
>
> Thanks.I here Imipramine is good for this, but my doc keeps saying "I don't think you'll like the side effects," so I've been hesitant to try it.
Posted by Incubusfan on January 26, 2009, at 22:29:42
In reply to Re: Desipramine vs Strattera for adult ADD. » Incubusfan, posted by theo on January 25, 2009, at 19:52:43
Yeah, the side effects of it don't seem as mild as Desipramine.
I've decided I'm going to ask my pdoc to try Desipramine + Wellbutrin. Considering he's prescribed me everything from SSRIs, to MAOIs, to benzos and stimulants, I can't see him saying no :)
Posted by SLS on January 27, 2009, at 7:24:42
In reply to Re: Desipramine vs Strattera for adult ADD., posted by Incubusfan on January 26, 2009, at 22:29:42
> Yeah, the side effects of it don't seem as mild as Desipramine.
>
> I've decided I'm going to ask my pdoc to try Desipramine + Wellbutrin. Considering he's prescribed me everything from SSRIs, to MAOIs, to benzos and stimulants, I can't see him saying no :)Is there any chance that you might be bipolar?
If this combination produces even a small improvement, you might want to try to build upon it by adding Lamictal first, and then possibly an atypical AP like Geodon or Abilify.
We'll see.
- Scott
Posted by incubusfan5 on January 27, 2009, at 10:52:00
In reply to Re: Desipramine vs Strattera for adult ADD. » Incubusfan, posted by SLS on January 27, 2009, at 7:24:42
> > Yeah, the side effects of it don't seem as mild as Desipramine.
> >
> > I've decided I'm going to ask my pdoc to try Desipramine + Wellbutrin. Considering he's prescribed me everything from SSRIs, to MAOIs, to benzos and stimulants, I can't see him saying no :)
>
> Is there any chance that you might be bipolar?
>
> If this combination produces even a small improvement, you might want to try to build upon it by adding Lamictal first, and then possibly an atypical AP like Geodon or Abilify.
>
> We'll see.
>
>
> - ScottI really don't know if I could be bipolar. If anything I'd probably be BP-II.
A couple of friends once made up a thing about me having "four seasons". In one season I'd work all the time, another I'd just relax and play games, another I'd do school hardcore, and lastly, I'd just hang out with people and chase girls.
My biggest issues are a constant anxiety and depression. Social anxiety is still there, but not quite as bad.
I was on Lamictal briefly, but quit because even the generic is extremely expensive. I don't have any health insurance, as I haven't been able to work for a year now. I do have money in the bank, but I fear that I'll spend all my money on medication and doctors, nothing will work, and I'll be broke and still sick.
Well, I've never tried TCAs before, so it's worth it to try at least a couple of them. I wasn't on Wellbutrin for long(14 days), but had no side effects at 150mg except excessive REM sleep and some tiredness in the morning.
My doctor wants me to try Seroquel, which my brother actually told me was the only thing to work on his anxiety. He couldn't deal with the weight gain/hunger and sedation though.
Thanks Scott, I always find your posts to be informative.
Posted by JadeKelly on January 31, 2009, at 10:53:53
In reply to Re: Desipramine vs Strattera for adult ADD. » SLS, posted by incubusfan5 on January 27, 2009, at 10:52:00
So if ADD were the primary concern, and depression secondary or minor, which is the better choice?
Scott, you said Srattera made you tired. Is it supposed to work immediately? Or is it made to build up in the system as a/d's do?
I read the thread, the choice is not obvious to me. My nephew just started Strattera with less than a robust response-one week on.He's in college and is having trouble concentrating.
Assuming dx of ADD is correct, would Desipramine be a good second choice or am I off here? He can't take anything addictive such as stims, etc.
Thanks-
~Jade
Posted by SLS on January 31, 2009, at 11:39:31
In reply to Desipramine vs Strattera adult ADD-SLS/ D/R, posted by JadeKelly on January 31, 2009, at 10:53:53
> So if ADD were the primary concern, and depression secondary or minor, which is the better choice?
If he is experiencing any improvement after one week on Strattera, I would be very encouraged.
I would stick with the Strattera and see how that goes. I watched someone with ADD have their depression resolve as the ADD resolved.
Look into clonidine for ADD. It can be used as an augmenter to Strattera or a stimulant. Some people get depressed on clonidine, but it might still be worth a shot. Right now, there are ongoing trials studying the use of memantine (Namenda)for ADD. You might be able to build a treatment regime around Strattera if it is at all helpful.
- Scott
Posted by psychobot5000 on February 2, 2009, at 21:24:30
In reply to Re: Desipramine vs Strattera adult ADD-SLS/ D/R » JadeKelly, posted by SLS on January 31, 2009, at 11:39:31
> > So if ADD were the primary concern, and depression secondary or minor, which is the better choice?
>
> If he is experiencing any improvement after one week on Strattera, I would be very encouraged.
>
> I would stick with the Strattera and see how that goes. I watched someone with ADD have their depression resolve as the ADD resolved.
>
> Look into clonidine for ADD. It can be used as an augmenter to Strattera or a stimulant. Some people get depressed on clonidine, but it might still be worth a shot. Right now, there are ongoing trials studying the use of memantine (Namenda)for ADD. You might be able to build a treatment regime around Strattera if it is at all helpful.
>
>
> - ScottI agree with Scott, and would also urge trying to stick to the Strattera for a little while. However, I do think desipramine would be a reasonable option to try, down the line--after strattera is given a chance.
Scott's suggestion of clonidine also seems to me a good one--however, I would suggest that instead of clonidine, your nephew could try its brother, guanfacine. They're almost the same drug, but guanfacine is better-established for ADD. For some subtle reasons involving the two drugs' properties (their binding to alpha 2a receptors, I believe), guanfacine probably works slightly better. It's a non-addictive option that's FDA-approved for ADHD.
(best of luck)
psychbot
Posted by SLS on February 2, 2009, at 21:53:44
In reply to Re: Desipramine vs Strattera adult ADD-SLS/ D/R, posted by psychobot5000 on February 2, 2009, at 21:24:30
Hi PB5000
> I would suggest that instead of clonidine, your nephew could try its brother, guanfacine.
I forgot all about guanfacine. It is a better choice for all of the reasons you cited.
- Scott
Posted by JadeKelly on February 4, 2009, at 21:05:46
In reply to Re: Desipramine vs Strattera adult ADD-SLS/ D/R » psychobot5000, posted by SLS on February 2, 2009, at 21:53:44
Posted by TriedEveryDrug on November 30, 2009, at 12:37:30
In reply to Desipramine vs Strattera for adult ADD., posted by SLS on January 20, 2009, at 13:04:28
> Desipramine has become a forgotten drug when it comes to treating adult ADD. It has repeatedly demonstrated efficacy. However, I am curious as to what differences there are between desipramine and Strattera (atomoxetine) as treatments for ADD. Are they equal in the numbers of people they help? Is the magnitude of improvement the same with both drugs? Even though both drugs are very selective NE reuptake inhibitors, Strattera may be more selective for the areas in the prefrontal cortex associated with ADD.
>
> Has anyone with ADD tried both desipramine and Strattera in order to compare the differences?
>
>
> - Scott
I realize this is an old thread, but I thought I would throw in my anecdotes because I have had a lot of experience with desipramine.I was first prescribed desipramine in college. I complained of depression, though ADD probably was my real problem. I could not afford prozac, so the school shrink gave me desipramine.
Literally overnight I went from a lazy, inattentive, failing student to getting As in my calculus classes. For me, for some reason, desipramine seems to improve my math abilities.
I also stopped making stupid mistakes on tests, like not noticing one of the choices in a multiple choice test. Anyway, it literally saved me from failing out of college.
I stopped taking it for reasons I cannot remember. Maybe the RX ran out. The only side effect I remember back then was it made food taste funny.
Later, after working for several years and trying everything for ADD (most things making me worse), I tried desipramine again.25mg at night. Bam! My work improved immensely and out of the blue I decided to take some pre-med classes. I got an A in general chemistry at Berkeley, which was not an easy class!
Problems though: this time it made me VERY depressed. Life felt BLEAK. I stayed on it for 3 months though, to get through my class. It also made me VERY quick to anger, and hateful. Very weird. I kept fantasizing about mass murder, especially on the highway. (Just fantasizing, nothing more) Not good.
I tried strattera a couple of times. Usually I had to give up within a week because of the insomnia. It would wake me up at 3am. wide awake. Then I would get more and more frazzled until I could not take being on it.
I suspect strattera might work for me, if I could get past like the first month or so.
But for my ADD, desipramine was the only thing that really worked. And it works very well. Unfortunately it makes me a depressed, angry a**hole.
Sorry for the long rambling post. BTW, I'm currently trying lexapro + strattera. I may try lexapro + desipramine if this goes nowhere.
Posted by SLS on November 30, 2009, at 12:49:29
In reply to Re: Desipramine vs Strattera for adult ADD. » SLS, posted by TriedEveryDrug on November 30, 2009, at 12:37:30
Hi.
Thanks for describing your experiences. It is important information.
I hope Lexapro allows you to return to desipramine if the Strattera doesn't work out. Either way, good luck.
- Scott
This is the end of the thread.
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