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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 simcha on August 18, 2010, at 17:26:47
Having recently come out of remission and on the search for new treatment I heard something from my current pdoc that poly-drug therapy for depression is now something that is frowned upon and can complicate depression more than help it? I've also read around here and some people claim that some pdocs will only do monotherapy because it's more effective?
I just wonder because I've been on many drugs at the same time for depression for years and years. The only monotherpay drug that worked for me was EffexorXR with the intolerable side effect of anorgasmia to the point of not being able to have an orgasm. It did wonders for my depression, but then again it was my first treatment and I was coming out of the worst depressive episode I've ever had so any improvement would have felt like a miracle.
I just ask because perhaps I'm missing something...
Posted by Dinah on August 19, 2010, at 7:50:55
In reply to Monotherapy vs. Polytherapy for Depression?, posted by simcha on August 18, 2010, at 17:26:47
I'd guess it depended on the type of depression.
I know someone IRL who goes on a bit of Celexa when he's depressed, and that does the trick for him. He stays on it for as long as he needs it, then weans off it until he needs it again.
While I by nature tend to be anxious and agitated. An antidepressant without a mood stabilizer on board has been tried, and it just doesn't work with me. Actually my arsenal of psych meds right now doesn't include an antidepressant at all, and my pdoc has given me permission to vary doses to meet my needs.
Does your current pdoc believe that depression is a single illness? Or does he see it as something that is the result of more than one cause? I'd imagine some types of depression are more suitable to monotherapy than others.
Posted by Christ_empowered on August 19, 2010, at 10:24:54
In reply to Monotherapy vs. Polytherapy for Depression?, posted by simcha on August 18, 2010, at 17:26:47
Psychiatry often seems to go by trends, not science. Cocktails seemed pretty common until recently; now it seems like docs are using fewer meds, but the meds they are using they use in higher doses. I suppose this approach is more rational than throwing 3-5+ meds at someone; then again, some people have multiple problems that might respond well to multiple meds, especially if some of those meds are just PRN (like a benzo or sleeping pill, even low-dose PRN antipsychotic).
What would concern me is having a shrink so focused on avoiding multiple meds that they might under-treat me. Then again, there is something to be said for avoiding drug-drug interactions and getting the med(s) used to high enough doses to really see if they'll work.
Posted by Phillipa on August 19, 2010, at 11:04:33
In reply to trends in psychiatry, posted by Christ_empowered on August 19, 2010, at 10:24:54
From what I see here lower doses and less meds are being prescribed. I've also heard that this country may be like the NHS and if so isn't two meds max? Phillipa
Posted by linkadge on August 19, 2010, at 11:04:59
In reply to trends in psychiatry, posted by Christ_empowered on August 19, 2010, at 10:24:54
I think that psychiatrists are pulled this way and that by the latest study which comes out.
There was a recent study which suggested that polypharmacology was associated with a higher hospitalization readmission rate. I don't know if it was just a correlational study though.
Fewer drugs makes more sense in terms of side effects and toxicity, but I don't know about efficacy.
Its really hard to say.
Linkadge
Posted by simcha on August 19, 2010, at 12:03:23
In reply to Re: trends in psychiatry, posted by linkadge on August 19, 2010, at 11:04:59
My current combination:
AM: Cymbalta 60mg
PM: BuproprionXL 450mg, Clonazepam 0.5-1mg, Trazodone 25mg
Now he's adding Lamictal saying that if I respond well to it, we might be able to eliminate the Cymbalta. I don't mind that. I think the culprit in my uncontrollable sweating and lack of sexual desire/functioning is Cymbalta. I've been taking it for a few years and dealing with the side effects because it seemed to be working well with the BuproprionXL. Now I'm depressed again and he's trying a new direction.
I don't think he was really adamant about bringing me down to one medication. He was just talking about how it's difficult for him to tell what is doing what in my combination since when I started with him, I was already on a mix of medications. He did talk about the trend toward monotherapy. My depression lately is affecting the emphasis I place on other people's words. I tend to find things in what others say and magnify their importance and sometimes I'll miss their main point. It's this darn lack of focus and brain fog.
Thanks for the responses.
Posted by bleauberry on August 19, 2010, at 18:05:44
In reply to Monotherapy vs. Polytherapy for Depression?, posted by simcha on August 18, 2010, at 17:26:47
I personally do not believe any doctor should have a predisposed bias to either monotherapy or polytherapy. The good doctor knows that each patient is different and each requires a unique work of art in terms of drug choice.
I think it is important to pay attention to the clues our bodies gives us. Symptoms are clues. For example, if brain fog is an issue, lamictal makes no sense. That is not an anti-brainfog med. Mental confusion is actually a common side effect. As for depression, it has been clinically shown to "delay" the return of depression (assuming you are one of the lucky ones where it initially works), but relapse usually happened within 9 months.
Given your symptoms, my first choice would be ritalin. That has a good likelihood of kicking cymbalta into action and improving the brain and similar symptoms.
In a perfect world it would be nice to remove cymbalta and wellbutrin completely and start fresh with something like ssri+nortriptyline....a true SNRI (the current combo is seen as SNRI but actually is very weak at that). But, two years on cymbalta means some rough challenging times during a slow weaning. It is nasty to get off of after longterm use, generally speaking.
The brain fog could be from a biological reason...unsuspected chronic infection for example...but it could also be directly related to cymbalta, wellbutrin, and klonopin. For one or all of them to be making you foggy sounds reasonable to me.
I personally do not favor adding yet one more med to a cocktail of 3 that is not working. That makes no sense. Just gets you in deeper over your head, even harder to get out when it doesn't work. But if one is to be added, at the very least it should be one notorious for targeting the symptoms you have. Ritalin fits that description. Adding a second or third med to a first that is partially working sounds reasonable to me, but adding to 3 existing nonperformers I see no logic in that. It better be a darn good choice, and I'm sorry but I just don't see lamictal as being that.
IMO
Posted by simcha on August 19, 2010, at 19:00:43
In reply to Re: Monotherapy vs. Polytherapy for Depression?, posted by bleauberry on August 19, 2010, at 18:05:44
I don't know of any psychiatrist that would put me on Ritalin, honestly. I don't have ADD. And I know that if I were to ask to be put on Ritalin, most docs would consider that request to be akin to "drug seeking behavior" due to the controlled status of that particular drug. I understand what you are saying that it could potentiate the Cymbalta. Perhaps you are aware of some advanced chemistry the pdocs haven't caught onto yet.
Another reason that I can't take a stimulant is that I have chronic insomina and Ectopic Atrial Tachycardia (rapid heart rate caused by a locus of over-active cells in my right atrium that make my heart beat fast while forcing my heartbeat to start from their location instead of where it's supposed to start, the sinus node). For both of those reasons, I'm not sure a stimulant would be a good idea. I'm supposed to avoid caffeine just because of both conditions so I don't think that a cardiologist or sleep specialist would allow me to go on a stimulant. I'm also on Sotalol for my EAT. I take 180mg 2 times per day. This complicates things for the pdoc, as you would imagine.
I had to make a decision. This depression sucks. I hate it. The best I could do for myself, given potential side effects of the three and the limitations of my other medical conditions, was to try Lamictal. If it doesn't work, I might get more aggressive about suggesting other solutions.
Posted by Phillipa on August 19, 2010, at 20:04:43
In reply to Re: Monotherapy vs. Polytherapy for Depression? » bleauberry, posted by simcha on August 19, 2010, at 19:00:43
Then you would also want to stay away from TCA's with the side effects of heart. As for withdrawing from cymbalta 60mg was a piece of cake for me went to 30mg one week and then off. And onto something forget what. No add med with insomnia and your heart would race. I tried lamictal only got to 50mg but no back side effects just spittting. Looked it up and it was an uncommon side effect. Phillipa
Posted by simcha on August 19, 2010, at 20:45:16
In reply to Re: Monotherapy vs. Polytherapy for Depression? » simcha, posted by Phillipa on August 19, 2010, at 20:04:43
Thanks for the response Phillipa. It's good to see that you're still here. :)
Do TCAs really affect the heart by increasing heart rate? I'd have to look it up and read about possible interactions with my Sotalol.
Posted by linkadge on August 19, 2010, at 20:45:27
In reply to Re: Monotherapy vs. Polytherapy for Depression? » bleauberry, posted by simcha on August 19, 2010, at 19:00:43
ritalin isn't the be all. If you have insomnia and a heart issue, I wouldn't bother with stimulants period.
The tachycardia from the cymbalata may be too much on its own.
Have you tried something like escitalopram?
Linkadge
Posted by Phillipa on August 19, 2010, at 21:32:04
In reply to Re: Monotherapy vs. Polytherapy for Depression? » Phillipa, posted by simcha on August 19, 2010, at 20:45:16
Simcha please do look them up as it's important for you to know exactly what they do as you are the one taking them and know exactly your condition. Love Phillipa
Posted by Hombre on August 20, 2010, at 1:14:36
In reply to Re: trends in psychiatry, posted by simcha on August 19, 2010, at 12:03:23
simcha,
Did you always have the sweating and anorgasmia, or did that get progressively worse over time? Did it get worse when the Cymbalta started pooping out?
I take Effexor XR and suffer from some sexual dysfunction as well. I've been experimenting with various herbs and formulas and am pretty happy with the results. I actually started looking into herbs because of the night sweats. I knew that was something the doctor wouldn't know how to handle, so I started googling night sweats as a symptom in Chinese medicine.
After a bit of detective work and trying a couple premade herbals formulas in the form of pills, I not only got rid of the sweating but also improved urination, which was starting to become difficult at times as well as sexual function and libido.
In terms of Chinese medicine, the sweats and the sexual difficulties point to weak kidneys, which in TCM also include the endocrine and adrenal functions.
If your problem is more of just not feeling aroused enough and/or not being able to orgasm, I'd suggest the formulas "Jin Gui Shen Qi Wan" or "You Gui Wan". Google will yield fruit. These also help feeling sluggish, tired, unable to get things moving.
If you tend to feel hot, thirsty, and have insomnia, heart palpitations, you may need something like "Liu Wei Di Huang Wan". That'll cool you off a bit and replenish your Jing, which is the Chinese version of Mojo in physical form.
Other herbs that may help with such problems:
- tribulus
- avena sativa
- maca
- tongkat ali
- ashwaghanda
- siberian (eleuthero) and asian ginseng (not so much American)
- horny goat weed
...and there a bunch more, some from Brazil that I can't remember how to spell.I also get a more robust antidepressant response when taking them with herbs. I think if the body gets out of balance over time, poop-out will occur. Herbs can help balance out the chronic chemical influences on your body and help you to regain balance and function.
Posted by simcha on August 20, 2010, at 14:05:41
In reply to Re: Monotherapy vs. Polytherapy for Depression? » simcha, posted by Phillipa on August 19, 2010, at 21:32:04
Linkadge and Phillipa,
Thanks for responding.
I haven't tried escitalopram. If the Lamictal doesn't work, maybe I'll suggest it since Celexa worked before it pooped out.
Yes, I've wondered about the Cymbalta for the past few years causing an uptick in my heart rate. When I was diagnosed the cardio-electrophysiologist told me he was certain that the Cymbalta didn't cause my condition. How he knows that, I don't know. He was a very brilliant guy and his explanations sometimes went over my head. My current pdoc would like to take me off of the Cymbalta ultimately for the reason that it may be increasing my heart rate and I sweat uncontrollably on it. (I agree with him.) So, we'll wait and see what, if anything, the Lamictal does. I just took my first 25mg dose last night and in 2 weeks I go up to 50mg.
Phillipa, yeah, I have to be quite careful about what I take. I'm on quite a combination of meds. I hate it, honestly. Keeping track of all of the pills and refills and paying the copays isn't fun. At least I have health insurance. I'd be destroyed if I didn't.
Posted by linkadge on August 20, 2010, at 21:29:48
In reply to Re: Monotherapy vs. Polytherapy for Depression?, posted by simcha on August 20, 2010, at 14:05:41
Cymbalta can absolutely increase heart rate. Increased heart rate and tachycardia are well known side effects of agents with norepinephrine reuptake capacity.
Effexor (which as less affinity for the norepinephrine transporter) is well known to increase blood pressure and / heart rate.
Linkadge
Posted by simcha on August 21, 2010, at 20:07:51
In reply to Re: trends in psychiatry, posted by Hombre on August 20, 2010, at 1:14:36
Hombre,
Thanks for your response. I have always been more sweaty than other people but since I've been on Cymbalta, it's gotten so bad that I have to carry around handkerchiefs all the time. I keep towels in my car for when I'm driving. I've always been fully functional sexually. When I got put on Cymbalta, I had some difficulty with anorgasmia initially, but that side effect abated slightly so that I could at least function but not like before Cymbalta. I think it's worse now because I'm depressed again.
I shy away from TCM and herbs because of the possible interactions with my medications. I'm on too many medicines that react to herbs. Also I have done enough research to know that the herbs sold at TCM shops could be laced with all sorts of nasty chemicals like DDT because they are grown in places where herbicides, fungicides, and fertilizers are used that are banned in most countries because of health risks. If it works for you, then great. I tried it once and not only did I not like the flavor, or having to simmer the herbs, or the expense, it didn't seem to help me much. I have many friends who swear by TCM and seem to have great results. So, maybe you're one of the lucky ones who respond well to TCM. I'm glad it works for you.
Linkadge, thanks for the extra information. Hopefully I can find something to replace the Cymbalta that actually works that won't make me feel like I have hot flashes and prevent me from enjoying sex.
Posted by Phillipa on August 21, 2010, at 21:16:26
In reply to Re: trends in psychiatry, posted by simcha on August 21, 2010, at 20:07:51
Hormones? Phillipa
This is the end of the thread.
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