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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 Deepreason on April 29, 2011, at 10:04:28
Brief history:
36 year old male
OCD, SAD, GAD leading to depression since early twenties.
Deterioration in condition 2.5 years ago that led to an incident of serotonin syndrome. Struggled mentally ever since.Medications tried: 5+ SSRI's in my twenties/thirties. Pregabalalin. Quetiapine.
Mirtazapine 30 mg + Venlafaxine 300 mg for the last 2 years. Good response when Sodium Valproate 1200 mg added to the Mirt + VFX combo. Zolpidem 10 mg as a sleeping aid for last 2 years.
I have recently gone through a full washout from the Venlafaxine/Mirtazapine combo whilst staying on the Valproate/Zolpidem combo, in order to switch to Phenelzine. The reason for this is that the VFX was making me feel too "wired". It was a painful couple of months but the thought that Phenelzine could be the answer to my problems sustained me
I have only been on the phenelzine at 60 mg for 3 weeks but have just seen my pdoc who wants me to try reducing the dosage to 30 mg as my anxiety levels are increased in the last week. I'm scared that I'm heading towards yet another failed drug trial and that this is now the end of the road with nothing else left to try.
Thankyou for reading my story and I'd be unbelievably grateful if anyone can offer any suggestions / hope that there might still be options out there for me. I'm terrified that at my next appointment my pdoc will say we've run out of things to try and this is how my life will remain.
Posted by B2chica on April 29, 2011, at 10:57:55
In reply to Suggestions for further medications, posted by Deepreason on April 29, 2011, at 10:04:28
i know two people here at work that suffer 1)from both SAD and GAD pretty rough and the second one only from SAD and they are both on Lexapro and it seems to work pretty well for them...
had you tried that in the past. any bad side effects? if not is it worth trying again?otherwise used to work for me was a low dose of zyprexa 5g. helped with anxiety and depression.
any higher and i started to gain weight.b2c.
Posted by desolationrower on April 30, 2011, at 4:14:05
In reply to Suggestions for further medications, posted by Deepreason on April 29, 2011, at 10:04:28
Since starting the MAOI, has your sleep changed noticably? Hve you felt different?
-d/r
Posted by Deepreason on April 30, 2011, at 5:25:46
In reply to Re: Suggestions for further medications, posted by desolationrower on April 30, 2011, at 4:14:05
Yes, I find it hard to get to sleep at night now. I also find I need a lot less sleep though. Whereas previously I needed 9 hours minimum to feel ok the next day, now I'm ok on 6 or 7 hours sleep.
Posted by mtdewcmu on April 30, 2011, at 16:06:29
In reply to Re: Suggestions for further medications, posted by B2chica on April 29, 2011, at 10:57:55
> i know two people here at work that suffer 1)from both SAD and GAD pretty rough and the second one only from SAD and they are both on Lexapro and it seems to work pretty well for them...
By SAD do you mean Social Anxiety Disorder or Seasonal Affective Disorder? I think Seasonal Affective Disorder was the original SAD, while Social Anxiety Disorder is another name for Social Phobia.
Posted by Deepreason on April 30, 2011, at 17:05:32
In reply to Re: Suggestions for further medications, posted by mtdewcmu on April 30, 2011, at 16:06:29
Sorry I meant Social Anxiety Disorder, too many acronyms!
Posted by desolationrower on April 30, 2011, at 19:02:37
In reply to Suggestions for further medications, posted by Deepreason on April 29, 2011, at 10:04:28
is your increased anxiety levels the OCD, the social phobia, or both (in what % each)
what atypical antipsychotics have you tried?
-d/r
Posted by desolationrower on April 30, 2011, at 19:03:57
In reply to Re: Suggestions for further medications, posted by desolationrower on April 30, 2011, at 19:02:37
also, valproate and phenelzine share a mechanism in common, so it could either do the same thing, or be additive. Perhaps you are responding differently than most people starting phenelzine because of this (less initial benefit)
-d/r
Posted by Deepreason on April 30, 2011, at 19:31:14
In reply to Re: Suggestions for further medications, posted by desolationrower on April 30, 2011, at 19:02:37
The increased anxiety seemed primarily focused on the OCD: my obsessions with symmetry and being nice to inanimate objects to create luck / a good day. I would say it accounted for 75% of the anxiety.
The remaining 25% social phobia manifested mainly as short temperedness with others. I've always found it hard to block out extraneous noise but it gets worse when my anxiety goes up.
In hindsight I wonder if I was going a little hypomanic on the phenelzine. I was needing less and less sleep and had started running in the evenings. I went from 1 mile runs in the first week to an 11 mile run in the 3rd week. I always feel the need to push myself further and harder in anything I do but this was a little over the top even for me.
The only antipsychotic I have tried is quetiapine. I had a 2 week trial during hospital but suffered from orthoststatic hypotension to the extent that I passed out one night and had to be carried to my room.
Thankyou for taking an interest -d/r and feel free to ask any more questions which you think might help.
Posted by Deepreason on April 30, 2011, at 19:43:17
In reply to Re: Suggestions for further medications, posted by desolationrower on April 30, 2011, at 19:03:57
> also, valproate and phenelzine share a mechanism in common, so it could either do the same thing, or be additive. Perhaps you are responding differently than most people starting phenelzine because of this (less initial benefit)
>
> -d/rI'm interested in more info on this subject as in addition to the anxiety I was also experiencing a spaced out feeling that was very similar to how I felt when I increased my valproate dosage too high in the past. A kind of hypnotised, muzzy feeling like I was moving in treacle.
I had inititally attributed this to the couple of extra diazepam I'd taken to offset some of the anxiety but again in hindsight, your suggestion of a possible synergy between the valproate and the phenelzine would feel closer to my exeperiences.
Could you point me in the direction of your source please? I have full journal access to look things up.
Posted by jedi on May 1, 2011, at 2:12:06
In reply to Suggestions for further medications, posted by Deepreason on April 29, 2011, at 10:04:28
> Brief history:
>
> 36 year old male
> OCD, SAD, GAD leading to depression since early twenties.
> Deterioration in condition 2.5 years ago that led to an incident of serotonin syndrome. Struggled mentally ever since.
>
> Medications tried: 5+ SSRI's in my twenties/thirties. Pregabalalin. Quetiapine.
>
> Mirtazapine 30 mg + Venlafaxine 300 mg for the last 2 years. Good response when Sodium Valproate 1200 mg added to the Mirt + VFX combo. Zolpidem 10 mg as a sleeping aid for last 2 years.
>
> I have recently gone through a full washout from the Venlafaxine/Mirtazapine combo whilst staying on the Valproate/Zolpidem combo, in order to switch to Phenelzine. The reason for this is that the VFX was making me feel too "wired". It was a painful couple of months but the thought that Phenelzine could be the answer to my problems sustained me
>
> I have only been on the phenelzine at 60 mg for 3 weeks but have just seen my pdoc who wants me to try reducing the dosage to 30 mg as my anxiety levels are increased in the last week. I'm scared that I'm heading towards yet another failed drug trial and that this is now the end of the road with nothing else left to try.
>
> Thankyou for reading my story and I'd be unbelievably grateful if anyone can offer any suggestions / hope that there might still be options out there for me. I'm terrified that at my next appointment my pdoc will say we've run out of things to try and this is how my life will remain.Deepreason,
When I first started phenelzine, more than a decade ago, I had the initial stage of hypomania that you describe. For me this passed rather quickly and phenelzine augmented with clonazepam has been the only combo to work for me. I initially took high doses of clonazepam, up to 4mg daily, until the phenelzine kicked in. This took almost a month for me after titrating up to 75mg. However, when the MAOI kicked in, it was like flipping a switch. My depression is atypical along with the social anxiety. The phenelzine and clonazepam was the only cocktail, out of over 45 different combinations, that worked for me. I believe the two medications work synergistically for atypical depression with social anxiety. I have never had the OCD.I would try to stick out the phenelzine at your current dose or higher and take something to take the edge off the anxiety until it has a chance to kick in. Many PDOCs will try to discontinue with the hypomanic switch, but this is a very common side effect when first starting phenelzine. Many people with long term depression misinterpret the hypomania as the true antidepressant effect of phenelzine. It is really a side effect. For me it felt good since I had been depressed for so long. I would think that the valproate would act to lessen the switch to mania, but I have not studied the drug.
I have tried to discontinue phenelzine, because of the side effects, at least a half dozen times. Each time, within a few months, my major depression returned. At this point, I am a lifer on the medication. Many people have posted that they have been on it for several decades. That will be me also.
This sure isn't my whole story. I have been posting about this medication for years on this forum. Feel free to Google my posts, as I have probably written hundreds of pages about my experiences with this medication. I still believe that phenelzine is the gold standard for atypical depression with social anxiety. It will often work where many other drugs have failed.
Good luck and be well,
Jedi
Posted by desolationrower on May 1, 2011, at 17:10:38
In reply to Re: Suggestions for further medications, posted by Deepreason on April 30, 2011, at 19:43:17
> > also, valproate and phenelzine share a mechanism in common, so it could either do the same thing, or be additive. Perhaps you are responding differently than most people starting phenelzine because of this (less initial benefit)
> >
> > -d/r
>
> I'm interested in more info on this subject as in addition to the anxiety I was also experiencing a spaced out feeling that was very similar to how I felt when I increased my valproate dosage too high in the past. A kind of hypnotised, muzzy feeling like I was moving in treacle.
>
> I had inititally attributed this to the couple of extra diazepam I'd taken to offset some of the anxiety but again in hindsight, your suggestion of a possible synergy between the valproate and the phenelzine would feel closer to my exeperiences.
>
> Could you point me in the direction of your source please? I have full journal access to look things up.they are both gaba-transaminase inhibitors. i think phenelzine is indirectly, a byproduct of mao metabolism or something.
I don't really stay organized in my sources, i just remember stuff i read. i use scholar.google.com. here is an paper that deals with it though: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1408023/
Anyway, maybe someone else know, but i forget how quickly antipsychotics work for OCD (as an addon to serotonergic drugs). quietiapine has the most 'other' stuff so you probably were getting 100% side effects (some people like those, especially the tiredness) so i'm surprised you ahven't been given another ones, like risperadone. It is pretty established as an add-on to a drug like an sri. Perhaps because of the mirtazapine, which has some similarities. but i think the d2 antagonism might be helpful to some degree... Normally, even for social anxiety, i think AA are bad, but you might find otherwise, because it sounds like OCD is really at the core here. It might help with the 'agitation' from starting an MAOI, if it is from excess 5ht2 activity.
Serotonin syndrome is from excess 5ht2 activation, so the fact you had this makes me think you might have some really overactive 5ht2
receptors that need to be dealt with... MAOIs and sometimes sris reduce 5ht2 receptor activity, but so do 5ht2 antagonists (which is weird and backward)
-d/r
Posted by B2Chica on May 2, 2011, at 12:19:19
In reply to Re: Suggestions for further medications, posted by Deepreason on April 30, 2011, at 17:05:32
oops, good catch.
i was talking about seasonal affective disorder...
b2c.
Posted by Deepreason on May 3, 2011, at 4:03:17
In reply to Re: Suggestions for further medications » Deepreason, posted by jedi on May 1, 2011, at 2:12:06
Thankyou very much for the time and effort people have put into their replies. I'm extremely grateful. I expect you hear it a lot but this isn't just an intellectual exercise to me, it's the life I'm living at the minute. The help you've offered is therefore really important and I thankyou deeply.
The main parts I've taken away from the discussion are to increase my dose of the phenelzine to 75 mg (agreed with my pdoc)and let the trial run for longer than the 3 weeks it had.
When I see him again in 2 weeks time I will discuss the possibility of switching away from the valproate to a mood stabiliser with a different mode of action in case a synergy between the valproate + phenelzine is leading to the sedated part of my feelings.
Regarding the anxiety I'm going to take a "wait it out" type approach and make use of some diazepam I have to get through the worst of it and see if a further month's trial causes it to subside.
The article linked was very useful to me for clearing up some of the shakier areas in my knowledge regarding 5ht etc. Thanks
Posted by deepreason on May 7, 2011, at 9:40:01
In reply to Re: Suggestions for further medications, posted by Deepreason on May 3, 2011, at 4:03:17
An interesting follow up on this one, I'm back at a 75 mg dosage of the Phenelzine now and still waiting for it to kick in.
My pDoc had me taking 45 mg at 09:00 and 30 mg at 12:00 due to the stimulant effects causing me insomnia. I noticed that although I couldn't sleep at night I did have a patch in the afternoon each day where I could hardly keep my eyes open. So as a trial, I changed my dosing times to 45 mg at 20:00 as the sleepiness seemed to occur about 3.5 hours after my dosage and 30 mg at 23:00.
Since the change in times, I have dropped straight off to sleep each night at 23:30-24:00 and not stirred until 09:00. No insomnia at all!
An additional benefit seems to be that my anxiety the following day is considerably lower. Not sure whether that can be attributedd to the change in timings or to the side effects wearing off as mentioned in other posts above.
Hope the above info helps some other people.
This is the end of the thread.
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