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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 Meatwood_Flack on July 18, 2012, at 22:12:49
I have been struggling the past six months with what appears to be melancholic depression (lessens at night, weight loss, insomnia, non-reactive mood) with no success on a trial of Zoloft or a partial trial of Effexor (was switched to Cymbalta, Abilify, Lamictal, Wellbutrin and Buspar about three weeks ago in hospital. What other avenues would you suggest if these don't pan out? I know it is still early, but so far I've noticed nothing in terms of response. Any suggestions would be appreciated. I am a new member but have read many of the posts here and feel like there's a lot of knowledge here.
Posted by papillon2 on July 18, 2012, at 23:10:32
In reply to Melancholic Depression, posted by Meatwood_Flack on July 18, 2012, at 22:12:49
Hey Fleetwood,
If your SSRI and SNRI don't work out, I would be inclined to try a tetracyclic anti-depressant called Mirtazepine. If that didn't work out I'd try a tricyclic anti-depressant (TCA) such as Nortriptyline. Some might suggest going straight to a TCA.
If you only got a partial response to the TCA, I would then suggest augmenting it with a mood stabilizer (e.g. Lamictal, low-dose Lithium) or an atypical anti-psychotic (e.g. Zyprexa). I would first go for a mood stabilizer over an anti-psychotic as their side effects tend to suck less.
I have achieved partial remission from melancholic depression with the following combination:
Nortriptyline (a TCA) 100mg
Lamictal 200mg
Melatonin 4mg for sleep
Lithium 250mg, which I unfortunately had to stop as my body wouldn't tolerate itI also take 3g high potency fish oil and some other supplements each day. Fish oil has been proven in scientific trials to have an anti-depressant effect and to improve cognitive function. It doesn't interfere with any psych meds that I know of, though it's always best to ask your doctor before taking any supplements.
You might like to read this short summary about melancholic depression and how best to treat it.
http://www.blackdoginstitute.org.au/docs/AboutMelancholicDepression.pdf
Melancholic depression is a b*tch. I spent four months in hospital with it last year. The good news is that having just started out with an SSRI and an SNRI, you have whole classes of anti-depressants and other types of medications to try if your current combo doesn't work out. So hang in there.
Posted by Phillipa on July 18, 2012, at 23:27:03
In reply to Re: Melancholic Depression » Meatwood_Flack, posted by papillon2 on July 18, 2012, at 23:10:32
Welcome to babble. May you receive many responses from those with same issue. Phillipa
Posted by Meatwood_Flack on July 18, 2012, at 23:42:22
In reply to Re: Melancholic Depression, posted by Phillipa on July 18, 2012, at 23:27:03
Posted by Meatwood_Flack on July 18, 2012, at 23:45:40
In reply to Re: Melancholic Depression » Meatwood_Flack, posted by papillon2 on July 18, 2012, at 23:10:32
> Hey Fleetwood,
>
> If your SSRI and SNRI don't work out, I would be inclined to try a tetracyclic anti-depressant called Mirtazepine. If that didn't work out I'd try a tricyclic anti-depressant (TCA) such as Nortriptyline. Some might suggest going straight to a TCA.
>
> If you only got a partial response to the TCA, I would then suggest augmenting it with a mood stabilizer (e.g. Lamictal, low-dose Lithium) or an atypical anti-psychotic (e.g. Zyprexa). I would first go for a mood stabilizer over an anti-psychotic as their side effects tend to suck less.
>
> I have achieved partial remission from melancholic depression with the following combination:
>
> Nortriptyline (a TCA) 100mg
> Lamictal 200mg
> Melatonin 4mg for sleep
> Lithium 250mg, which I unfortunately had to stop as my body wouldn't tolerate it
>
> I also take 3g high potency fish oil and some other supplements each day. Fish oil has been proven in scientific trials to have an anti-depressant effect and to improve cognitive function. It doesn't interfere with any psych meds that I know of, though it's always best to ask your doctor before taking any supplements.
>
> You might like to read this short summary about melancholic depression and how best to treat it.
>
> http://www.blackdoginstitute.org.au/docs/AboutMelancholicDepression.pdf
>
> Melancholic depression is a b*tch. I spent four months in hospital with it last year. The good news is that having just started out with an SSRI and an SNRI, you have whole classes of anti-depressants and other types of medications to try if your current combo doesn't work out. So hang in there.Lots of good information I can use as suggestions to my doc should we need to change anything. Much appreciated.
Posted by papillon2 on July 19, 2012, at 0:47:36
In reply to Re: Melancholic Depression, posted by Meatwood_Flack on July 18, 2012, at 23:45:40
Just notices your name is Meatwood, not Fleetwood. LOL. Sorry!
Posted by Meatwood_Flack on July 19, 2012, at 0:56:42
In reply to Re: Melancholic Depression, posted by papillon2 on July 19, 2012, at 0:47:36
Not a problem. Just my homage to the inventors of soap opera rock. ha
Posted by ron1953 on July 19, 2012, at 1:15:24
In reply to Melancholic Depression, posted by Meatwood_Flack on July 18, 2012, at 22:12:49
Meat:
Lemme aks you this: what's going on in your life? Is your situation possibly part of why you're depressed? Maybe you can expand on the context of your recent melancholy.
Posted by SLS on July 19, 2012, at 4:40:32
In reply to Melancholic Depression, posted by Meatwood_Flack on July 18, 2012, at 22:12:49
> I have been struggling the past six months with what appears to be melancholic depression (lessens at night, weight loss, insomnia, non-reactive mood) with no success on a trial of Zoloft or a partial trial of Effexor (was switched to Cymbalta, Abilify, Lamictal, Wellbutrin and Buspar about three weeks ago in hospital. What other avenues would you suggest if these don't pan out? I know it is still early, but so far I've noticed nothing in terms of response. Any suggestions would be appreciated. I am a new member but have read many of the posts here and feel like there's a lot of knowledge here.
Another key feature of melancholic depression is psychomotor disturbance. It more often presents as retardation, but can also manifest as agitation. TCAs are considered to be more effective to treat melancholic depression than are SSRIs. Someone mentioned nortriptyline. That's a good choice because, as a TCA, it has perhaps the mildest of side effects. However, if you don't respond to nortriptyline, that doesn't mean that you won't respond to another TCA. I would look at trying imipramine as a second choice if necessary.
- Scott
Posted by bleauberry on July 19, 2012, at 5:31:08
In reply to Melancholic Depression, posted by Meatwood_Flack on July 18, 2012, at 22:12:49
While scientific studies do not completely back up my opinion here, I am convinced melancholic depression resides mostly somewhere within the norepinephrine/dopamine circuits. Some of the meds you took were sort of partially working in that area but not really much.
Ideas to consider:
Do not count on any single med to do the job.
Think in terms of SSRI + TCA, to get a balanced approach to both serotonin and norepinephrine. Such as zoloft+nortriptyline, prozac+nortriptyline, and similar variations.
My personal opinion is that if an ssri is to be considered in the mix, prozac is the best of the bunch.
See if you can get just a few samples doses of Ritalin and Adderall. These work instantly, so they are a good probing test. Your response to them, either good or neutral or bad, will tell you a lot that will help guide future medication decisions.
No matter what meds you take, try including the herb Rhodiola Rosea with them.
The MAOIs should be considered if the above ideas don't work out well.
I am very familiar with other types of medical problems, mostly in the infectious disease areas and toxicity areas. Specific kinds of depression are almost hallmark clues with most of them. So regardless of what you do in terms of meds, I think it is wise to do what you can to "probe" for possible hidden causes, which is fairly easy to do with a handful of certain herbs. If your depression came out of nowhere for no apparent reason and it happened in a relatively quick timeframe, that would tend to point me in the direction of an "event" as the cause, such as a tick bite, exposure to something, hard to know for sure but something happened.
Posted by SLS on July 19, 2012, at 6:25:15
In reply to Re: Melancholic Depression, posted by bleauberry on July 19, 2012, at 5:31:08
Hi BB.
> While scientific studies do not completely back up my opinion here, I am convinced melancholic depression resides mostly somewhere within the norepinephrine/dopamine circuits. Some of the meds you took were sort of partially working in that area but not really much.
>
> Ideas to consider:
> Do not count on any single med to do the job.
> Think in terms of SSRI + TCA, to get a balanced approach to both serotonin and norepinephrine. Such as zoloft+nortriptyline, prozac+nortriptyline, and similar variations.
> My personal opinion is that if an ssri is to be considered in the mix, prozac is the best of the bunch.
> See if you can get just a few samples doses of Ritalin and Adderall. These work instantly, so they are a good probing test. Your response to them, either good or neutral or bad, will tell you a lot that will help guide future medication decisions.
> No matter what meds you take, try including the herb Rhodiola Rosea with them.
> The MAOIs should be considered if the above ideas don't work out well.
> I am very familiar with other types of medical problems, mostly in the infectious disease areas and toxicity areas. Specific kinds of depression are almost hallmark clues with most of them. So regardless of what you do in terms of meds, I think it is wise to do what you can to "probe" for possible hidden causes, which is fairly easy to do with a handful of certain herbs. If your depression came out of nowhere for no apparent reason and it happened in a relatively quick timeframe, that would tend to point me in the direction of an "event" as the cause, such as a tick bite, exposure to something, hard to know for sure but something happened.
BB - I think you are pretty much on target here, although I am not so sure about the Zoloft. I would be more inclined to choose Effexor as an adjunct. You could be right, though. Sheldon Preskorn would probably agree with you. Remeron might be an interesting choice for monotherapy. Regarding MAOIs and TCAs: According to more recent research, TCAs don't work as well for atypical unipolar depression as MAOIs, but MAOIs seem to work about as well as TCA for melancholic depression. I don't think there is any literature dealing with this, but think I would choose amphetamine over methylphenidate as a biological probe, especially if psychomotor agitation is present. Amphetamine might help for a few hours to a few days, but that might be enough reason to pursue TCA or MAOI.I wish I knew these things for sure. I don't. Of course, if I did, I would probably be writing papers. It is difficult to navigate the sea of conflicting literature.
- Scott
Posted by Meatwood_Flack on July 19, 2012, at 12:14:21
In reply to Re: Melancholic Depression, posted by ron1953 on July 19, 2012, at 1:15:24
I was in counseling for anxiety at the end of last year, had a blood pressure scare so I got on medication and stopped drinking alcohol and decided to stop a 30-year smokeless tobacco habit. Fourteen days into it, I get slammed with the worst depression of my life.
Posted by Meatwood_Flack on July 19, 2012, at 12:18:01
In reply to Re: Melancholic Depression » Meatwood_Flack, posted by SLS on July 19, 2012, at 4:40:32
Thanks, I will mention those if need be. My pdoc doesn't like me researching depression, she says it's only exacerbating things, but my depression is such that I can't read anything else with any focus, or watch TV, or listen to music, etc.
Posted by Meatwood_Flack on July 19, 2012, at 12:22:11
In reply to Re: Melancholic Depression, posted by bleauberry on July 19, 2012, at 5:31:08
I think it is a matter of one stressor too many in too short a time frame but probing for other causes makes sense since it's not assured, as in the case of someone who can point to a recent breakup as the cause.
Posted by zazenducke on July 19, 2012, at 12:28:39
In reply to Re: Melancholic Depression » ron1953, posted by Meatwood_Flack on July 19, 2012, at 12:14:21
> I was in counseling for anxiety at the end of last year, had a blood pressure scare so I got on medication and stopped drinking alcohol and decided to stop a 30-year smokeless tobacco habit. Fourteen days into it, I get slammed with the worst depression of my life.
You might want to google blood pressure medicines causing depression. A lot of them do.
Posted by ron1953 on July 19, 2012, at 13:52:49
In reply to Re: Melancholic Depression » ron1953, posted by Meatwood_Flack on July 19, 2012, at 12:14:21
> I was in counseling for anxiety at the end of last year, had a blood pressure scare so I got on medication and stopped drinking alcohol and decided to stop a 30-year smokeless tobacco habit. Fourteen days into it, I get slammed with the worst depression of my life.
Coincidence? I don't think so. Stopping two long-term addictions at once would knock anyone for a loop. My question is: Should you be primarily treated for depression or for addiction/withdrawal-related problems? And I know from personal experience that BP meds have a host of side-effects, including depression and fatigue - I can't tolerate them. And having stopped a long-term addiction myself (Klonopin), I know that regaining some semblance of balance takes quite a long time - months or even years.
I hope your doctor is looking at the big picture.
Posted by Meatwood_Flack on July 19, 2012, at 17:22:15
In reply to Re: Melancholic Depression » Meatwood_Flack, posted by zazenducke on July 19, 2012, at 12:28:39
I tested that a few months ago by dropping the bp med for a couple of weeks with no changes in the depression.
This is the end of the thread.
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