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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 7 to 31 of 31. Go back in thread:
Posted by g_g_g_unit on February 13, 2012, at 0:10:24
In reply to Re: parnate agitation » g_g_g_unit, posted by phidippus on February 12, 2012, at 16:09:12
> I'm starting to think your bipolar. Every AD causes you agitation, it seems.
>
> EricI've kind of suspected it for a while. Maybe this will change my psychiatrist's mind.
Posted by phidippus on February 13, 2012, at 14:54:33
In reply to Re: parnate agitation » phidippus, posted by g_g_g_unit on February 13, 2012, at 0:10:24
What's your track record with mood stabilizers?
Eric
Posted by g_g_g_unit on February 13, 2012, at 23:44:38
In reply to Re: parnate agitation » g_g_g_unit, posted by phidippus on February 13, 2012, at 14:54:33
> What's your track record with mood stabilizers?
>
> EricI'm actually not totally convinced the Parnate is triggering a latent BP disorder, since the effect only lasts 2-3 hours after each dose (which would be consistent with a stimulant effect). After that, I became tired, inattentive, less anxious and the irritability mostly disappears (which is likewise consistent with stimulant withdrawal). So, unless stimulant-related irritability is a sign of BP ..
That said, I've only tried Depakote, which I didn't like. I also tried combining Neurontin (which technically isn't a mood-stabilizer, right?) with Dexedrine and found it smoothed out the anxiety and irritability, but canceled out the attentional benefits. I find 'natural' mood stabilizers like magnesium and taurine helpful, but nothing in the MS department seems to be very good for my attention.
Posted by SLS on February 14, 2012, at 5:28:35
In reply to Re: parnate agitation, posted by g_g_g_unit on February 13, 2012, at 23:44:38
> That said, I've only tried Depakote, which I didn't like.
I find that Depakote works great for bipolar II mania, but not so much for depression. Some people feel somewhat more depressed on Depakote.
In the past, lithium had been the most popular augmenter of Parnate. As an augmenter, one needs only to take a relatively low dosage - 300-600 mg/day. It might stabilize mood "drift" in depression, but actually feels like an antidepressant if it hits the right target.
Trileptal is a good choice if you start experimenting with mood-stabilizers. It is weight-neutral and is not sedating.
Well, let's take just one step at a time.
Good luck.
- Scott
Posted by g_g_g_unit on February 14, 2012, at 7:20:54
In reply to Re: parnate agitation » g_g_g_unit, posted by SLS on February 14, 2012, at 5:28:35
> I find that Depakote works great for bipolar II mania, but not so much for depression. Some people feel somewhat more depressed on Depakote.
>
> In the past, lithium had been the most popular augmenter of Parnate. As an augmenter, one needs only to take a relatively low dosage - 300-600 mg/day. It might stabilize mood "drift" in depression, but actually feels like an antidepressant if it hits the right target.
>
> Trileptal is a good choice if you start experimenting with mood-stabilizers. It is weight-neutral and is not sedating.
>
> Well, let's take just one step at a time.
>
> Good luck.
>
>
> - ScottThanks Scott. I wrote to Dr Ivan Goldberg and he said that Lithium is his mood-stabilizer of choice when augmenting Parnate.
Which do you believe produces the least cognitive impairment and 'flattening' effect?
Posted by SLS on February 14, 2012, at 7:45:04
In reply to Re: parnate agitation » SLS, posted by g_g_g_unit on February 14, 2012, at 7:20:54
> > I find that Depakote works great for bipolar II mania, but not so much for depression. Some people feel somewhat more depressed on Depakote.
> >
> > In the past, lithium had been the most popular augmenter of Parnate. As an augmenter, one needs only to take a relatively low dosage - 300-600 mg/day. It might stabilize mood "drift" in depression, but actually feels like an antidepressant if it hits the right target.
> >
> > Trileptal is a good choice if you start experimenting with mood-stabilizers. It is weight-neutral and is not sedating.
> >
> > Well, let's take just one step at a time.
> >
> > Good luck.
> >
> >
> > - Scott
>
> Thanks Scott. I wrote to Dr Ivan Goldberg and he said that Lithium is his mood-stabilizer of choice when augmenting Parnate.
>
> Which do you believe produces the least cognitive impairment and 'flattening' effect?
I really liked the way Trileptal felt. Although it didn't help improve my depression, my thoughts were very clear and I was not at all sedated. Unfortunately, Trileptal has not attracted sufficient attention to encourage clinical study. Perhaps this is because its sister drug, Tegretol, has already demonstrated efficacy. I guess it is assumed that Trileptal is as effective as Tegretol. I happen to agree that it this.A friend of mine is doing well with Keppra as an antimanic drug for bipolar II. I don't know to what extent it helps with depression.
This is going to seem counterintuitive, but Topamax (topiramate) can act as a mood stabilizer with little or no cognitive impairments. The key is not to trigger the impairments in the first place. You need to start very low and titrate very gradually. I established a dosage of 200 mg without any hint of impairment. I felt that it gave me more energy and motivation. It just wasn't enough for me to justify continuing with it. Topamax is more effective as a mood stabilizer than is generally thought. Just drink some extra water to avoid kidney stones.
- Scott
Posted by phidippus on February 14, 2012, at 8:45:30
In reply to Re: parnate agitation » SLS, posted by g_g_g_unit on February 14, 2012, at 7:20:54
I find Lithium and Lamictal produce the least cognitive impairment and 'flattening' effect.
Eric
Posted by SLS on February 14, 2012, at 8:55:57
In reply to Re: parnate agitation » g_g_g_unit, posted by phidippus on February 14, 2012, at 8:45:30
> I find Lithium and Lamictal produce the least cognitive impairment and 'flattening' effect.
That's great that Lamictal does not produce cognitive impairments and "flattening" effects for you. For me, it is quite the contrary, particularly at dosages above 200 mg. 300 mg produces a better antidepressant response, but I experience an unremitting "brain fog" that reduced my ability to function. Short-term memory was impaired most. I experience less cognitive impairments with Topamax 200 mg than I do with Lamictal. These adverse effects are not at all uncommon with Lamictal.
Of course, some people become zombies on even low dosages of lithium.
For me, Trileptal was unusually "clean".
To be trite, we are all different.
- Scott
Posted by g_g_g_unit on February 15, 2012, at 20:13:56
In reply to Re: parnate agitation » phidippus, posted by SLS on February 14, 2012, at 8:55:57
Just an update: I saw my psychiatrist today. He believes irritability is a potential side-effect of increased adrenergic activity and doesn't necessarily point to Bipolar.
Regardless, he's prescribed Depakote (250-500mg) to take in the meantime in the hope that it might curb side-effects and allow me to reach a higher dose of Parnate.
I asked about clonidine for sleep. He's going to look into its safety and also thinks it might be a useful option to control overstimulation.
Posted by SLS on February 16, 2012, at 3:11:25
In reply to Re: parnate agitation, posted by g_g_g_unit on February 15, 2012, at 20:13:56
> Just an update: I saw my psychiatrist today. He believes irritability is a potential side-effect of increased adrenergic activity and doesn't necessarily point to Bipolar.
>
> Regardless, he's prescribed Depakote (250-500mg) to take in the meantime in the hope that it might curb side-effects and allow me to reach a higher dose of Parnate.
>
> I asked about clonidine for sleep. He's going to look into its safety and also thinks it might be a useful option to control overstimulation.
I like what your doctor had to say.If you do opt for clonidine, be aware that a rather sizable percentage of people experience depression as a side effect. However, it might be exactly what you need as a sympatholytic. Prazosin, another sympatholytic drug, is sometimes used in PTSD to reduce anxiety and improve sleep. Of course, there is propranalol.
http://www.consumerreports.org/health/best-buy-drugs/prazosin-for-ptsd/overview/index.htm
"Prazosin is the most thoroughly studied drug in regard to PTSD and sleep among the class of medications known as alpha-1 blockers. In addition to preventing nightmares and insomnia, it can help improve overall symptoms, such as flashbacks, startle response, and irritability or anger, and it can be taken with an antidepressant."
Good luck.
- Scott
Posted by g_g_g_unit on February 16, 2012, at 5:34:27
In reply to Re: parnate agitation » g_g_g_unit, posted by SLS on February 16, 2012, at 3:11:25
> > Just an update: I saw my psychiatrist today. He believes irritability is a potential side-effect of increased adrenergic activity and doesn't necessarily point to Bipolar.
> >
> > Regardless, he's prescribed Depakote (250-500mg) to take in the meantime in the hope that it might curb side-effects and allow me to reach a higher dose of Parnate.
> >
> > I asked about clonidine for sleep. He's going to look into its safety and also thinks it might be a useful option to control overstimulation.
>
>
> I like what your doctor had to say.
>Yeah, he's a smart guy. I kind of wish he'd opted for something like klonopin - I thought it might be easier to reap an instant effect, and that it would also help insomnia. But he isn't a big fan, alas.
> If you do opt for clonidine, be aware that a rather sizable percentage of people experience depression as a side effect. However, it might be exactly what you need as a sympatholytic. Prazosin, another sympatholytic drug, is sometimes used in PTSD to reduce anxiety and improve sleep. Of course, there is propranalol.
>
> http://www.consumerreports.org/health/best-buy-drugs/prazosin-for-ptsd/overview/index.htm
>
> "Prazosin is the most thoroughly studied drug in regard to PTSD and sleep among the class of medications known as alpha-1 blockers. In addition to preventing nightmares and insomnia, it can help improve overall symptoms, such as flashbacks, startle response, and irritability or anger, and it can be taken with an antidepressant."
>
> Good luck.
>
>
> - Scott
Thanks for the tip, Scott. It seems Prasozin is available here. However, didn't you say it decreases DA in the nucleus accumbens? Wouldn't that exacerbate anhedonia?
Posted by SLS on February 16, 2012, at 7:07:43
In reply to Re: parnate agitation » SLS, posted by g_g_g_unit on February 16, 2012, at 5:34:27
> > > Just an update: I saw my psychiatrist today. He believes irritability is a potential side-effect of increased adrenergic activity and doesn't necessarily point to Bipolar.
> > >
> > > Regardless, he's prescribed Depakote (250-500mg) to take in the meantime in the hope that it might curb side-effects and allow me to reach a higher dose of Parnate.
> > >
> > > I asked about clonidine for sleep. He's going to look into its safety and also thinks it might be a useful option to control overstimulation.
> >
> >
> > I like what your doctor had to say.
> >
>
> Yeah, he's a smart guy. I kind of wish he'd opted for something like klonopin - I thought it might be easier to reap an instant effect, and that it would also help insomnia. But he isn't a big fan, alas.
>
> > If you do opt for clonidine, be aware that a rather sizable percentage of people experience depression as a side effect. However, it might be exactly what you need as a sympatholytic. Prazosin, another sympatholytic drug, is sometimes used in PTSD to reduce anxiety and improve sleep. Of course, there is propranalol.
> >
> > http://www.consumerreports.org/health/best-buy-drugs/prazosin-for-ptsd/overview/index.htm
> >
> > "Prazosin is the most thoroughly studied drug in regard to PTSD and sleep among the class of medications known as alpha-1 blockers. In addition to preventing nightmares and insomnia, it can help improve overall symptoms, such as flashbacks, startle response, and irritability or anger, and it can be taken with an antidepressant."
> >
> > Good luck.
> >
> >
> > - Scott
>
>
> Thanks for the tip, Scott. It seems Prasozin is available here. However, didn't you say it decreases DA in the nucleus accumbens? Wouldn't that exacerbate anhedonia?Not necessarily.
As Linkadge has noted, there are regions of the nucleus accumbens that are hyperactive in depression. That would seem counterintuitive at first, but not if one thinks in terms of circuitry. That DBS in the nucleus accumbens leads to an antidepressant effect would corroborate this observation. DBS is inhibitory upon the propagation of nerve messages. It interferes with nerve function, and does not stimulate nerves to relay messages downstream. DBS attenuates rather than stimulates neuronal activity.
I've got all of these circuit interactions running around my mind, but couldn't begin to put them into words.
The bottom line is that prazosin might reverse anhedonia seen in depression by modulating the messages being sent to the nucleus accumbens (just one of the structures involved in the experience of reward and pleasure).
Let us pretend that this is all wrong. Theories often are. However, the observed effect of prazosin seems to reduce depression and anhedonia in some, but not all, people. If you intend to try prazosin, let me know and I will pass along a few observations.
- Scott
Posted by sigismund on February 16, 2012, at 12:20:22
In reply to Re: parnate agitation » g_g_g_unit, posted by SLS on February 16, 2012, at 7:07:43
>If you intend to try prazosin, let me know and I will pass along a few observations.
I'm thinking of trying it. Pass them along anyway.
(I don't sleep well enough for much in the way of dreams or nightmares. Trimipramine gave me dreams but I felt so zapped on awakening.)
Posted by SLS on February 16, 2012, at 15:37:17
In reply to Re: parnate agitation » SLS, posted by sigismund on February 16, 2012, at 12:20:22
> >If you intend to try prazosin, let me know and I will pass along a few observations.
>
> I'm thinking of trying it. Pass them along anyway.
>
> (I don't sleep well enough for much in the way of dreams or nightmares. Trimipramine gave me dreams but I felt so zapped on awakening.)How many consecutive nights did you try taking trimipramine? How much did you take?
With prazosin, one should start at taking 1 mg three times a day. Prazosin has a short half-life, so the divided dosing is necessary. I suppose twice-a-day dosing would work, too. For me 6 mg/day (2 mg t.i.d.) is working very well. One can go as high as 40 mg/day, so there is quite a bit of room to work with.
Prazosin may cause the following side effects:
Dizziness
Orthostatic hypotension
Headache
Giddiness
Sleep disturbances
Muscle & joint pains
Fatigue
Weakness
Somnolence
Diarrhea
Nausea
Weight gain
Decrease in sexual interest
Tingling and numbness in both the limbs
Increased urination
Nasal congestionMany of these are really startup side effects that tend to disappear. Dizziness is to be expected, of course, as prazosin has been used to treat hypertension. For me, postural hypotension has persisted, perhaps because I am taking Parnate.
Early in treatment, fatigue, weakness, tiredness, somnolence, reduced libido, and amotivation appeared in me. I was actually fooled into thinking that prazosin was making my depression worse at the higher dosage, so I reduced it. Well, reducing the dosage allowed these effects to dissipate, but I also lost the improvement in mood that I had been experiencing. Of course, I then returned to the higher dosage. Within a week, all of these side effects disappeared with the notable exception of decreased libido. I remain clear-headed. There is no evidence of "brain-fog" or a mood-flattening effect. I am no longer fatigued and sleepy. My libido has increased somewhat over the past two weeks, but I don't know how to interpret this. This increase might be the result of my depression remitting rather than a dissipation of a side effect.
When taking prazosin, one should expect dizziness, fatigue, weakness, tiredness, sleepiness, and even a decrease in motivation to appear as side effects, and are not to be confused for a worsening of depression. These things are likely to disappear within two weeks.
From RxList:
"Clinical trials were conducted on more than 900 patients. During these trials and subsequent marketing experience, the most frequent reactions associated with MINIPRESS (prazosin hcl) therapy are: dizziness 10.3%, headache 7.8%, drowsiness 7.6%, lack of energy 6.9%, weakness 6.5%, palpitations 5.3%, and nausea 4.9%. In most instances, side effects have disappeared with continued therapy or have been tolerated with no decrease in dose of drug."
- Scott
Posted by sigismund on February 16, 2012, at 17:18:15
In reply to Re: parnate agitation, posted by SLS on February 16, 2012, at 15:37:17
>How many consecutive nights did you try taking trimipramine?
Only once.
>How much did you take?
12.5 or something like that, maybe a bit less.
I spent much of the day after on the couch.
Less bad than ami or doxepin.
Posted by sigismund on February 17, 2012, at 3:19:22
In reply to Re: parnate agitation » SLS, posted by sigismund on February 16, 2012, at 17:18:15
I took a smidgen out of a 50mg cap, maybe 5mg trimipramine, and I will see how that goes. It just needs to be helpful and not blitz me. I don't expect more than that.
Sorry to hijack your thread gggg, hope you don't mind.
Posted by SLS on February 17, 2012, at 6:40:24
In reply to Re: parnate agitation, posted by sigismund on February 17, 2012, at 3:19:22
> I took a smidgen out of a 50mg cap, maybe 5mg trimipramine, and I will see how that goes. It just needs to be helpful and not blitz me. I don't expect more than that.
>
> Sorry to hijack your thread gggg, hope you don't mind.
Good luck with that. Please let me know how it goes.Is trimipramine (Surmontil) the most expensive TCA where you live? It is in the US. There are no generics available.
- Scott
Posted by sigismund on February 17, 2012, at 13:46:21
In reply to Re: parnate agitation » sigismund, posted by SLS on February 17, 2012, at 6:40:24
>Is trimipramine (Surmontil) the most expensive TCA where you live?
Yes, it's not on the scheme thing (NHS? PBS?) and cannot be generic so 50 50mg caps cost $17.95.
Last night I used maybe 5mg (with 150mg gabapentin just to help me lie still in bed) and I slept so much better........just feel a little vague this morning. Unlike the 12.5mg dose no vivid dreaming, just a little. Sometimes there's no dreaming for me and no deep sleep either. It's like a light bulb is on all night.
Posted by ed_uk2010 on February 17, 2012, at 14:03:52
In reply to Re: parnate agitation » SLS, posted by sigismund on February 17, 2012, at 13:46:21
>Last night I used maybe 5mg (with 150mg gabapentin just to help me lie still in bed) and I slept so much better........just feel a little vague this morning.
Perhaps less is more Sigi. You could reduce the dose to find out whether you feel less vague, but you might not feel vague when you get used to it anyhow.
Posted by sigismund on February 17, 2012, at 16:28:41
In reply to Re: parnate agitation » sigismund, posted by ed_uk2010 on February 17, 2012, at 14:03:52
It's nice to be able to sleep, Eddy.
I also like mirtazepine for sleep.
I could go a combo of mirtazepine and Dexedrine.
Posted by ed_uk2010 on February 18, 2012, at 11:37:35
In reply to Re: parnate agitation » ed_uk2010, posted by sigismund on February 17, 2012, at 16:28:41
>I also like mirtazepine for sleep.
Good for sleep, bad for waking up. Also, prepare to lock the fridge.
Posted by alchemy on November 5, 2012, at 15:49:04
In reply to Re: parnate agitation, posted by SLS on February 10, 2012, at 6:11:15
Have u found any relief from ur agitation? I think it is giving me some, or swinging me for that bipolar sht. Especially soon after i get up. And then everything i have tried to reduce agitation or stabilize makes me agitated! Except xanax. Earlier today i was more depressed and tired.
Posted by g_g_g_unit on November 6, 2012, at 6:31:57
In reply to Re: parnate agitation, posted by alchemy on November 5, 2012, at 15:49:04
> Have u found any relief from ur agitation? I think it is giving me some, or swinging me for that bipolar sht. Especially soon after i get up. And then everything i have tried to reduce agitation or stabilize makes me agitated! Except xanax. Earlier today i was more depressed and tired.
No, I'm sorry to say I ended up discontinuing Parnate due to ongoing agitation and insomnia. It only began to help my depression at 60mg. I keep wondering if higher doses would have benefited anxiety, but unfortunately my psychiatrist wouldn't go over 60mg.
I probably should have been more aggressive in attacking the agitation, since it was a really good AD; I only tried Valium (which sedated me) and clonazepam (which had no benefit).
Posted by jono_in_adelaide on November 6, 2012, at 10:00:45
In reply to Re: parnate agitation » alchemy, posted by g_g_g_unit on November 6, 2012, at 6:31:57
If it was a good antidepressant, I'd go back to it, and take Valium for the anxiety - the sedation wears off over 1-2 weeks. other options are Ativan or Frisium (less sedating)
Posted by alchemy on November 6, 2012, at 18:06:01
In reply to Re: parnate agitation, posted by jono_in_adelaide on November 6, 2012, at 10:00:45
I finally realized that I had had some sour cream on a baked potato (and Wendy's chili). I think that that was what sent me into extreme agitation land.
I have not seen any improvement and am really discouraged. I have been on Parnate for 3 weeks now and am up to 30mg. I know some people need higher doses, but they have at least some mild improvement by now. I also didn't get the 2-3 short days of hypomania that a lot of people experience.
This is the end of the thread.
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