Posted by JohnL on November 28, 1999, at 5:24:00
In reply to A babblers short story(long), posted by Phil on November 27, 1999, at 20:41:07
Hi Phil. I probably can't help much, but since you asked for feedback here is my two cents.The first thing I wondered is why the Amitriptyline was ever stopped? Though there are plenty of studies suggesting SSRIs and TCAs are equally efficacious, I tend to see more evidence that TCAs are stronger in depressions like yours. That is suggested by Dr Ivan Goldberg anyway. Also by a $150 twenty pound book called Psychopharmacology I was browsing through at the bookstore. Also various psychopharmacology discussions I've stumbled onto when doing net searches. There was one interesting topic in the book to help predict response. The patient is given a very short trial of a psychostimulant. If there is a possitive response, it predicts a positive response to Imipramine. If neutral or negative response, then that predicts good response with Amitriptyline or Nortriptyline. (I actually might have this backwards, I'm not sure. But the method of pinpointing likely response was interesting.)
Three possiblities off the top of my head. 1)Add a TCA to an SSRI. 2)Add Naltrexone to an SSRI, with the possible additional augmentation of Clomirpramine or Nortriptyline. I mention Naltrexone because it seems to anecdotally work best in a subset population of patients rich in a history of alcohol/drug problems. But it seems to work with serotonin type drugs only. 3)Lithium is often the ingredient that turns partial response into full response.
Your type of depression sounds a lot like mine. Since I have experience with all the SSRIs and can claim only partial response, I generally tend to feel the SSRIs alone won't likely do the job for you or me. I get the gut feeling a TCA almost surely needs to be in the mix. But don't overlook the solid track record of Lithium or the sometimes miraculous novel approach of Naltrexone. If you're like me though, side effects often prevent a good trial of a med...either too low a dose or not enough time...to really make a fair judgement on whether something worked or not. The only ones I can claim a true fair trial of are SSRIs...and I can honestly say they fall short.
poster:JohnL
thread:15847
URL: http://www.dr-bob.org/babble/19991123/msgs/15867.html