Posted by JohnL on October 22, 2000, at 7:43:11
In reply to Re: Remeron + Wellbutrin - Remeron + Neurontin = ? » JohnL, posted by SLS on October 21, 2000, at 10:42:01
Dear Scott,
You ask some good questions and make some good points. I must admit, it is difficult for me to get ideas across in writing in just a few paragraphs. I can easily see how things I say could be perceived in ways not intended. I'll try to address the issues you mentioned.1. As I've said a million times, a 1 or 2 week trial is not intended to get a total response...I agree, it takes longer to do that...instead, it is to compare the choices, and THEN choose the best of the bunch for a conventional 6 to 8 week trial. For example, in the SSRI class one could try Effexor, then Zoloft, then Prozac. Almost certainly one will in some way seem better to the patient in as little as a week. Perhaps side effects were nill, or they felt a little improvement, or something. There will be some kind of hint that the person likes one better than the others. THEN we go back to the favorite of the comparisons and apply traditional psychiatric principles to it...that is, a longer trial. The whole purpose of quick trials is merely to separate inferior matches from superior ones. That's all. They almost always make themselves known very clearly, IF the patient has the chance to compare. If there are no favorites...like maybe every drug in the class made the patient feel worse right away...then we move onto to totally different class and probe there. We're trying to find out what system in the brain is malfunctioning. Is it serotonin? Dopamine? NE? Some kind of instability? What? Reactions to meds will provide us clues to figure all this out. It usually doesn't take more than a week or two to gather the needed clues.
2. So, the 6 to 12 week trial, or whatever, is still part of the game. It's just that we want to be sure we are on the best drug in its class before committing to a longer trial or before probing other medication classes. Quick comparisons usually point us in the right direction. One drug will almost always stand out as being better than the others. An important point here though, this method should not be used in patients who are clearly suididal or psychotic. Though the patient may be very very depressed or anxious or whatever, they must at least be somewhat stable. So for those people truly on the edge of insanity and about to fall off into space, this method is not appropriate. Hospitalization and conventional psychiatry would be appropriate.
3. I hope you can see, by this method we are not "casting aside" any drug. We are merely trying to find a favorite. The best match. There's no rule that says we can't try our second favorite instead. But almost certainly, the completely unfavored ones will be eliminated quickly. No prescious time wasted on 6 or 12 week trials with them. There's always a better one.
4. As you mentioned, I too hope the psychiatric community finds Jensen's methods valid. So far so good though. They have been endorsed by Menninger's Clinic in Kansas, which was rated as one of the top two psychiatric hospitals in the country. If you go there for treatment, you'll probably see the Jensen method in action. And if you go to one of three medical schools in the country, you'll have to study it. It's one of the things they're teaching.
5. You're absolutely right...I had NO expectation whatsoever that Adrafinil would be good for me. NE drugs generally were very unpredictable for me, sometimes throwing me into a deep depression on the very first day. It's just that what I read about it in literature looked so enticing, I couldn't resist. And in the back of my mind, I knew that it worked by a completely different way than other NE meds...that is, it doesn't increase NE levels. Just for the record, years ago I DID have a decent response to Nortriptyline, a NE/5HT tricyclic. And I liked my first couple days on Desipramine as well. With both, the side effects were incredible. I couldn't take it. But response WAS indeed pretty good in a very short time. The NE drugs that made me feel bad were Reboxetine and Moclobemide. And Serzone. Here again, I think this highlights how a favorite in the bunch can be found. I didn't need to be on any of these for a month to decide if I liked it or not. I could tell you by day 3. The best overall for a longer trial was Adrafinil. But I certainly could have stayed with Nortriptyline or Desipramine in the hopes that the side effects would subside over time. There's no question they could be good for me. I felt good effects from them in the first week. It's just those darn TCA side effects! Whew. I'm not made of iron ya know. :-)
6. I felt a boost from Adrafinil on day 1. I was sad to see it fade by day 3. But that good early response was what I was looking for. After a week, the good response started to creep back in subtly. It really didn't kick in full until week three. But I did know for sure I was onto something good on the very first day. But all the characteristics of a "superior match"...that's what we're looking for in this whole process...were present. Those characteristics for me were...I didn't get worse; I did feel better on day 1; side effects were tolerable right from the getgo. That's all I needed to say, "OK, this one passes the test. I'll give it the six weeks and see what happens". That's how it works.
Did this help or did I just make it more confusing? Without writing a book, or without sitting face to face with someone for a couple hours, I find this concept very challenging to put into a few paragraphs. Anyway, always nice to hear from you, and always nice to try to answer some questions. You ask some very good questions.
John
poster:JohnL
thread:46914
URL: http://www.dr-bob.org/babble/20001022/msgs/47061.html