Posted by shar on December 3, 2000, at 23:50:47
In reply to Re: Dysthymics-My recent diagnosis-Help-Longer » shar, posted by SLS on December 3, 2000, at 20:30:21
Thank you all for responding! I think this p-doc is willing to work with me, and try different things, but I did not get the sense that she was willing to be aggressive in going after a solution. Plus, she said "nobody is happy all the time" and I thought well, DUH, why would she even say that to me? I am an idiot that expects her to come up with a magic potion?!
I don't believe I'll go back to her. My current p-doc is not that knowledgeable, but she is willing to work with me and learn. And, I think will be aggressive.
One of the things that made me believe dysthymia is a fitting diagnosis is that it can commonly begin in childhood and early adolescence, which is when mine began. Plus all the stuff about being viewed by others as pessimistic, not having fun, etc.
She (p-doc) mentioned Lithium I think. And said a thyroid supplement might help.
I am too tired right now to write more, but thanks to you all for your responses. And your research, SLS. You are all very kind and generous.
More later. Shar
> Sorry, Shar.
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>
> This turned out to be longer than I intended. I hope it doesn't cause more confusion rather than less. I just figured I'd look into some things for you. I have no intentions of proof-reading it, so I'll leave that to you.
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> > I finally met with a real pyschopharmacologist, hoping at long last that I would be able to get above my depression.
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> > My diagnosis is dysthymia (I've heard that before but did not realize it was essentially a death sentence for feeling good).
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> I'm not sure that it is a death sentence. I like the idea of using Parnate or Nardil at some point as does Bradley. I think adding Ritalin to any treatment combination might help. Double-depression has historically been thought of as being very difficult to treat. It is easier to get rid of the "major" depression than it is the "minor" depression or dysthymia. "Minor" depression and dysthymia are thankfully now being recognized as major, serious disorders with rates of suicide perhaps higher than that of major recurrent depression. Chronicity is a MF.
>
> Is dysthymia a disorder distinct from major depression? Recently, there has been growing debate as to whether they are separate disorders or two different presentations along a "spectrum" of depressive illness. Currently, my reading leads me to believe that dysthymia exists as a separate disorder and that it is often confused diagnostically and nosologically as being a less severe or subsyndromal presentation of major depression. Dysthymia is not the same as "subsyndromal depression". Both exist independantly. Subsyndromal or subthreshold depression does *not* produce anhedonia or depressed-mood. In addition, chronic dysthymia may involve the endocrine system and the immune system to a degree greater than that of major depression. Irregularities of these systems have been observed. A more critical question is whether or not dysthymia is to be treated any differently than is major depression. I do think that there may be some little "tricks" that can help with dysthymia. The first ones that come to mind are the additions of Ritalin and thyroid hormone.
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> I have always thought of treating double depression as if one were treating two separate disorders. I think it is unreasonable to treat double-depression with just one drug. Once the major depression is adequately treated with a drug regime, keep taking it and forget about it. Now begin treating the residual dysthymia from scratch as if you were addressing it for the very first time, leaving in place the successful treatment regimen for major depression. Anyway, that's how I would approach the situation.
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> > MEDS. She said she thinks I need higher doses than most people because I smoke. I did some research and it looks like the most common meds that work (or are used for dysthymia) are Zoloft (sertraline), amisulpride, moclobemide (Manerix), and Prozac (fluoxetine). It also appears that researchers believe it can take longer (up to 6 months) for meds to kick in for dysthimics.
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> Have you ever tried Risperdal or Zyprexa in combination with antidepressants?
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> I wonder if selegiline (Eldepryl) might help. Selegiline is an MAO-inhibitor that is fairly selective for the dopamine enzyme. Perhaps you can ask AndrewB about that. He has noted that it takes a few months to "kick-in". Perhaps this is indicative of a population of misdiagnosed dysthymics being successfully treated with selegiline.
>
> As far as the drugs you have mentioned, I think drug manufacturers like when someone finds a new use for an old drug. That one drug constantly appears in trials for treating dysthymia is not necessarily an indicator that it is better than other drugs not chosen for testing. I need to look more into this. Certainly, amisulpride looks good based upon what people here have experienced with it.
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> Has modern medicine been able to exclude certain antidepressants in the treatment of dysthymia because they are consistantly found to be ineffective? I haven't seen anything that supports this notion. Trial and error still seems to be the modus operendus. However, I think using more than one drug is usually necessary.
>
> It may not be so surprising that Zoloft worked so well for you. I came across several studies showing it to be particularly effective in treating dysthymia. If I were you, I would take an inventory of which drugs produced an improvement, regardless of degree or duration. I would then consider choosing from them safe combinations to try. Combinations of Zoloft + Wellbutrin or Effexor + Wellbutrin sound like they might be worth looking at. Don't forget about adding Ritalin or thyroid to either of these.
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> > I tried Zoloft, the drug from heaven for me and it pooped out really fast. Prozac did nada but I only did 20 mg. Haven't tried the others. Right now I take Effexor XR 300 mg, Wellbutrin SR 200 mg, klonopin to sleep.
>
> Let's see how close you come with this combo. If not totally without positive effect, take note. Prozac sometimes needs to be administered at 60+ mg a day. Likewise, there are some people who need 600+ mg of Effexor. Believe it or not.
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> If inadequate, perhaps adding Ritalin (or another stimulant) and thyroid (Cytomel and/or Synthroid) might do the trick. If not, I would consider swapping the Effexor for Zoloft, leaving everything else in place.
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> You might want to consider psychotherapy as an adjunct to medication. Perhaps old and chronic depressive thought styles and stressors are making your chronic dysthymia more resistant to pharmacotherapy. Psychotherapy is actually critical to an integrated treatment plan to kill the dysthymic beast. Do you have an "avoidant personality" or are you particularly avoidant of things and situations you feel might be potentially harmful? Would you consider your home life as a child to be an adverse environment? Do you think you were depressed prior to puberty? Has the term "depressive personality disorder" ever been used?
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> I know you can get well. Unfortunately, Shar, it will probably not happen by the time you wake up tomorrow morning. :-) Sorry. I wish I could give you some patience, but I can't give you what I don't have. Educated trial and error. You'll get there.
>
> Good luck. I have prayed for you.
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>
> - Scott
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>
> ---------------------------------------------------------------
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>
> 54: Cochrane Database Syst Rev 2000;(2):CD001130
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> A comparison of drugs versus placebo for the treatment of dysthymia.
>
> Lima MS, Moncrieff J
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> Department of Mental Health, Universidade Federal de Pelotas, Avenida Duque de Caxias, 250, Pelotas, Rio Grande do Sul, Brazil, 96100. mslima@nutecnet.com.br
>
> OBJECTIVES: Dysthymia is a depressive disorder of chronic nature but of less severity than major depression, which depressive symptoms are more or less continuous for at least two years. The aim of this review was to conduct a systematic review of all RCTs comparing drugs and placebo for dysthymia. SEARCH STRATEGY: Electronic searches of Cochrane Library, EMBASE, MEDLINE, PsycLIT, Biological Abstracts and LILACS; reference searching; personal communication; conference abstracts; unpublished trials from the pharmaceutical industry; book chapters on the treatment of depression. SELECTION CRITERIA: The inclusion criteria for all randomised controlled trials were that they should focus on the use of drugs versus placebo for dysthymic patients. Exclusion criteria were: non randomised, mixed major depression/ dysthymia (trials not providing separate data) and depression secondary to other disorders (e.g. substance abuse). DATA COLLECTION AND ANALYSIS: The reviewers extracted the data independently. In order to achieve an intention-to-treat analysis, when trials failed to report it was assumed that people who died or dropped out had no improvement. Authors of relevant trials were contacted for additional and missing data. Absence of treatment response as defined by authors was the main measure of outcome used. Relative Risks (RR) and 95% confidence intervals (CI) of dichotomous data were calculated with the Random Effects Model. Where possible, number needed to treat (NNT) and number needed to harm (NNH) were estimated, taking the reciprocal of the absolute risk reduction. MAIN RESULTS: Currently the review includes 15 trials. Similar results were obtained in terms of efficacy for different groups of drugs, such as tricyclic (TCA), selective serotonin reuptake inhibitors (SSRI), monoamine oxidase inhibitors (MAOI) and other drugs (sulpiride, amineptine, and ritanserin). The pooled RR for absence of treatment response was 0. 68 (95% CI 0.59-0.78) for TCA and the NNT was 4.3 (95% CI 3.2-6.5). SSRIs showed similar RR for this outcome: 0.64 (95% CI 0.55-0.74), the NNT being 4.7 (95% CI 3.5-6.9). Concerning MAOIs, the RR was 0. 59 (95% CI 0.48-0.71) and the NNT was 2.9 (95% CI 2.2-4.3). Other drugs (amisulpride, amineptine and ritanserin) showed similar results in terms of absence of treatment response. Using more stringent criteria for improvement - full remission - the results were unchanged. Patients treated on TCA were more likely to report adverse events, compared with placebo. REVIEWER'S CONCLUSIONS: Drugs are effective in the treatment of dysthymia with no differences between and within class of drugs. Tricyclic antidepressants are more likely to cause adverse events and dropouts. As dysthymia is a chronic condition, there remains little information on quality of life and medium or long-term outcome.
>
> Publication Types:
> Review
> Review, academic
>
> PMID: 10796749, UI: 20257829
>
>
> ------------------------------------------------------------------
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>
>
> 17: Depress Anxiety 2000;12(1):30-9
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> Subsyndromal symptomatic depression: a new concept.
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> Sadek N, Bona J
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> Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia, USA.
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> [Medline record in process]
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> Although DSM-IV acknowledged the clinical significance of some subthreshold forms of unipolar depression, such as minor depression (MinD) and recurrent brief depression (RBD), clinicians continued to struggle with the concept of "subthreshold" depression. A substantial number of patients continued to present with depressive symptoms that still did not satisfy any DSM-IV diagnosis. Generally, these patients failed to complain of anhedonia and depressed mood, a criterion that DSM-IV mandates for any diagnosis of depression. Therefore, researchers reexamined the question of whether this cluster of depressive symptoms, in the absence of anhedonia and depressed mood, was clinically significant. Some researchers labeled this cluster of symptoms, "subsyndromal symptomatic depression" (SSD). Specifically, SSD is defined as a depressive state having two or more symptoms of depression of the same quality as in major depression (MD), excluding depressed mood and anhedonia. The symptoms must be present for more than 2 weeks and be associated with social dysfunction. Using Medline Search, the authors reviewed the literature on the epidemiology, demographics, clinical characteristics, and psychosocial impairment of SSD. SSD is found to be comparable in demographics and clinical characteristics to MD, MinD, and dysthymia. SSD is also associated with significant psychosocial dysfunction as compared with healthy subjects. Further; it has significant risk for suicide and future MD. Few studies have been conducted on the treatment of SSD. The high prevalence of SSD, the significant psychosocial impairment associated with it, and the chronicity of its course make subsyndromal symptomatic depression a matter for serious consideration by clinicians and researchers.
>
> PMID: 10999243, UI: 20454556
>
>
> ------------------------------------------------------------------
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>
> : Am J Psychiatry 2000 Dec 1;157(12):1966-1972
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> Three-Year Follow-Up of Women With the Sole Diagnosis of Depressive Personality Disorder: Subsequent Development of Dysthymia and Major Depression.
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> Kwon JS, Kim YM, Chang CG, Park BJ, Kim L, Yoon DJ, Han WS, Lee HJ, Lyoo IK
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> [Record supplied by publisher]
>
> OBJECTIVE: The authors sought to determine whether subjects with the sole diagnosis of depressive personality disorder are at higher risk for developing dysthymia and major depression than are healthy comparison subjects. METHOD: Eighty-five women with depressive personality disorder who had no comorbid axis I or axis II disorders and 85 age-matched healthy comparison women were initially recruited and reinterviewed 3 years later to evaluate the cumulative incidence rate of dysthymia and major depression. RESULTS: At the 3-year follow-up assessment, the women with depressive personality disorder had a significantly greater odds ratio for developing dysthymia than did the healthy comparison women. The difference in odds ratios for the development of major depression between women with and without depressive personality disorder did not reach statistical significance. CONCLUSIONS: The present study, the first to determine the subsequent development of dysthymia and major depression in subjects with the sole diagnosis of depressive personality disorder, found that subjects with depressive personality disorder had a greater risk of developing dysthymia than did healthy comparison subjects at 3-year follow-up. Findings of the current study also suggest that depressive personality disorder may mediate the effects of a family history of axis I unipolar mood disorders.
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> PMID: 11097962
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>
> ----------------------------------------------------------
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>
> 23: Am J Psychiatry 2000 Sep;157(9):1436-44
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> Double-blind comparison of sertraline, imipramine, and placebo in the treatment of dysthymia: effects on personality.
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> Hellerstein DJ, Kocsis JH, Chapman D, Stewart JW, Harrison W
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> Outpatient Mental Health Services, Beth Israel Medical Center, New York, NY 10003, USA. dhellerstein@bethisraelny.org
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> OBJECTIVE: Although previous studies have shown that dysthymia, or chronic depression, commonly responds to antidepressant medications (with improvements in depressive symptoms and psychosocial functioning), there have been no systematic studies of the impact of antidepressant treatment on personality variables in patients with this disorder. METHOD: In a multicenter study, 410 patients with early-onset primary dysthymia were treated in a randomized prospective fashion with sertraline, imipramine, or placebo. The data were analyzed in terms of the subjects' scores on the Tridimensional Personality Questionnaire, a 100-item self-report instrument that measures four temperamental dimensions: harm avoidance, reward dependence, novelty seeking, and persistence. RESULTS: At baseline, the harm avoidance scores of the dysthymic subjects were approximately 1.5 standard deviations higher than those of a previously reported community sample. After treatment, there was a significant decrease in harm avoidance scores, with no significant between-group differences. Remission of dysthymia was associated with significantly greater improvement in harm avoidance, with the greatest numerical change found in the patients treated with sertraline. Subjects' Tridimensional Personality Questionnaire scores were correlated at a 0.50 level with the Social Adjustment Scale both pre- and posttreatment, suggesting that a high degree of harm avoidance may be associated with poor social functioning. CONCLUSIONS: Before treatment, chronically depressed patients demonstrate an abnormality in temperament, as measured by elevated degrees of harm avoidance. Remission of dysthymia is associated with improvement in this aspect of temperament.
>
> Publication Types:
> Clinical trial
> Multicenter study
> Randomized controlled trial
>
> PMID: 10964860, UI: 20422057
>
>
> :-) :-) :-) :-) :-) :-) :-) :-) :-) :-) :-) :-) :-) :-) :-) :-) :-) :-) :-) :-)
poster:shar
thread:49856
URL: http://www.dr-bob.org/babble/20001130/msgs/49877.html