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Re: This combination may work. svevo1922

Posted by Elizabeth on December 15, 2001, at 23:09:53

In reply to This combination may work., posted by svevo1922 on December 15, 2001, at 17:22:03

Hi there. I hope that the cocktail you're trying now is helpful for you. If it doesn't prove to be the right thing, though, I have a couple of thoughts that might be relevant to your situation.

First of all, there are some MAOIs that don't cause weight gain much (if at all), and these might be helpful to you without the side effects that clomipramine has caused. The two drugs I am thinking of are Parnate (tranylcypromine) and selegiline (also known as deprenyl or l-deprenyl in some places). The latter is used mainly for Parkinson's disease; the dose required for depression will be quite a bit higher than what you would take for PD. They do have side effects (insomnia is very common with both) but can be very helpful for people with problems such as yours.

Another thought I have is: what happened with the Zoloft, the Celexa, and the RIMA that you tried? And have you tried any of the other SSRIs (Paxil, Luvox) or Effexor (a serotonin/norepinephrine reuptake inhibitor)?

There are also other new-generation antidepressants that might help you. Wellbutrin in particular comes to mind. It may be used alone, and it also can be added to other antidepressants to augment them and reduce weight gain if that is a problem. So adding Wellbutrin to clomipramine might be worth a try, since clomipramine worked so well for you.

You said you tried Remeron but stopped because of weight gain. What dose were you taking? For some people, the weight gain goes away at higher doses.

I don't think you're being "self-defeating" or "resistant." A lot of people feel unattractive as a result of depression, and if antidepressants make you look significantly worse just as you're getting your self-esteem back, that's a problem. (FWIW, I have a similar experience: I feel as if I am very unattractive when I am depressed, and effective antidepressants allow me to look in the mirror and feel pleased with my appearance -- I can see that I'm an attractive young person, not just a collection of flaws.)

> I continued to take .05 mg of lorazepam (ativan) twice a day.

Does that help you, and if so in what way?

The Dexedrine sounds like it's doing you some good. I have problems with energy too (I think most depressed people do!) and I'd like to try a stimulant too. Dexedrine may very well help you manage your weight too (it's not supposed to be used for this purpose, but it can be a nice bonus effect).

> Maybe in another post I'll describe in more detail how the new combination has changed my mood and thought patterns. Briefly, everything is a lot easier. I'm still working to do what I can about the side effects and to discipline myself to work productively. Before, I felt terribly overwhelmed almost all the time.

I think that's probably the Dexedrine. Stimulants help a lot with anergia -- lack of energy and motivation. This is a big problem for me and is the main reason I want to try a stimulant.

> I told my pdoc that I felt relieved but also somewhat sad because this development now has completely put the lie to the concept that willpower alone suffices or even makes a big difference.

I believe there's such a thing as free will, but it's not absolute -- we all have limitations on what we can force ourselves to do, and that's not a reason to be ashamed or disappointed in ourselves.

> In addition to drug therapy, I've tried many other methods to get my depression under control. A therapist I've been seeing recently has, for example, told me to relax, to take risks, and not to care whether I think other people are judging me. I told my pdoc that I tried that and could have recited those things to myself till kingdom come with virtually no change.

Yes, it is not very helpful for people to tell you what to feel. You feel however you're going to feel! Will power has little effect (if any) over our emotions. It's not as though you don't *want* to relax, or to let yourself do what you'd like without feeling judged -- but it's not as simple as that.

> I'm not arguing that therapy is totally worthless, but just what is the point of therapy that only works when you've already experienced a sea change in mood?

I think that depression can cause a lot of secondary changes and do a lot of damage to your life. In addition to medication, I need help getting my life back together, figuring out what I want to do and what I'm capable of doing, etc. That's stuff that talk therapy could help me figure out.

> At the risk of receiving threats from the therapist's lobby, if you feel just good enough and are already motivated, nearly any therapy works and almost any psychobabble convinces.

I think that people who advocate talk therapy as a "cure" don't understand that. It may be that they've never had the problem of simply not feeling well enough to benefit from talk therapy.

(BTW: This board isn't really where the "therapist's lobby" types hang out -- if you're looking for them (for some reason), go to Psycho-Social-Babble.)

> But lest we forget: the side effects. I have gained about eight pounds, which I'm not happy about, but I'm hoping that the Dexedrine will help control it.

Adding Wellbutrin might prove helpful if the Dexedrine isn't enough. It's also possible that a different AD which wouldn't cause weight gain would help you as much as clomipramine does.

You should know that the Prozac is probably causing the clomipramine to be metabolized more slowly, leading to higher levels of clomipramine. (Prozac has this effect on all the tricyclics, I believe.) So you may have as much clomipramine in your body as if you were taking quite a bit more. Ask your doctor about it -- he might want you to get a serum level drawn to make sure the level is not too high. If the dry mouth is much worse than it was on the higher dose of clomipramine, you might be better off going down to 25 mg.

> Although the jury is out on whether exercise and diet make any difference, before taking the stimulant I was too tired and overwhelmed to exercise and too dispirited to make an effort to watch what I ate, which I usually do.

Although weight gain isn't so much of a problem for me, I understand what you mean. I'm not overweight, but I am out of shape, and getting back in shape is something I'd really like to do, but I just don't have the motivation, the drive, to get out and exercise.

> I have excruciating dry mouth, and nothing, not sugarless gum, not water, not tray after tray of ice cubes all day long, is helping.

Dry mouth is a problem for me too (buprenorphine causes very bad dry mouth for me), although I usually find that chewing gum or candy helps me to salivate. There is a medication called bethanechol that can help control it, but that's very short-acting. Aricept, a cholinesterase inhibitor used for Alzheimer's disease, might help more, but there's also the risk of increased depression (on the other hand, Aricept could help with concentration -- not everybody will become more depressed on it, and some might even benefit). I found that lithium made me drool more, and lithium might also increase the antidepressant effects. The dry mouth might also get better with time (it has for me). If nothing else helps, it might be good to keep a bottle of cold water with you and take sips from it regularly. Use Blistex or other medicated chap stick on your lips. It's important to try to do what you can to reduce the dry mouth, because in addition to causing sores in your mouth, dryness can also increase your risk of dental problems such as cavities and gingivitis.

> There are nasty gastrointestinal effects and bad restless leg syndrome, although not the worst I've ever had.

An increased dose of a benzodiazepine (such as Ativan) at bedtime might help with the RLS. GI problems from tricyclics are very hard to control; if constipation is the problem (it's a very common one), you might try regular Metamucil. This is also a side effect that Aricept might help with.

> I'm trying to figure out the right amount and time to take Dexedrine so that I'm awake and calm, neither wired nor tired, and able to get the sleep I need when I go to bed.

Dexedrine Spansules are usually taken twice a day, I think. I took a stimulant called Cylert in college, and it was really nice because in addition to giving me energy and motivation during the day, it also helped me sleep better and more regularly. It was long-acting so I just took one in the morning, and then I would start getting tired right around bedtime when it started to wear off. Maintaining a regular sleep-wake cycle has been a problem for me all my life (my mother even remembers me having troubles with this as an infant), so this was a really nice surprise.

> Some "happy pill" collection, huh?

Hey, if it gives you the chance to be happy (which everyone deserves), nobody should fault you for taking it. I just hope you can get the side effects under control. It would be great if the Prozac turned out to work as well as the clomipramine, because that would probably be much more tolerable. (Right now it's hard to tell because you're taking what is effectively a full dose of clomipramine because of the metabolic inhibition from the Prozac.)

> But it is at least a start and for that I am grateful.

Congratulations. :-) I hope that things keep improving for you. Welcome to Psycho-Babble!





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