Posted by dewdropinn on July 26, 2007, at 14:00:19
In reply to Re: Patch decision - What to do?, posted by JohnSky on July 26, 2007, at 10:27:38
Even though Lithium is sometimes thought of as having antidepressant qualities, I don't think it's particularly effective in this capacity -- it made me feel a bit stupid and spacey, and it certainly didn't help my mood. The anti-psychotics can have a whole range of effects and side effects -- I marvel at the extreme reaction people have to various atypical anti-psychotics -- from miraculous improvements to a rapid descent into total wackiness. So, I would say all bets are off as far as assessing what lithium and seroquel are doing for the overall picture. I would trust your doctor though -- he's prescribed you EMSAM, so he's clearly open to experimentation -- I would keep him appraised of your mood fluctuations.
The dietary precautions with the 9mg patch are definitely soft. I'm guessing that you're familiar with the mechanisms involved with the tyramine reaction. If not, it's associated with MAOI metabolism in the liver -- the theory behind the patch is that it largely bypasses the liver, and thereby bypasses the whole tyramine problem. During the clinical trials, they worked very hard to induce the tyramine reaction, and as far as I know, they were unable to -- the lack of dietary risks was supposed to be one of the major selling points of the drug, which is why Bristol-Meyers fought with the FDA to get these warnings removed -- it would seem they had the clinical evidence in hand, but the FDA was unyielding. The FDA decision was based on the fact that, even though the patch largely bypasses the liver, at the higher doses a sufficient amount of the drug could conceivably accumulate in the liver so as to pose a risk. So, that's the scoop on the dietary restrictions. The big risk with the patch is associated with drug-drug interactions -- over-the-counter drugs like Sudafed and any other decongestants can trigger a hypertensive reaction, so this should be the primary safety concern.
I removed the patch at bedtime both when I was at 6mg and now that I am at 9mg -- I literally could not sleep if I kept it on, unless I took klonopin or ativan. When I started removing the patch at bedtime, I found that I was able to fall asleep without any additional medication.
One final thought -- raising the EMSAM dose to 9mg should help the overall depression situation, so long as more serious bipolar issues are present. Lithium and seroquel may be needed, but the pharamocology of the 2 drugs may be compromising or altering the efficacy of EMSAM -- both drugs impact serotonin and dopamine (albeit in different ways), so it would seem to follow that they will at the very least impact the effect of EMSAM (for the better or worse.) I've already mentioned lamictal -- so that's an option. But an even easier option would be Klonopin, which would address any residual insomnia and anxiety. Some doctors -- particularly doctors under the age of 40 -- are ridiculously skittish about giving patients benzos for fear of addiction. They instead give non-benzo hypnotics, which are somewhat unpredictable, and APs like seroquel, which have no long-term track record and some worrisome potential side effects. One of my very old school pdoc pals said that, in all of his years of practice, the benzos were simply the greatest anti-anxiety/sedative drugs of all-time -- and the addiction risks vary considerably from one drug to the next -- halcyon being the most addictive, klonopin being the least. Having given all the non-benzos and most of the APs a whirl, I believe the old guy was right -- that's my personal opinion and the very old school doc's assessment, rather than any kind of universally excepted truth. In any event, I would definitely consider Klonopin -- it will help with the anxiety and insomnia, it will greatly simplify your regiment, and so long as you don't escalate the dose, the risk of long-term dependency is low.
That's my 2 cents -- just let me know if you have any other questions.
> Forgot to ask. If I go up to 9mg does the preferred method seem to be to take it off at night? Also, Are most people abiding by the dietary restrictions or are they "soft".
>
> John
poster:dewdropinn
thread:769334
URL: http://www.dr-bob.org/babble/20070719/msgs/772127.html