Posted by yxibow on June 21, 2008, at 3:34:30
In reply to Re: Rocket Fuel Failed; What Magic Combo Is Next?, posted by BGB on June 11, 2008, at 16:49:11
> Thanks to everyone that responded! What great advice! I am going to give my current p-doc one more shot to get me off some of this medication, and if he continues to refuse, I am finding a new one. This has been an excellent lesson for me--just because a doctor has awards all over his walls, and other psychiatrists (and patients) think that he's god's gift, doesn't mean he's a good doctor for me. Believe it or not, my p-doc has even been discussed and praised here on this very board (mostly due to his rTMS clinic). I don't know how I'm going to find another one...but something has to change!
>
> Thanks again to everyone for your responses. I really do appreciate the time and thought that you put into your replies.
>
> Take care,
> B =)
I would personally try a second opinion, not necessarily a second doctor, at first -- for one reason, every time you establish a relationship with a doctor, it is a personal repartee and the doctor is aware (hopefully) of what has been tried in a journal.For a second opinion, I wouldn't send a diagnosis necessarily, that is up to you, but I would have your doctor include what has been tried.
Under HIPAA and under various state laws, if you're in the US, you will have to sign a bidirectional agreement form, that is your doctor will fax a signature of release of records to the second opinion doctor, and vice versa.
What you noted was important -- "you are on a ton of medications..." Sometimes simplification is better than polypharmacy, sometimes not.
That is an awful lot of serotonin going on -- Cymbalta as said in general has a 6:1 serotonin to NE ratio -- you're on Remeron at a dose far beyond the alpha range into the 5HT blockade, the Lamictal may boost the serotonergic effects, its hard to say what it does exactly, and 150mg of Trazodone is just on the cusp of serotonergic activity.
Some who have tried MAOIs will say go straight to an MAOI -- I personally disagree with using MAOIs first, they, and perhaps this is a generalization across the board, but they do share black box properties not quite like Clozaril, but there are definite informed consent that one needs to know before going ahead.It is noted by the manufacturer that the lowest dose of EMSAM (selegeline transdermal) does not have have the tyramine problem. But one may need greater than the lowest dose, and that does have similar issues to standard MAOIs.
This may be really offensive, and I apologize if it is, because I know that there are people with treatment resistent depression -- and you could certainly be one of them, but to take one myself (this is a projection -- I know, I have been told this before -- we all project at times because we have memories of what has happened to ourselves) strikes me vicerally, because its almost like creating PKU or diabetes I/II for yourself.
You have to be careful about going out to eat and how much of a restricted item is in the meal you're about to eat -- and if there is a language barrier, you may not know at all. If you're a vegetarian, it creates a larger problem (which is why I personally couldn't take an MAOI -- yes, projection.)
At home, favorite foods may have to be forgone, labels may have to be read (okay, as a vegetarian I read labels too just for ethical reasons, so I can resonate there...)
I guess if it is a choice between "Honestly, I can't think about anything other than suicide. It's all that goes through my mind." as an ideation and... I won't go further... then there are perhaps certain things one has to forgo and be careful of and maybe a second opinion will have a list of medications that include MAOIs. Its like my yet eternal choice of Clozaril that hasn't materialized for a lot of personal and pharmaceutical reasons.
So for whatever medication, sometimes you have to either choose side effects, or live with a condition. This is true for all things in life. The benefits have to outweigh the risks -- and if the risks are actual suicide then there are a few types of medications that do lessen that -- APs (neuroleptics) and Lithium, in some cases.
There have been days in the past and days recent when I have also had ideations. I am clinically depressed on top of a major condition that has no single point of solution. But I choose not to add yet more serotonin to the mixture, and I think my doctor would agree. I also think personally that raising SSRIs could hasten things I don't want to think of but are always at the back of my mind with the AP I am on.So long story short -- I would advocate a tricyclic before going to MAOIs. They vary widely in their effectiveness -- Doxepin is probably the least effective for what you are suffering from just from a wild guess. Imipramine or Amitriptyline are probably more effective.
They are also not without their risks -- anticholinergic at the top, and mm... excess dosage, I hate to say that to a depressed person or anyone on the board for that matter, but I was told that too, in a roundabout way.
But since you haven't tried anything in that spectrum, you could.
Also, on another subject, addressing "over the 10 years..." Some people will disagree, but I do believe very strongly that most cases of mental illness are due to some biochemical disorder or genetic tendency.And this is fluid and a moving target... so a retrial of a medication that you used 10 years ago may produce different effects now than it did before. Of course visiting the laundry list of medications that really didn't work is daunting, so I'm not saying to go back to everything, but maybe the one that did a little inch to things.
As for the buprenorphine -- I would be careful of interactions with that large list... yes, a number of individuals have discussed this one the board.I even have thought about it. At least in this country under the Drug Addiction Treatment Act of 2000, only a psychiatrist who specializes in addiction medicine and has the additional training can do such trials if they even have done so in their practice.
It could be a double edged sword, not to mention your doctor does not know you're taking it. Adding an opiate (and this doesn't contain naloxone) could initially create euphoria, but could also increase depression.
As for rTMS that is still an "Investigational Device Exemption" under the FDA. There have not been a lot of placebo effect studies. This and its status may be changing in the near future.
ECT I would reserve for last resort, even over an MAOI. Although at an institution I am familiar with, no patient has ever died of it in modern times, there are a littany of memory effect issues (and cost of it, which may not be insurance covered) that have been discussed before so I won't go into them, but they can be minor to major. And there is also the possibility of having to do it multiple times.
So in this rambling discussion as I am probably known for I would say:
Get a second opinion. Have an open mind, but it would be good not to place "magical expectations", for a lack of better words -- there will be some results and presumably some different list of medications, but some may include some you have tried and some that may be contraindicated at the moment, it is certainly possible. Do include and maybe write down your own list of things you want to bring up and any health issues, and other things you want to point out.
Try a tricyclic, or other tricyclics. They do have more drug interactions, so combinations with other therapies may have to be considered.
If that fails, and a good number of weeks have to have passed before consideration, I would possibly try maybe the low dose EMSAM patch, if warranted by whatever doctor you have.
Beyond that, there are augmenters, you have tried one, there is Deplin, which for a certain small set of people does work, but may cause some anxiety.And yes, beyond that there are MAOIs. For that I leave up to your choice.
People have different definitions of "magic combinations", "magic medications" -- for me, I have been told there is no "magic bullet." It's true, there is nothing that will knock all the multifaceted things that are going on at the same time in 2008. On the other hand, some people think that a medication or a set of them are "magic", that is, a feeling of success.
But beyond all of this, I wouldn't also rule out psychotherapy, because there are psychological components to depression as well. Taking a medication is not the only thing in life that will rule out things. Yes, there are "cocktails" for HIV/AIDS (not without serious side effects), etc.About the only thing I can think fore example that is a sure fire "cure" in any medical situation is perhaps an antibiotic (if not overused and become useless to the general population which is increasingly the case) for a known strep infection (provided one doesn't have allergies to the drug).
Anyhow I wish you luck on whatever decision you do go with.-- best wishes
-- tidings
- Jay
poster:yxibow
thread:833832
URL: http://www.dr-bob.org/babble/20080617/msgs/835748.html