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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 14 of 14. This is the beginning of the thread.
Posted by sweetmarie on March 22, 2001, at 7:24:44
I have already started a thread on this subject, and received a lot of reassurance that my case is not as unusual as I believed it to be (long term Dysthymia, plus long period of major severe depression - approx 7 years). As I siad in my original post, I`ve tried loads of different meds (too many to recall all of them), plus ECT and several years of `talk therapy`. I`ve been really encouraged by responses that I`ve received from others who have managed to remain optimistic, despite being extremely depressed. It`s actually been a quite humbling experience.
The reason for starting this new thread is an attempt to hear from anyone who has been through long-term severe depression, and come out the `other side`.
If anyone has a `success` story they can share with me (and others), I would be very pleased to hear. I guess, just to get further reassurance.
Thanks,
Anna.
Posted by Lorraine on March 22, 2001, at 10:20:40
In reply to treatment resistant depression (part 2), posted by sweetmarie on March 22, 2001, at 7:24:44
Success story? Well, I was on Effexor for two years with a complete remission in my viewpoint. Then I got off it because the side effects (weight gain and sexual dysfunction) bothered my husband too much. LOL. Actually, they bothered me too. Then I was on Moclobemide and had a lovely experience on it for 4 months before the side effects (edginess and palpitations) wore me down.
Then a period of hope followed by despair began while me and my new pdoc started trying lots of different combos over a very short period of time. All of these were quick acting drugs (not SSRI's or MAOs) so a week or so on them was a sufficient test. I kept meticulous notes on the effects of each on my particular targets (energy, mood, cognitive functions, anhedona, and anxiety). I also tried very hard to pin point what was working. SSRI's were not working. Amphetamine worked for energy and cognitive function but not mood. Right now I am on Selegiline, which is an MAO B inhibitor and does not require dietary restrictions below 15 mg/day and Neurontin. I am having a very positive effect on this combo. Not quite home free, but SUBSTANTIALLY better. We started augmenting the Selegiline with Neurontin at 100 mg 3x day. I improved cognitively, energy-wise, but again had no mood support. My pdoc said that Neurontin at higher doses gives mood support. We went up to 300 mg 3x a day and "wala" "Houston, we have ignition" This combo needs to be tweaked. For one thing, I still have mild physical anxiety (difficulty taking deep breaths and chest pain). I talked with my pdoc yesterday and we are going to try adding Mirapex (a D2/D3 agonist)to the mix slowly and watch the effects. Mirapex has anti-depressant properties, is activating, and helps with anhedonia and sexual dysfunction. By the way Selegiline helps with sexual dsyfunction as well. So now the thought is perhaps if I add the Mirapex, I can decrease the Selegiline a tad and ease the foot off the amphetamine peddle possibly lessen the physical anxiety (which I believe that Selegiline aggravates mildly). If this doesn't work then maybe we add Pindolol (a beta blocker) to the mix for the physical anxiety. Meanwhile, I have stepped up the aerobic exercise for the anxiety.
So, yes, there is a light at the end of the tunnel (hell, I'm fully functional now--I actually "leave the house" LOL). Does it take work if you are treatment resistant? Yes, Yes, Yes, Yes. I think the trick is to find a very knowledgable and adventurous pdoc and take meticulous notes. Really think through what is working and why. The notes really are key.
My pdoc by the way ran a QEEG on me and ran it through a covariance analysis using a data base of 7000 other people to determine what drug combos were likely to work for me. He came up with amphetamine and mood stabilizer. Amphetamine, for his purposes, includes MAOs. Neurontin is a mood stabilizer. But among the mood stabilizers, I tried and rejected, Depakote and Lomictal. I pushed for Neurontin because it was known to have an anti-anxiety effect as well as a mood stabilizing effect in addition to the mood stabilizing effect. (That was my piece of homework.) I'm the one who pushed for the Selegiline retrial (it made me hyperventilate without the Neurontin augmentation). But I wanted the Selegiline because it's cognitive impact is so positive and the sexual support it provides helps with the side effects of other drugs--like Neurontin which I suspect dampens my sexual function.
Both me and my pdoc believe that the traditional MAOs would work on me. What we are trying to do is come up with an MAO that doesn't impair my sexuality, make me gain weight, or have dietary restrictions. I think we are finally marching in the right direction, but it has been an extraordinarily frustrating and difficult journey for me.
I hope that I have helped with this message.
Posted by Noa on March 22, 2001, at 16:31:30
In reply to Re: treatment resistant depression (part 2), posted by Lorraine on March 22, 2001, at 10:20:40
Each of us has a different story--I like your request for some success stories. Here is mine:
I have had "double depression" (of the "atypical style") for years and finally feel successful in the treatment.
Initially, when I was in my early twenties, psychotherapy and a brief hospitalization helped, as did group therapy. Then, a few years later, with a recurrence, Prozac helped, but I only took it for a year. Repeated this again a year or so later.
Still struggled with the dysthymia, but held my own for a couple more years. But, then the major depression came back again.
Tried several ADs, including Prozac, which had less benefit this time around. It pooped out and then I couldn't tolerate the side effects at higher doses. Same with Paxil. Wellbutrin didn't sit well with me--ringing in my ears.Then, had some success with Effexor. It, too started to poop out and I had a hard time with higher doses. We added cytomel (thyroid T3)--with good improvement lasting for a while, but leveling off somewhat after a while. Then, added ritalin, also helped, but started to level off some. Then, added synthroid for more thyroid effect, which also added benefit, but started to level off after a while.
At some point, switched from regular effexor to XR, which helped a lot with some side effects, so I could tolerate a bit more of it.
Then, discovered I have sleep apnea. Got that treated (use cpap machine) and saw big improvement in fatigue, and initially, with depression, too, but but still had nagging dysthymia and anxiety, and after a while, went back to having the major depressive episodes several times a year. Increased effexor dose.
Increased stress in my life triggered even worse major depression. Added serzone, both to replace trazodone, which was to help with sleep (countering side effect of effexor), and to add more AD effect. Seemed to help some but then got even more depressed a couple of months later.
This time, the depression was also accompanied by fatigue (which hadn't been as much of a problem since started the cpap treatment a few years back), and vague aches and pains, as well as cognitive slowing ("brain fog"), and other non-specific symptoms like swollen ankles.
Pdoc speculated about some kind of bipolar spectrum depression, because of frequency of episodes--ie, could it be "cycling"? Recommended trying lithium regardless, as it has AD benefits as an augmentation strategy. Started lithium, mood got gradually better for about 8 weeks, then drastically worse (as did the physical symtpoms) due to lihtium effects on thyroid. Stopped lithium.
Got thyroid looked into more carefully, endo dxed hypothyroidism, increased cytomel and synthroid doses, then really started seeing major improvement.
Autumn saw a bit of incrased sleepiness again, and some "grumpiness", so I also suspect some seasonal component, and am hoping to get a light box before the fall season next year.
Also, I switched from Ritalin to Adderall and find it much better for me--helps me feel calm and focused.
Current cocktail:
Effexor 262.5
Serzone 350
Adderall 10 mg 2x plus 5 in late afternoon
Synthroid 50
Cytomel 12/5 2xI also take Allesse 28, an oral contraceptive, for symptoms of insulin resistance/polycystic ovary syndrome, and this might be helping my mood, too. It certainly seems to be helping to lessen my cravings for carbohydrates, which helps the overall picture.
I also started exercising in December and this helps my mood a lot. There is an especially powerful short term antidepressant/calming/anxiety-reducing effect that is unlike any med I have ever tried (including Klonopin).
Have had to "tweak" the cocktail here and there because of activating effects of effexor, and probably will do a bit more tweaking as I am still working on some of these (particularly what seems to be overactivity in the bladder), but pretty much, I would call this cocktail successful for me.
I still have a lot of "mess" (literal and figurative) to clean up after all these years, but it has been almost a year that things are better for me, and this is the steadiest period of improvement I have seen ever. Enough so that I no longer walk around in fear of depression's "other shoe falling". I can get up in the morning relatively sanely and cheerfully (and often without the alarm clock, which is still a shock to me!), can go to work in a decent mood and actually get work done and not fall to pieces all the time, and can enjoy things and get together with people on weekends, etc etc. It is a world of difference.
Through all of this, psychotherapy helped me survive and adapt, and now that I am functioning better, I feel I am able to use it to move forward more. And, not to forget....started participating here about a year and a half ago, which helped get me through some of the worst times because of the emotional support, but is also a major factor in my success story because the of how empowering the information and support has been. I think it was an important aspect of getting it all sorted out.
Posted by SLS on March 22, 2001, at 19:30:48
In reply to Re: treatment resistant depression (part 2), posted by Noa on March 22, 2001, at 16:31:30
Hi Noa.
I guess I haven't kept up with things as well as I "should". I figured you continued to feel better upon adding Serzone. I am frustrated for you to here otherwise.
> Pdoc speculated about some kind of bipolar spectrum depression, because of frequency of episodes--ie, could it be "cycling"? Recommended trying lithium regardless, as it has AD benefits as an augmentation strategy. Started lithium, mood got gradually better for about 8 weeks, then drastically worse (as did the physical symtpoms) due to lihtium effects on thyroid. Stopped lithium.
Of course, you have tried Lamictal. ???
I have recently become more impressed with the ability of low dosages of the atypical neuroleptic antipsychotics to produce robust antidepressant effects, especially when used in conjunction with antidepressants. They share a property with Serzone that is speculated to be important to treat depression and the negative symptoms of schizophrenia. They all block serotonin 5-HT2a receptors. The dopamine receptor blocking properties of the APs might also be critical to their effectiveness. Risperdal and Zyprexa have been chosen most often to fill the role of an augmentation agent in depression. Seroquel is also being tried currently, but I don't yet have an impression as to its effectiveness. If you are interested, you may want to hang out for awhile to see how well Geodon acts to treat uncomplicated depressive illness specifically (without comorbidity). No weight-gain.One other thought. You may want to discontinue the T3 temporarily to see what happens with T4 alone. Cytomel made me feel MUCH worse, while Synthroid made me feel somewhat better. Perhaps the body will know how much supratherapeutic T4 to convert to T3 to produce a healthier balance (ratio)? A shot in the dark before the light? :-)
- Scott
Posted by SLS on March 22, 2001, at 20:04:51
In reply to treatment resistant depression (part 2), posted by sweetmarie on March 22, 2001, at 7:24:44
Hi Anna.
I think I have a place along this thread.
> If anyone has a `success` story they can share with me (and others), I would be very pleased to hear. I guess, just to get further reassurance.
Often, success stories and not-quite-success stories can be told by the same person. I am one of them.
Doctors began treating me for major depression (later to be determined to be bipolar disorder) in 1982. By 1986, I had been through over 20 drugs and a few combinations. Some of these were investigational drugs never to be marketed anywhere and some procured from foreign markets.
In April of 1987, I began to see a new doctor. His first choice was to combine Parnate (an MAO-inhibitor) with desipramine (a tricyclic). The son of a bitch worked. Success.
Unfortunately, after six months of remission and a world regaling me with a kaleidoscope of wonderful experiences, I began to become manic. Within three months, I was nearly psychotic and in a mixed-state. I was in obvious need for some intervention. The doctor discontinued both antidepressants and added lithium and Klonopin to treat the mania. I am not convinced that it is always in the patient's best interests to discontinue antidepressants when mania emerges, especially when a patient has such a history of treatment resistance. Mood-stabilizers and antimanic agents are to be administered anyway. Perhaps this is enough to treat mania while the antidepressant are continued. I would like to see some investigations into such an important teatment issue. Anyway, after two months without antidepressants, I relapsed into depression. Instead of immediately returning to what had worked so well, this doctor chose to play with a brand new toy that had just become available. Prozac. It didn't work. Then he decided to put me on just one drug of the original combination. Dumb. His lack of common sense and my unquestioning faith in expertise cost me the entire decade of the 1990's to be spent lying on a couch and staring into space. To make a long and too common a story short, the same drugs that got me well in the first place never worked again. Not-quite-success. Not yet.
My initial recipe for success:
Parnate (tranylcypromine) - 60mg
Norpramin (desipramine) - 150mg
- Scott
Posted by Noa on March 23, 2001, at 7:25:18
In reply to Re: treatment resistant depression (part 2) » Noa, posted by SLS on March 22, 2001, at 19:30:48
Hey, Scott,
I think you misread--it was a long post, a synopsis of my "TRD" story, and what you responded to was not the end of the story.
The serzone - lithium chapter was over a year ago.
I am really doing quite well now. I appreciate your caring, of course.
Posted by loosmrbls on March 23, 2001, at 9:53:00
In reply to treatment resistant depression (part 2), posted by sweetmarie on March 22, 2001, at 7:24:44
I have a success story. After two years of being on numerous different antidepressants and combinations of them, I finally had success with celexa and lithium combined together.
I am one of those, like others I have read here, where the doctors think I may be more of a bipolar variant than a true "treatment-resistant unipolar depression."
My suggestion for people who have had poor luck with several different antidepressants and psychotherapy is to try augmenting the antidepressant with a mood-stabilizer. I know a lot of people who have had success with this. There are now 6 different medications that can be used as a mood stabilizer.
As for hope, I have been dysthymic (and hypomainc?) for years and major depressive for two years and thought nothing was going to work. So hang in there and don't give up!
Posted by ChrisK on March 24, 2001, at 5:07:28
In reply to treatment resistant depression (part 2), posted by sweetmarie on March 22, 2001, at 7:24:44
I sought help for my depression for the first time 20 years ago when I was 17yo. Since then it has been an on again off again struggle but mostly on again. My depression peaked within the last 5 years. I went through a period where I lost 3 good jobs during a four year period and was struggling on next to nothing.
Three years ago everything came to a head and I tried suicide twice. Both ended up in the local ICU and then a trip to the psych hospital for some rest. That's where I met my current pdoc. Since then we have put in a lot of time and effort to straighten me out.
After battling through seemingly endless trials of SSRI's, Effexor, Remeron,, etc I wanted to try TCA's since my father (also depressive) reacted to amitriptyline. I started on Nortriptyline and did better than any other trials. Biggest problem was that I still had a lot of suicidal thoughts.
The best med change I ever made was to start Zyprexa. I t alleviated almost all of my negative thinking and obsession with death. I still wasn't completely out of the depression but I was almost functional again. I still wasn't working and really lacked emotions but I wasn't wanting to kill myself.
For the next year or so we tried to eliminate the anhedonia and get some type of activating med that would help with the anergia too. I went through most of the stimulating meds from Wellbutrin to Adderall and ritalin. Nothing really changed my mood even if I was a little more active.
During this time I got well enough to take on a part time job. The big change though came this year. On January 2nd I started taking Mirapex. After a lot of internet research I convinced my pdoc that it was worth a try and now I'm glad he agreed. I finally have emotions back. I can enjoy simple things.
This year I am working a few more hours per week and feel like I'm getting something out of my job (even though it has absolutley nothing to do with what I was doing in the past and went to college for). I joined a social/charitable group and stay active with them. I joined a dart league and look forward to a golf league this summer. These are things that never would have been part of my life a year ago.
I'm not saying that my med program is the best for everyone but it has worked out for me. It's only been three months but I have hope that it will last. Right now I'm down to just the Nortriptyline, Zyprexa and Mirapex. There were times when I couldn't keep track of all of the meds I was taking - sometimes up to 6 at a time.
There is hope. If I can get through things after 20 years of lost hope then I truly believe that there is something out there to help just about anybody.
Chris
Posted by SLS on March 24, 2001, at 8:32:30
In reply to Success Stories, posted by ChrisK on March 24, 2001, at 5:07:28
Hi Chris.
I am sorry if this post has drifted too far from the thread, but I wanted to seize the opportunity to ask you a few questions that you are an ideal person to ask.
> After battling through seemingly endless trials of SSRI's, Effexor, Remeron,, etc I wanted to try TCA's since my father (also depressive) reacted to amitriptyline. I started on Nortriptyline and did better than any other trials. Biggest problem was that I still had a lot of suicidal thoughts.
I started taking nortriptyline about three weeks ago. I have been taking 100mg. My blood level was tested at 123 ng/ml. How much nortriptyline are you taking and what is your blood level? Have you ever lost the antidepressant effect from taking to high a dosage?
> The best med change I ever made was to start Zyprexa. I t alleviated almost all of my negative thinking and obsession with death. I still wasn't completely out of the depression but I was almost functional again. I still wasn't working and really lacked emotions but I wasn't wanting to kill myself.
I have tried both Risperdal and Zyprexa. Each produced an unexpected mild improvement of depression at 1.0mg and 2.5mg respectively. However, when it seemed necessary to raise the dosages to 1.5mg and 5.0mg, I experienced some sort of cognitive disturbance that includes a further impairment of both memory and the abilility to learn new things. I also felt somehow "spacy" or "foggy" and distant and numb from everything around me. There was even some blunting of affect. These effects lasted for over a week with both drugs, and my doctor suggested that if they hadn't subsided after a week, then it was unlikely that they would.
Have you experienced anything like this? Do you think that such effects would disappear with time?
> During this time I got well enough to take on a part time job. The big change though came this year. On January 2nd I started taking Mirapex. After a lot of internet research I convinced my pdoc that it was worth a try and now I'm glad he agreed. I finally have emotions back. I can enjoy simple things.
I was looking forward to adding Mirapex to either Risperdal or Zyprexa. From looking at the PB board, it seems that robust, long-lasting improvements have occurred in people who have added Mirapex to either one of these APs. I will try Mirapex anyway at some point. Although I might go on to try Geodon (ziprasidone), I am pessimistic that it will produce the same adverse cognitive effects as did Risperdal and Zyprexa.
I am so glad that your story qualified for inclusion in the "success" column.
Thanks, Chris.
- Scott
Posted by ChrisK on March 24, 2001, at 9:23:29
In reply to Re: Success Stories » ChrisK, posted by SLS on March 24, 2001, at 8:32:30
Scott,
I've been taking 100 mg/day of Nortriptyline for almost two years now. I don't know what my blood level is - I just know that it has been the most stable AD I've taken as far as results being those expected. I really haven't lost the effect and have never gone above 150 mg/day at any time.
As far as the Ap's go I did try Risperdal at one time. 2.0 mg/day made me into a zombie. I was in a fog with no emotions at all for 2 weeks before giving it up. When I originally started Zyprexa I was given the 2.5 mg pills and I was left to adjust my dose as needed. I ended up with my current dose of 7.5 mg/day. (Some of that comes from being about 250 pounds and med resistant.) I do have short term memory problems but I'm not exactly sure what to blame it on. I also have a past history of alcoholism which I'm sure doesn't help the memory problems. I still notice effects to my thinking if I miss two doses of Zyprexa. I do believe that the Zyprexa does not help the memory problem but I'm willing to accept that if it means the remission of my suicidal thoughts.
As for the Mirapex, I would reccommend a trial to anyone. The side effect profile is very small and it has been studied favorably for its AD effects. I would definitely reccommend it for anyone having problems with anhedonia.
Looking at my meds I consider each of them valuable for the symptom that they each address.
Nortriptyline: typical depression sadness, weeping, moodiness, poor self esteem, etc.
Zyprexa: Ruminating/obsessive thoughts esp. death
Mirapex: Anhedonia/anergia
Hope this helps,
Chris
Posted by Lorraine on March 24, 2001, at 11:54:05
In reply to Re: Success Stories » SLS, posted by ChrisK on March 24, 2001, at 9:23:29
I was taking 10 mg Selegiline (an MAO B inhibitor) and Neurontine (900 mg). I convinced my pdoc to try Mirapex. I started at .125 mg and it hit me hard. I felt really pretty loopy and wiped out. Also almost fell asleep at the wheel driving -- during the day! Anyway I know the latter is a side effect of Mirapex.
My question to you is was my one day experience an adequate trial or is this a drug that you need to take for a week or so to be able to truly gage its effects?
Also, what was starting it like for you?
Do you know if this falling asleep during driving is a side effect that goes away with time?
I'd really appreciate you response to these questions. I'm doing pretty well on my current cocktail, 5 mg dexidrine, 5 mg selegiline and 900 mg Neurontin. Although I still have physical anxiety (tightness in chest, difficulty taking in a deep breath). I was thinking Mirapex was activating and could take the place of the dexidrene (which took the place of 5 mg of Selegiline). Mirapex felt more like a doggy-downer than a puppy upper to me. Dr. Koop notes that there is a "mild" interaction between Mirapex and Neurontin and it is possible that the Mirapex was enhancing the Neurontin effects.
Finally, did Mirapex have any impact on anxiety?
Thank you.
Posted by ChrisK on March 24, 2001, at 12:48:10
In reply to Re: Success Stories Chris, posted by Lorraine on March 24, 2001, at 11:54:05
I am basically med resistant. I had no problem going to 3 mg/day of Mirapex within a few days. I am not the best judge for people that find side effects right away.
I know that other meds I have taken have left me without side effects. The biggest thing that impacted my anxiety was Zyprexa. If you have anxiety problems with depression I would reccommend the AP's rather than the Benzo's to start with. The bezo's are great but if you want a combination med then you may want to look at augmenting your AD.
Hope this helps,
Chris
Posted by michael on March 24, 2001, at 14:37:28
In reply to Re: Success Stories Chris » Lorraine, posted by ChrisK on March 24, 2001, at 12:48:10
So Chris,
I take it that you're taking 1mg three times a day of mirapex? (I may have already asked you about your dosage-sorry if I'm repeating myself)
Also, re: side effects, I'm curious if you noticed any sexual side effects - either positive or negative? Or no impact at all? If I'm getting too personal, I appologize, and please just don't bother to respond to that issue. Thanks for any info... michael
> I am basically med resistant. I had no problem going to 3 mg/day of Mirapex within a few days. I am not the best judge for people that find side effects right away.
>
> I know that other meds I have taken have left me without side effects. The biggest thing that impacted my anxiety was Zyprexa. If you have anxiety problems with depression I would reccommend the AP's rather than the Benzo's to start with. The bezo's are great but if you want a combination med then you may want to look at augmenting your AD.
>
> Hope this helps,
> Chris
Posted by ChrisK on March 25, 2001, at 4:03:54
In reply to Re: Success Stories Chris » ChrisK, posted by michael on March 24, 2001, at 14:37:28
Michael,
Yes I am taking 1mg three times per day. It's considered a moderate dose. I am considering doubling it next week when I see my pdoc. The one study that I read showed that patients on 5 mg/day reacted even better than the grooup at 3mg/day but that they didn't stay on the dose long enough due to problems with the naseau side effect. The literature says to titrate slowly to your dose because there were a lot of upset stomachs during the testing.
As far as the sexual effects the equipment is working better than in the past but some of the desire is still lacking. I'm hoping that some of the romance comes back soon. I do have the feeling that it will be back but it's been gone so long that I understand it will take some more time to get back.
This is the end of the thread.
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