![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 17 of 17. This is the beginning of the thread.
Posted by jerrympls on December 13, 2004, at 17:53:06
I'm currently on:
Cymbalta - 60mg
Klonopin - 1mg a.m. 2mg at bedtime 1mg prn
Dexedrine - 15mg 3x daily
Seroquel - 150mg bedtime (for insomnia)
Mirapex - .5mg for restless legsI haven treatment-resistant depression. I'm extremely apathetic and emotionally numb. I get no enjoyment from anything - all desires are dead. I feel blank. The dexedrine is mainly so I can focus and work. Other than that - I have no friends nor the energy for them. I'm a musician and haven't played for many years. I used to get warmth from listening to music - but not in many years. One thing that DOES help all this is opiates -mainly hydrocodone. My pdoc did some opiate trials with me about a year ago - but decided against continuing because she got scared about using them. Now in my record it says "Opiate trial was a failure," even though they helped me emensouly.
As for asking me about what else have I tried - I've tried it all - every SSRI, SNRI, MAOI, tricyclic (imipramime, desipramine), ECT and the VNS implant. I'm in therapy as well.
I'm running out of hope.
Thanks in advance for anyone taking a stab at this.
Jerry
Posted by Racer on December 13, 2004, at 19:46:27
In reply to Can someone evaluate my meds?, posted by jerrympls on December 13, 2004, at 17:53:06
I am not one of the experts, but I wonder if the Cymbalta might be adding to the amotivation? It's had that effect for me. Provigil has helped me a lot, with countering that amotivation and in generally brightening my mood. Doesn't work for everyone, but it might be worth a try?
Best luck, and someone who knows something will be along soon. ;-)
Posted by jerrympls on December 13, 2004, at 20:18:05
In reply to Re: Can someone evaluate my meds?, posted by Racer on December 13, 2004, at 19:46:27
> I am not one of the experts, but I wonder if the Cymbalta might be adding to the amotivation? It's had that effect for me. Provigil has helped me a lot, with countering that amotivation and in generally brightening my mood. Doesn't work for everyone, but it might be worth a try?
>
> Best luck, and someone who knows something will be along soon. ;-)I thought about that and I think it is contributing. My pdoc and I are going to revisiting other AD's - perhaps a tricyclic. I haven't felt this apathetic in the 13 years I've had depression. I don't doubt the Cymbalta is playing a part.
Thanks
Jerry
Posted by banga on December 13, 2004, at 21:08:46
In reply to Re: Can someone evaluate my meds? » Racer, posted by jerrympls on December 13, 2004, at 20:18:05
I was going to also say--that Cymbalta may have a role in your present difficulties. I personally was not impressed with Cymbalta, it was not for me. I was caught in an odd place---more agitated and anxious, yet less motivated to get out of bed and do something with the agitation.
That waas the last straw. No more SSRis or SNRIs for me. I will only try a tricyclic that actsi primarily on norepinephrine.
Sorry I dont have more to comment, I am not versed enough in psychotropic meds to give more than impressions and personal experiences.
Take care!
Posted by gnepig on December 13, 2004, at 21:23:47
In reply to Re: Can someone evaluate my meds? » Racer, posted by jerrympls on December 13, 2004, at 20:18:05
I have been cutting back on my Cymbalta due to same effects. After reading other's comments of SRI's, and Effexor and Cymbalta, I have decided they have no place in my life either. Will continue to monitor posts to gain insight. P gnepig
Posted by jerrympls on December 13, 2004, at 21:58:39
In reply to Re: Can someone evaluate my meds?, posted by gnepig on December 13, 2004, at 21:23:47
Interesting you both have had similar problems with Cymbalta. My thought was to switch to a tricyclic too. I think today's meds - SSRIs and SNRIs are crap - dulling.
Posted by rvanson on December 14, 2004, at 4:55:18
In reply to Can someone evaluate my meds?, posted by jerrympls on December 13, 2004, at 17:53:06
> I'm currently on:
>
> Cymbalta - 60mg
> Klonopin - 1mg a.m. 2mg at bedtime 1mg prn
> Dexedrine - 15mg 3x daily
> Seroquel - 150mg bedtime (for insomnia)
> Mirapex - .5mg for restless legs
>
> I haven treatment-resistant depression. I'm extremely apathetic and emotionally numb. I get no enjoyment from anything - all desires are dead. I feel blank. The dexedrine is mainly so I can focus and work. Other than that - I have no friends nor the energy for them. I'm a musician and haven't played for many years. I used to get warmth from listening to music - but not in many years. One thing that DOES help all this is opiates -mainly hydrocodone. My pdoc did some opiate trials with me about a year ago - but decided against continuing because she got scared about using them. Now in my record it says "Opiate trial was a failure," even though they helped me emensouly.
>
> As for asking me about what else have I tried - I've tried it all - every SSRI, SNRI, MAOI, tricyclic (imipramime, desipramine), ECT and the VNS implant. I'm in therapy as well.
>
> I'm running out of hope.
>
> Thanks in advance for anyone taking a stab at this.
>
> JerrySounds like you have tried it all.
If I were you, and I am not a doctor BTW, I'd dump your Pdoc for one that would resume treatment on the opiates. If thats what works, use it, I say.
Life's too short, and too many of these Pdocs just want to play it safe and collect your health insurance money, while leaving you out to dry, IMO.
Posted by ed_uk on December 14, 2004, at 5:54:02
In reply to Re: Can someone evaluate my meds?, posted by rvanson on December 14, 2004, at 4:55:18
Hi Jerry,
Have you tried nortriptyline? It's often effective for severe depression. You might be interested in my post about opioids, scroll up the page and you'll see it.
Regards,
Ed.
Posted by jujube on December 14, 2004, at 9:01:22
In reply to Re: Can someone evaluate my meds?, posted by ed_uk on December 14, 2004, at 5:54:02
Ed,
Do you know if Nortriptyline works on both serotonin and norepinephrine?
Tamara
Posted by Bill LL on December 14, 2004, at 9:19:15
In reply to Can someone evaluate my meds?, posted by jerrympls on December 13, 2004, at 17:53:06
Jerry- You sound like the patients treated by the authors of this article. Maybe you could try talking to your doctor again. If that doesn't work, perhaps you could find another doctor who would precribe an opiate.
Am J Psychiatry 156:2017, December 1999
© 1999 American Psychiatric AssociationLetter to the Editor
Treatment Augmentation With Opiates in Severe and Refractory Major Depression
ANDREW L. STOLL, M.D., and STEPHANIE RUETER, B.A.
Belmont, Mass.
To the Editor: Substantial evidence supports the antidepressant efficacy of opiates (1). This report summarizes our open-label experience using the µ-opiate agonists oxycodone or oxymorphone in patients with highly refractory and chronic major depression.
Mr. A was a 44-year-old man with severe and chronic depression. Numerous trials of antidepressants produced only limited benefit. Mr. A also had an extensive history of opiate abuse, and he noted that the only times he ever felt normal and not depressed was during opiate use. Because of the refractory nature of his depressive symptoms and his apparent self-medication with opiates, Mr. A was given a trial of oxycodone under strict supervision. After 18 months of oxycodone treatment (10 mg/day), Mr. A remained in his longest remission from depression without the emergence of opiate tolerance or abuse.
Ms. B was a 45-year-old woman with bipolar disorder and opiate abuse (in remission for 2 years). A trial with standard mood stabilizers had failed, and she had experienced mania with several standard antidepressant drugs. As with Mr. A, Ms. B reported feeling well only when taking opiates, particularly oxymorphone. Oxymorphone (8 mg/day) was thus cautiously added to ongoing lamotrigine therapy (as a mood stabilizer), and she remained well for a minimum of 20 months without drug tolerance or abuse.Mr. C was a 43-year-old man with chronic major depression that was unresponsive to numerous antidepressants with and without augmentation. Detailed questioning revealed that he once experienced marked antidepressant effects from opiates that he received after a dental procedure. There was no history of opiate abuse, and a cautious trial of oxycodone was initiated. Mr. C experienced a dramatic and gratifying antidepressant response from oxycodone (10 mg t.i.d. for 9 months) without opiate tolerance or abuse.
This report describes three patients with chronic and refractory major depression who were treated with the µ-opiate agonists oxycodone or oxymorphone. All three patients experienced a sustained moderate to marked antidepressant effect from the opiates. The patients described a reduction in psychic pain and distress, much as they would describe the analgesic effects of opiates in treating nocioceptive pain.Two of the three patients described in this report were previous abusers of opiates. Although the clinical use of opiates in patients with a history of opiate addiction is usually contraindicated, in these cases there was a strong indication that they were self-medicating their mood disorders (2) with illicit opiates. None of the patients abused the opiates, developed tolerance, or started using other illicit substances.
We used oxycodone in three additional patients without histories of opiate abuse. In two of these three patients, oxycodone produced a similar sustained antidepressant effect. Two of these patients experienced mild-to-moderate constipation, and one experienced daytime drowsiness from the opiates. Opiates should be considered a reasonable option in carefully selected patients who are desperately ill with major depression that is refractory to standard therapies.
REFERENCES
Bodkin JA, Zornberg GL, Lukas SE, Cole JO: Buprenorphine treatment of refractory depression. J Clin Psychopharmacol 1994; 15:49–57
Khantzian EJ: Self-regulation and self-medication factors in alcoholism and the addictions: similarities and differences. Recent Dev Alcohol 1990; 8:255–271[Medline]
> I'm currently on:
>
> Cymbalta - 60mg
> Klonopin - 1mg a.m. 2mg at bedtime 1mg prn
> Dexedrine - 15mg 3x daily
> Seroquel - 150mg bedtime (for insomnia)
> Mirapex - .5mg for restless legs
>
> I haven treatment-resistant depression. I'm extremely apathetic and emotionally numb. I get no enjoyment from anything - all desires are dead. I feel blank. The dexedrine is mainly so I can focus and work. Other than that - I have no friends nor the energy for them. I'm a musician and haven't played for many years. I used to get warmth from listening to music - but not in many years. One thing that DOES help all this is opiates -mainly hydrocodone. My pdoc did some opiate trials with me about a year ago - but decided against continuing because she got scared about using them. Now in my record it says "Opiate trial was a failure," even though they helped me emensouly.
>
> As for asking me about what else have I tried - I've tried it all - every SSRI, SNRI, MAOI, tricyclic (imipramime, desipramine), ECT and the VNS implant. I'm in therapy as well.
>
> I'm running out of hope.
>
> Thanks in advance for anyone taking a stab at this.
>
> Jerry
Posted by ed_uk on December 14, 2004, at 9:34:19
In reply to ? for Ed (Sorry to interrupt the thread Jerry) » ed_uk, posted by jujube on December 14, 2004, at 9:01:22
Hi,
Nortriptyline mainly acts as a norepinephrine reuptake inhibitor, it is only a very weak serotonin reuptake inhibitor. It also blocks 5-HT2 receptors.
Regards,
Ed.Bill pinched my article which I pinched out of a journal!!!
Posted by jujube on December 14, 2004, at 9:48:45
In reply to Re: For jujube, posted by ed_uk on December 14, 2004, at 9:34:19
Thanks Ed. You are such an incredible wealth of knowledge - it's amazing. One more question. In your opinion, would nort work well with Celexa (nort for energy and motivation and Celexa for anxiety)?
Tamara
> Hi,
>
> Nortriptyline mainly acts as a norepinephrine reuptake inhibitor, it is only a very weak serotonin reuptake inhibitor. It also blocks 5-HT2 receptors.
>
> Regards,
> Ed.
>
> Bill pinched my article which I pinched out of a journal!!!
>
Posted by ed_uk on December 14, 2004, at 9:56:50
In reply to Re: For jujube » ed_uk, posted by jujube on December 14, 2004, at 9:48:45
>would nort work well with Celexa (nort for energy and motivation and Celexa for anxiety)?
Hi,Yes, it could do. Nortriptyline sometimes causes drowsiness though.... other people find it stimulating. Desipramine would be less likely to cause drowsiness than nortriptyline. Also, if citalopram is responsibe for reducing your energy and motivation, nortriptyline might not be adequate to ofset this. On the other hand, combining nortriptyline with citalopram could have a good antidepressant effect, it is a logical combination. In general, nort causes less dizziness and hypotension than clomipramine.
Regards,
Ed.
Posted by jujube on December 14, 2004, at 10:08:40
In reply to Re: For jujube, posted by ed_uk on December 14, 2004, at 9:56:50
> >would nort work well with Celexa (nort for energy and motivation and Celexa for anxiety)?
>
>
> Hi,
>
> Yes, it could do. Nortriptyline sometimes causes drowsiness though.... other people find it stimulating. Desipramine would be less likely to cause drowsiness than nortriptyline. Also, if citalopram is responsibe for reducing your energy and motivation, nortriptyline might not be adequate to ofset this. On the other hand, combining nortriptyline with citalopram could have a good antidepressant effect, it is a logical combination. In general, nort causes less dizziness and hypotension than clomipramine.
>
> Regards,
> Ed.
Thanks Ed. I am actually leaning towards Provigil as an augmenter to Celexa, which I believe works on both norepinephrine and dopamine (but I am not too sure about how it works), with Xanax as needed for anxiety, if my pdoc agrees. What do you think of that combo? Would that help me get my energy and motivation back?(Sorry Jerry. This is my last question. I apologize profusely for momentarily highjacking your thread with my self-centered questions. Hope you get some solid suggestions to take to your pdoc. Good luck to you.)
Tamara
Posted by Ritch on December 14, 2004, at 10:16:13
In reply to Can someone evaluate my meds?, posted by jerrympls on December 13, 2004, at 17:53:06
I'm currently on:
Cymbalta - 60mg
Klonopin - 1mg a.m. 2mg at bedtime 1mg prn
Dexedrine - 15mg 3x daily
Seroquel - 150mg bedtime (for insomnia)
Mirapex - .5mg for restless legsI don't know if there is anything I could mention that you probably haven't heard or considered before, but here goes... I agree with the other posters about the Cymbalta-wasn't too impressed with it. Thought Effexor was still a lot better. The Klonopin could definitely be worsening things. If I go above 1mg a day it starts running me down and making me sullen. The dexedrine.. it worked well for me in the past.. but you might be getting a tolerance to it and stims can induce depression after a few weeks. I remember getting 'blah' on dexedrine after a few weeks and feeling very bored. The Seroquel could be zombifying you to some extent as well. You noted that it is for insomnia.. from the dexedrine and Cymbalta..? I haven't found stims and AP's to work too well together either. I tried Mirapex before too and it didn't do anything but make me very lethargic.. but it looks like you are taking it at night only. It kind of looks like stuff got added on to counter effects of other meds.. My 'suggestions' would be to try to get the clonazepam reduced slowly (I haven't been on a benzo yet that didn't depress me at some dosage level). Also, perhaps get the dex tapered down some-maybe you got some major tolerance issues? Then, maybe you could sleep better. I hope this helps. My 2c would be to *reduce* the potential culprits and see if you get some help that way.
Posted by ed_uk on December 14, 2004, at 10:38:57
In reply to Re: For jujube » ed_uk, posted by jujube on December 14, 2004, at 10:08:40
Hi,
Provigil can be useful to decrease drowsiness. If your lack of motivation is caused by feeling tired all the time, Provigil might help. It might also increase your energy.
On the other hand, if serious depressive symptoms are your main problem, a tricyclic might be better.
Regards,
Ed.
Posted by Laree on December 14, 2004, at 21:49:35
In reply to Can someone evaluate my meds?, posted by jerrympls on December 13, 2004, at 17:53:06
I tried Seroquel for a short time about 2 years back (for insomnia as well) and it made me feel VERY "hung-over" the next morning/day, foggy, and even somewhat apathetic/moody as well. I tend to think that atypical AP's are extremely potent & should be reserved soley for those with psychosis or related disorders. Of course, there are always exceptions, but I think you get my drift...
Also, I have heard that Klonopin (namely taken over a significant period of time) can cause/exacerbate depression. I am currently taking it but it has caused no problems in that area (at least yet, knock on wood!) as far as i can tell. I have been on Valium a couple of times, which is in the same class of drugs as Klonopin, and it has made me feel really depressed while on it in the past. Everyone's different!!
Best,
L.
> I'm currently on:
>
> Cymbalta - 60mg
> Klonopin - 1mg a.m. 2mg at bedtime 1mg prn
> Dexedrine - 15mg 3x daily
> Seroquel - 150mg bedtime (for insomnia)
> Mirapex - .5mg for restless legs
>
> I haven treatment-resistant depression. I'm extremely apathetic and emotionally numb. I get no enjoyment from anything - all desires are dead. I feel blank. The dexedrine is mainly so I can focus and work. Other than that - I have no friends nor the energy for them. I'm a musician and haven't played for many years. I used to get warmth from listening to music - but not in many years. One thing that DOES help all this is opiates -mainly hydrocodone. My pdoc did some opiate trials with me about a year ago - but decided against continuing because she got scared about using them. Now in my record it says "Opiate trial was a failure," even though they helped me emensouly.
>
> As for asking me about what else have I tried - I've tried it all - every SSRI, SNRI, MAOI, tricyclic (imipramime, desipramine), ECT and the VNS implant. I'm in therapy as well.
>
> I'm running out of hope.
>
> Thanks in advance for anyone taking a stab at this.
>
> Jerry
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.