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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 24 of 24. This is the beginning of the thread.
Posted by CK1 on October 17, 2005, at 22:54:37
Hi Peep,
I just started Nardil a few days ago and I'm feeling better already, but my doctor thinks I have soft/fuzzy bipolar since my Paxil pooped out after a few years and my response to SSRI's since then hasn't been good. I haven't responded to 4 straight SSRI's since, my friend, Paxil left me high and dry!He believes that even if I get a great response from Nardil, it might poop out just like Paxil. According to him, SSRI's only poop out because of bipolar disorders and long term reduction of dopamine.
If Nardil flops (which it better not!), he thinks putting me back on Paxil and adding Seroquel or another AP will bring Paxil back to life so to speak. He's added antipsychotics to an SSRI for many of his patients whose drugs pooped out on them and most seem to regain their response long term.
Does anyone have experience with the SSRI + AP combo? It seems interesting! I like what I see! Antipsychotics seem like very cool drugs, despite the TD thing.My new doc and I are looking long term. I don't like this "doing great for a year or two and then back to square one" crap. Getting better and then getting worse again isn't cool in my book. I want to stay "up." SSRI + Seroquel, Zyprexa, etc. Tell me more, give me stories, help me out.
Peace people.
ck
Posted by med_empowered on October 18, 2005, at 0:22:46
In reply to SSRI + Low Dose Antipyschotic for TRD, posted by CK1 on October 17, 2005, at 22:54:37
hi. "poop-out" doesn't necessarily mean you're bipolar, especially if you've been on SSRIs long-term..poop-out has been observed with most antidepressants, some more than others (paxil is actually a pretty bad one), and it doesnt mean there's a problem with **you**. That said..the SSRI+atypical combo can be extremely helpful. Of all the atypicals (risperdal, geodon, seroquel, zyprexa, abilify, clozapine), I prefer **low-dose** abilify. Its usually non-sedating, especially at low doses, it is more or less weight neutral, and it doesn't seem to cause major metabolic problems (diabetes and such). Some people have a problem with start-up anxiety/akathisia that usually goes away after a bit. I didn't; from day 1, I went from being miserable, depressed, unable to leave my apt. due to anxiety to...happier, more productive, able to leave my house **without fear**. That said..there are some downsides. The dose should be carefully calibrated, because overdoing it with an AP can cause more akathisia, EPS, raise the risk of TD, cause cognitive impairment, and pretty much negate the benefits of the combo. Because of their unique profiles, low-dose atypicals are pretty well tolerated and effective for antidepressant augmentation; at higher doses, though, you lose some of those advantages...when my abilify dose climbed to 15mgs, for example, I began to develop low-level akathisia, I was slowed down mentally, and I generally felt a little too "tranquilized". It wasn't sedation--abilify is non-sedating--it was just that at higher doses, the antipsychotic effects become more pronounced, while at lower doses the mood-stabilizing/lifting properties are more pronounced (especially when used w/ an antidepressant). Also keep in mind that SSRIs tend to boost the blood levels of antipsychotics sooo...you may be taking, say, 5mgs of zyprexa or abilify daily, but the combo is making your blood levels higher, so its actually like youre taking 7.5, 10mgs (I just made those numbers up, but you get the point). Antipsychotics can be added to ANY antidepressant regimine--I got good effects adding mine to a pre-existing Tofranil and Cymbalta combo--so this might be a good time to experiment with an antidepressant outside the realm of SSRIs. You could try Effexor, Cymbalta, Wellbutrin...lots of stuff (many people respond to a Wellbutrin+SSRI combo really well). This way you could get an **amazing** response...its also possible that you could only have to use the atypical for a little while, and then perhaps use it as-needed to maintain repsonse. Anyway, sorry this was soooo long...I wish you the best of luck, and plese keep us all here posted.
Posted by B2chica on October 18, 2005, at 10:20:18
In reply to Re: SSRI + Low Dose Antipyschotic for TRD, posted by med_empowered on October 18, 2005, at 0:22:46
just wanted to chime in. it's taken a while to find a good combo for me and i'm on a lot but i feel really good for the first time in a long time. i'm on wellbutrin and zoloft (and ritalin, zyprexa, xanax) and adding the ssri (zoloft) to the combo is what made it work for my depression.
best wishes
b2c.
Posted by blueberry on October 18, 2005, at 18:43:41
In reply to SSRI + Low Dose Antipyschotic for TRD, posted by CK1 on October 17, 2005, at 22:54:37
My doc also combines antipsychotics with antidepressants in many patients. Somehow the combinations synergistically release more dopamine and norepinephrine.
I was on 20mg prozac and 5mg zyprexa for 5 years. Five good years. It did eventually begin to fade a bit and then I had a breakthrough manic episode, so now I'm on the hunt again. But if you are looking for something that can work good and work for a long time, APs + ADs in my experience are good combos. Keep the AP dose low to keep any longterm risks at a bare minimum. I had no problems in 5 years in terms of diabetes or TD or anything related to APs.
Posted by Racer on October 18, 2005, at 18:50:52
In reply to SSRI + Low Dose Antipyschotic for TRD, posted by CK1 on October 17, 2005, at 22:54:37
Actually, the whole SSRI poop-out thing is pretty much to be expected -- more a question of "when" than "if," regardless of unipolar/bipolar. My pdoc told me that at a recent conference, everyone was saying that anyone who's experiencing anxiety as well as depression was "really" Bipolar II. He disagrees, saying that anxiety and depression can be comorbid without the one being hypomania. What I'm getting at is that diagnoses in psychiatry are a little more amorphous than we might like to think. ;-]
SSRIs seem to poop out after a couple of years, which is maybe related to the way the body uses serotonin. While we're hoping that the serotonin in the brain sticks around a bit longer, it's also sticking around longer in the digestive tract, where most of the serotonin in the body is used. Whether that's true or not, what is known is that SSRIs tend to poop out for most people given 'enough' time. How long it takes varies from person to person, but it's not unexpected that it will happen.
You mention that you tried four other SSRIs, but did you try any of the TCAs before heading to an MAOI? I just wonder, since there are a few other options that come up here a lot, and I kinda worry about seeing that your doctor seems to have jumped from step 1 to step 7 in terms of medication choices. It also doesn't sound as though you've tried augmenting the SSRIs, rather than switching to a class of drugs that comes with some kinda annoying lifestyle restrictions.
Med_empowered knows much more than I do about the atypical antipsychotics, so I'll trust that his information is correct. I hope you'll look into some of the other options, like TCAs, Effexor, Cymbalta, Wellbutrin, Remeron, etc.
Good luck.
Posted by tecknohed on October 18, 2005, at 20:29:37
In reply to SSRI + Low Dose Antipyschotic for TRD, posted by CK1 on October 17, 2005, at 22:54:37
Hi CK!
> I just started Nardil a few days ago and I'm feeling better already.....
Wow, that was quick! Can you explain a bit more? In what ways do you feel better? Is it a strong effect? Any side effects yet?
Regards,
Kev.
Posted by CK1 on October 18, 2005, at 21:10:37
In reply to Better already? » CK1, posted by tecknohed on October 18, 2005, at 20:29:37
Hey Teck,
No, I meant that I was feeling better, not "better" in the sense that it's kicked in. Believe me, I know when something's kicked in and this hasn't (of course) but I do feel better.
I was sleeping 10-12 hours a day and now I'm getting up after 8 feeling refreshed. Anxiety has gone down a bit too. I'm starting at 15mg for a week then going to 30 for a week then 45 for a week and staying there until I get a response.
I haven't had any side effects besides it's getting harder to sleep. I've heard the insomnia can get bad, but we'll see.
I was starting to avoid going to my speech class because just setting foot in there and having to do skits in front of 30-40 people makes me feel horrendous! My heart was beating way too fast whenever I heard the teacher say, "today we're going to do presentations." It was getting bad. I've gone to this class all this week and the panic seems to be gone but I'm still nervous. It's been 5 days and I'm not expecting anything positive for another 3-4 weeks.
I'll keep you informed on my quest to kill my anxiety. I'm just patiently waiting for that euphoric effect that Ace continues to speak of. We'll see.................
Posted by tecknohed on October 19, 2005, at 11:00:44
In reply to Re: Better already?, posted by CK1 on October 18, 2005, at 21:10:37
Euphoric effect!? Please be carefull what you wish/wait for CK. This 'euphoria' can happen FOR SOME, but it should be seen as a BONUS - nothing more. I'd hate to see you get better only to be dissapointed just because you dont feel 'euphoric'.
Sorry, I'm not trying to crush your hopes, just offering a bit of wisdom thats all. I hope you DO get what you hope for (-:teck
Posted by ed_uk on October 19, 2005, at 13:47:20
In reply to Re: SSRI + Low Dose Antipyschotic for TRD » CK1, posted by Racer on October 18, 2005, at 18:50:52
Hi Racie :-)
>.......everyone was saying that anyone who's experiencing anxiety as well as depression was "really" Bipolar II........
Everyone? Good grief, how ridiculous! ;-) Some pdocs do come up with some silly ideas. I'm relieved that your pdoc disagrees.
Love
~ed xx
Posted by Racer on October 19, 2005, at 14:20:24
In reply to Re: SSRI + Low Dose Antipyschotic for TRD » Racer, posted by ed_uk on October 19, 2005, at 13:47:20
> Hi Racie :-)
>
> >.......everyone was saying that anyone who's experiencing anxiety as well as depression was "really" Bipolar II........
>
> Everyone? Good grief, how ridiculous! ;-) Some pdocs do come up with some silly ideas. I'm relieved that your pdoc disagrees.
>
> Love
>
> ~ed xx
If he didn't disagree with that, he wouldn't be my pdoc anymore...It does seem ridiculous. But if you look at the history of psychiatry in the past thirty or forty years, you'll see patterns and trends. Thankfully, they pass...
Next time I see him, I'll ask him to keep me up to date on those "everyone says" things, so I can pass them on to you. ;-D One of the others we talked about was that EVERYONE who is somewhat anxious in social situations and a bit klutzy was definitely Aspergers! Uh, OK, so I guess that means me and half the people I know... Wish I'd known that sooner...
As for meds, while I may not always agree with some of the dx's people get, if the drugs used work, then that's enough for me.
Posted by ed_uk on October 19, 2005, at 14:25:30
In reply to LoL! If he didn't... » ed_uk, posted by Racer on October 19, 2005, at 14:20:24
Hi Racie,
>Next time I see him, I'll ask him to keep me up to date on those "everyone says" things, so I can pass them on to you. ;-D
Please do :)
>One of the others we talked about was that EVERYONE who is somewhat anxious in social situations and a bit klutzy was definitely Aspergers!
IMO, Asperger's is starting to be used as a euphemism for anyone who's a bit 'odd'. I guess I must be Asperger's.
~ed xx
Posted by CK1 on October 19, 2005, at 17:01:43
In reply to Re: LoL! If he didn't... » Racer, posted by ed_uk on October 19, 2005, at 14:25:30
Thanks for all your comments. I'm up to 30mg Nardil a day now and today was great! Whenever I start an SSRI, I normally get very jittery/caffeinated/anxious, but I've had none of these symptoms since starting Nardil. In fact, it has been the mildest in terms of side effects of any drug I've ever tried! It doesn't cause extreme startup anxiety like the SSRI's.
I've been dreading going to my speech class but I actually spoke up in front of the class and made everyone laugh with a funny comment. After that, I worked out and I called all my friends who I have stayed away from the past month. I needed to do this because I don't want to lose contacts, not because I was feeling hypomanic. Normally caffeine makes me extremely jittery, but I had one cup of coffee this morning and it didn't make me anxious. I pushed the limit and had two more for the hell of it and the caffeine just made me more outgoing. Weird! So far so good with Nardil.
Posted by tecknohed on October 20, 2005, at 1:04:01
In reply to Nardil Day 5, posted by CK1 on October 19, 2005, at 17:01:43
Hey thats great CK!
You're doing the right things too - being 'out there' and getting things done is by far the best way to tell how a meds really working, maybe even encouraging it to work better too. No good just sitting around waiting for it to do all the work for you!
I hope this is a sign of good things to come (just watch the caffein intake) (-:
Kev
Posted by Chairman_MAO on October 21, 2005, at 0:23:05
In reply to Nardil Day 5, posted by CK1 on October 19, 2005, at 17:01:43
I've tried many drugs--licit and illicit--and there is no better drug for social phobia than Nardil.
(Clonazepam or GHB )+ amphetamines can produce a similar response, but Nardil's got the most punch.If I could ifnd some way to deal with the sexual side effects, I'd be back on it in a flash. It turned my life around in a way that Parnate never did.
I am on Parnate now because the sex effects were THAT BAD.
Posted by theo on October 22, 2005, at 16:33:57
In reply to Re: SSRI + Low Dose Antipyschotic for TRD, posted by med_empowered on October 18, 2005, at 0:22:46
Of all the atypicals (risperdal, geodon, seroquel, zyprexa, abilify, clozapine), I prefer **low-dose** abilify.
What dose of Abilify do you take? Do you take it morning or night?
I have a new scrip for Abilify and am scared to try! The whole permanent tardive dyskinesia thing scares me!
I was prescribed 5mg tablets and my doc wants me to start with only 2.5mg.
Any advice or input on this med? I've never taken a med in this class. I'm trying it for low feelings of self, low grade depression, mild feeling of gloom and doom. I believe I'm also suffering from ADD symptoms, everything, even talking sometimes seems exhausting!
By the way, I am currently on no meds so I will be trying Abilify monotherapy. I just quit Cymbalta and after being off it for a couple of weeks am realizing how horrible it made me feel.
Posted by Jedi on October 25, 2005, at 2:09:37
In reply to Nardil Day 5, posted by CK1 on October 19, 2005, at 17:01:43
> Thanks for all your comments. I'm up to 30mg Nardil a day now and today was great!
Hi CK1,
Congratulations on your choice to skip the 25 other trials and go to the gold standard for social anxiety and atypical depression. I went through the SSRIs, TCAs, atypicals, etc. and many combinations of each. This took a good three to four years of my life away and set me back socially and financially.
Chances are good that you will have some side effects, but these are nothing compared to treatment resistant depression and SAD.
You may go through a period of hypomania. This condition is very euphoric for a person that has been seriously depressed. Keep a close eye on it and try not to make major life changes while in this phase. The hypomania will pass and it may feel like the med is pooping out. However, this is not the true therapeautic effect.
Nardil has worked long term for me. Every time I have come off of it, I became seriously depressed within a few months. I am a lifer! I will augment with other meds but Nardil is the rock.
The two worst side effects for me have been weight gain and delayed orgasm. As a young man, your testosterone level will probably be high enough to counteract the sexual side effects. The only thing I've found that works for the weight gain and carbohydrate cravings is lots of exersise. Good luck and watch the tyramine.
Jedi
Posted by SLS on October 25, 2005, at 7:45:00
In reply to Re: Nardil Day 5 » CK1, posted by Jedi on October 25, 2005, at 2:09:37
Hi.
> You may go through a period of hypomania. This condition is very euphoric for a person that has been seriously depressed.
This is very true.
> Keep a close eye on it and try not to make major life changes while in this phase.
I agree.
> The hypomania will pass and it may feel like the med is pooping out. However, this is not the true therapeautic effect.
If there is a bipolar thing going on there and the mania continues, it is usually a very simple thing to treat. I used Zyprexa the last time something similar happened to me with Nardil. I used it only temporarily. Depakote works for me too. I have become seriously manic only a handful of times that were directly attributal to drug intervention.
- Scott
Posted by CK1 on October 25, 2005, at 10:49:02
In reply to Re: Nardil Day 5, posted by SLS on October 25, 2005, at 7:45:00
Thanks for the comments guys. My experience with Nardil thus far has been pleasant. The first few days I couldn't sleep and would get dizzy a lot and need to lie down but these side effects have totally gone away. I bumped the dose to 30mg about 5 days ago and I'm thinking about bumping to 45mg in the next few days. That seems to be the norm. It still hasn't "kicked in" yet but I don't expect it to click for another few weeks around the 4-6 week mark. My depression is totally gone. I would wake up in the morning and not want to get out of bed but now I wake up happy. I'm happy but still nervous so there's room for improvement (LOTS!) but I'm happy I have Nardil by my side.
Posted by mknight on October 25, 2005, at 16:12:36
In reply to Re: Nardil Day 11, posted by CK1 on October 25, 2005, at 10:49:02
Any thoughts on MAOIs and TCAs causing more liver damage than other psychotropic drugs?
Posted by SLS on October 25, 2005, at 16:25:32
In reply to Re: Nardil Day 11, posted by mknight on October 25, 2005, at 16:12:36
> Any thoughts on MAOIs and TCAs causing more liver damage than other psychotropic drugs?
What kind of liver damage have you seen reported in the medical literature? Could you direct me to an Web link that describes it?
Nardil is not easy on the liver.
- Scott
Posted by CK1 on October 25, 2005, at 22:12:09
In reply to Re: Nardil Day 11 » mknight, posted by SLS on October 25, 2005, at 16:25:32
Never heard that before. My liver's very strong though. :)
Posted by Chairman_MAO on October 25, 2005, at 22:30:20
In reply to Re: LoL! If he didn't... » Racer, posted by ed_uk on October 19, 2005, at 14:25:30
>IMO, Aspberger's is starting to be used as a >euphemism for anyone who's a bit 'odd'. I guess I >must be Asperger's.Not if your clinician is worth his/her degree. My mother deals with such disorders and could probably talk for hours on all of ths symptom clusters involved.
Posted by ed_uk on October 26, 2005, at 14:57:49
In reply to Re: LoL! If he didn't... » ed_uk, posted by Chairman_MAO on October 25, 2005, at 22:30:20
>Not if your clinician is worth his/her degree.
I haven't encountered any such clinicians
I get the impression that you don't like me
Posted by mknight on October 29, 2005, at 22:02:33
In reply to Re: Nardil Day 11 » mknight, posted by SLS on October 25, 2005, at 16:25:32
> > Any thoughts on MAOIs and TCAs causing more liver damage than other psychotropic drugs?
>
> What kind of liver damage have you seen reported in the medical literature? Could you direct me to an Web link that describes it?
>
> Nardil is not easy on the liver.
>
>
> - ScottI do so much research that I just catalog something in my brain without remembering exactly where I read it. Biopsychiatry.com is probably one place. The most important source is Stephen Stahl's Prescriber's Guide that mentions being watchful of hepatotoxicity.
This is the end of the thread.
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