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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 8 of 8. This is the beginning of the thread.
Posted by gardenergirl on December 7, 2005, at 14:08:03
Hi everyone,
I met with my pdoc yesterday and told her that although I'm feeling pretty good, and I don't feel particularly depressed, I'm still having a big problem with not getting my work done.I realize that this is also a behavioral issue. I've certainly learned that procrastination and avoidance gives me temporary relief from anxiety related to school and work tasks. But of course the long term consequence is the giant "I'm so behind now I don't know what to do first" monkey on my back.
At any rate, she brought up the idea of adding provigil to my current mix: Nardil 60mg, Lamictal 75 mg (I also take 100 ucg of Synthroid). She thought Provigil might help with motivation, but she also said that even if it makes me feel more active, it's up to me what I do with that energy, i.e. putz around still or actually get some work done.
She also suggested that Provigil likely would not be covererd by my insurance, since I don't have a documented sleep disorder and I don't do shift work. It does appear on my formulary, so I'm not sure if she's right on that one.
We also talked about using caffeine therapeutically, and she said the equivalent of 4 cups of coffee per day was acceptable. I probably don't get that much, as I drink diet coke, not coffee.
Okay, any suggestions? I know I really need to work on the behavioral aspect of it, by setting short term goals, writing them down, and somehow making myself feel more accountable. But what about the phsyiological aspect?
Thanks in advance,
gg
Posted by RobertDavid on December 7, 2005, at 15:12:09
In reply to Provigil to help with apathy and procrastination?, posted by gardenergirl on December 7, 2005, at 14:08:03
Coffee gave me temorary energy, then anxiety and total loss of energy. I now take it on an as needed basis.
When I first tried provigial, my doc gave me a script for 5 pills to save money. He said the good thing about provigil is that you know day 1 if it works for you.
When I took 50mgs I cleaned my entire house, did errands, got lots done and without the jitters of coffee. All were things I was just putting off doing. Provigil was real smooth and increased my energy and motivation. I don't think it's much help if you're depressed though.
Personally, from what you've described I'd give it a shot. You may find that you can save money buy buying 100mg pills and breaking them in half, maybe even in quarters. Anyway, just getting a script for a few pills would give you some answers without spending a lot of money.
Good luck!
Posted by linkadge on December 7, 2005, at 21:32:26
In reply to Re: Provigil to help with apathy and procrastination?, posted by RobertDavid on December 7, 2005, at 15:12:09
The best thing for procrasitation with me, is trying to combine what you don't want to do, with something you do want to do.
So I take my notes to the gym, and run and read at the same time.
Coffee helped a little, but the real reason I was procrasting was because of fear.
I started to realize that leaving things created more fear than facing them right away.
Provigil may help, but you need to ask yourself why you are putting things off. If it is not related to alertness, then it probably won't help.
Just my 2 cents.
Linkadge
Posted by Racer on December 8, 2005, at 13:14:23
In reply to Provigil to help with apathy and procrastination?, posted by gardenergirl on December 7, 2005, at 14:08:03
Well, you know all the qualifiers, right? About putting things off, and getting past the behavioral elements, and all that? Of course you do, so I'll cut to the chase...
My experience with Provigil was great. It did brighten my mood, augmented my AD, and helped a lot with many of my symptoms. The biggest problem was that it was short acting, and left me kinda crashed mid-day. The fix for that was easy -- front loaded split dosing. I took 100mg at breakfast, then another 50mg around noon. That fixed the worst of the trouble.
I did get the headaches from it, but they weren't painful -- more like the discomfort of wearing a too-tight swim cap, if that makes sense.
The fact that you will know if it will help within a day or two -- first day, it might be nerves that hype you up, or you might just be too tired, etc -- is a real bonus. And even if you do get the headaches, they really and truly do go away. (By the way, now that I think of it, the first day I took it, I did get a really horrendous headache. But only that day, and I was cleaning a noxious mess, so it might have been the cleaner, too.)
As for caffeine, colas do have a fair amount of the stuff. I looked it up once, and I think cola and coffee were closer than I expected. You might be surprised.
As for insurance, who knows where she's getting her information. She may not have looked into it recently, because if it is on your formulary, it should be covered.
Best luck to you, my friend.
Posted by hawkeye on December 13, 2005, at 14:06:00
In reply to Provigil to help with apathy and procrastination?, posted by gardenergirl on December 7, 2005, at 14:08:03
I take Provigil and I believe that you should give it a try.
The makers of Provigil (Modafinil) have an online service that assists in getting approval from insurance:
http://www.provigil.com/patient/reimbursement/reimbursement.aspx
They also have a financial assisstance (free) program:
http://www.provigil.com/patient/reimbursement/assistance.aspx
Also, your PDOC might get in touch with the company rep in youer area. These reps can be very generous in providing samples. My PDOC is usually well stocked with samples of Provigil. I am his only patient that uses it so I can go for months without having to fill a script at a pharmacy.
There have been recent studies demonstrating the effectiveness of Provigil in overcoming the apathy,lethargy, and tiredness caused by some anti-depressants. If your PDOC says the right words, this should make it more difficult for your insurance company to deny you coverage for the drug.
Sometimes whether you get approval depends upon who reviews your application. You should definetly try again. I live in the Washington, D.C. area. Several years ago there was a court challenge to insurance companies' challenging the meds prescribed by doctors. The courts here ruled that the insurance companies can't do this because it constitutes practicing medicine without a license.
You should check the PDR for the approve uses of the drug and see if your doctor can squeeze you into one of those categotires.
Modafinil is proving clinically useful in the treatment of narcolepsy, a neurological disorder marked by uncontrollable attacks of daytime sleepiness. In September 2003, an advisory panel to the FDA endorsed its use for treating shift work sleep disorder and obstructive sleep apnea.
Experimentally, modafinil is also used in the treatment of Alzheimer's disease, depression, attention-deficit disorder, myotonic dystrophy, multiple sclerosis-induced fatigue, post-anaesthesia grogginess, cognitive impairment in schizophrenia, spasticity associated with cerebral palsy, age-related memory decline, idiopathic hypersomnia, jet-lag, and everyday cat-napping. Depressives who feel sleepy and fatigued on SSRIs can augment their regimen with modafinil.
If your PDOC can't/won/t fit you into one of the FDA approved uses, he should be insistent. My PDOC told the insurance company that he has tried everything else and Provigil is the only med. that works for my depression. It wasn't easy to get the approval (Care First) but he was persistent and we finally got it approved.
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Modafinil augmentation of antidepressant
treatment in depression
by
Menza MA, Kaufman KR, Castellanos A
Department of Psychiatry,
University of Medicine and Dentistry of New Jersey,
Robert Wood Johnson Medical School,
Piscataway 08854, USA.
menza@umdnj.edu
J Clin Psychiatry 2000 May; 61(5):378-81ABSTRACT
BACKGROUND: Despite a relative lack of controlled data, stimulants are often used to augment antidepressant treatment in patients who have had only a partial response to first-line therapy. Modafinil is a novel psychostimulant that has shown efficacy in, and was recently marketed for, treating excessive daytime sleepiness associated with narcolepsy. The mechanism of action of modafinil is unknown, but, unlike other stimulants, the drug is highly selective for the central nervous system, has little effect on dopaminergic activity in the striatum, and appears to have a lower abuse potential. METHOD: In this retrospective case series, we describe 7 patients with DSM-IV depression (4 with major depression and 3 with bipolar depression) for whom we used modafinil to augment a partial or nonresponse to an antidepressant. The Hamilton Rating Scale for Depression was administered as part of routine clinical practice prior to treatment and at each subsequent visit. RESULTS: At doses of 100 to 200 mg/day, all 7 patients achieved full or partial remission, generally within 1 to 2 weeks. All patients had some residual tiredness or fatigue prior to starting modafinil, and this symptom was particularly responsive to augmentation. Side effects were minimal and did not lead to discontinuation of the drug in any of the patients. CONCLUSION: Modafinil appears to be a drug with promise as an augmenter of antidepressants, especially in patients with residual tiredness or fatigue. It is a particularly attractive alternative to other stimulants because of its low abuse potential and Schedule IV status.
http://www.modafinil.com/modep.html
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Research ArticleModafinil enhances the increase of extracellular serotonin levels induced by the antidepressant drugs fluoxetine and imipramine: A dual probe microdialysis study in awake rat
Luca Ferraro 1, Kjell Fuxe 2 *, Luigi Agnati 3, Sergio Tanganelli 1, Maria Cristina Tomasini 1, Tiziana Antonelli 1
1Department of Clinical and Experimental Medicine, Section of Pharmacology, University of Ferrara, Italy
2Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
3Department of Biomedical Sciences, University of Modena, Italy
email: Kjell Fuxe (Kjell.Fuxe@neuro.ki.se)*Correspondence to Kjell Fuxe, Department of Neuroscience, Karolinska Institutet, 17177 Stockholm, Sweden
Funded by:
Laboratoire L. Lafon
Fondazione Cassa di Risparmio di FerraraKeywords
antidepressant • dorsal raphe • prefrontal cortex • ascending 5-HT pathwaysAbstract
In view of a postulated role of the vigilance-promoting drug modafinil in depression, the interaction of modafinil and two classical antidepressant drugs, fluoxetine and imipramine, were studied in 5-HT levels in the dorsal raphe-cortical system using dual-probe microdialysis. Fluoxetine (1-10 mg/kg) dose-dependently increased dorsal raphe-cortical 5-HT levels. Modafinil at a very low dose (3 mg/kg), by itself ineffective, enhanced the fluoxetine (5 mg/kg)-induced increases of 5-HT levels in both brain areas. A synergistic interaction was observed in the prefrontal cortex with fluoxetine (1 mg/kg) in terms of 5-HT release, but not in the dorsal raphe. Imipramine (1.3 mg/kg) increased 5-HT levels in the dorsal raphe, but not in the prefrontal cortex, while the higher doses (10.9-21.8 mg/kg) caused substantial increases in both brain areas. Modafinil (3 mg/kg), injected before imipramine (1.3 mg/kg), which by itself was ineffective on cortical 5-HT levels, increased cortical 5-HT levels. On other hand, modafinil failed to affect the high-dose imipramine (10.9 mg/kg)-induced increase of 5-HT levels in the prefrontal cortex and the imipramine (1.3; 10.9 mg/kg)-induced increase of 5-HT levels in the dorsal raphe nucleus. These results demonstrate that modafinil in low doses enhances the acute effects of fluoxetine and imipramine on 5-HT levels in the dorsal raphe nucleus (fluoxetine only) and especially in the prefrontal cortex of the awake rat. These findings suggest a therapeutic potential of low doses of modafinil in the treatment of depression when combined with low doses of classical antidepressants, especially by increasing 5-HT transmission in cortical regions. Synapse 55:230-241, 2005. © 2005 Wiley-Liss, Inc.
http://www.jrnlappliedresearch.com/articles/Vol4Iss2/Bransfield-Jar-spring.pdf
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Other References
DeBattista C, Doghramji K, Menza MA et al. (2003), Adjunct modafinil for the short-term treatment of fatigue and sleepiness in patients with major depressive disorder: a preliminary double-blind, placebo-controlled study. J Clin Psychiatry 64(9):1057-1064.
Markovitz PJ, Wagner S (2003), An open-label trial of modafinil augmentation in patients with partial response to antidepressant therapy. J Clin Psychopharmacol 23(2):207-209.
Schwartz TL, Leso L, Beale M et al. (2002), Modafinil in the treatment of depression with severe comorbid medical illness. Psychosomatics 43(4):336-337.
Posted by gardenergirl on December 13, 2005, at 17:23:14
In reply to Re: Provigil to help with apathy and procrastinati, posted by hawkeye on December 13, 2005, at 14:06:00
Posted by AuntieMel on December 21, 2005, at 9:29:21
In reply to Provigil to help with apathy and procrastination?, posted by gardenergirl on December 7, 2005, at 14:08:03
I just saw this.
I have been convinced I need something on the stimulant side for a long time, but my doc didn't agree. Finally I told him I couldn't stay awake during the day and he gave me provigil.
It did help a lot with focusing. A whole lot.
I didn't have any trouble with the insurance company either.
Posted by gardenergirl on December 21, 2005, at 13:40:30
In reply to Re: Provigil to help with apathy and procrastinati » gardenergirl, posted by AuntieMel on December 21, 2005, at 9:29:21
Thanks, Mel. I'm still considering it. Glad to hear it was helpful and easy for you.
gg
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