![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 14 to 38 of 76. Go back in thread:
Posted by SLS on April 22, 2006, at 14:35:49
In reply to Re: Another drug failure, posted by linkadge on April 22, 2006, at 12:26:14
> Nortryptaline, lamictal, abilfy seems to be a good base.
I think so too.
> Have you tried omega-3 augmentation?
Yes, but not with the combination of things I'm on right now.
> I'd add around 1 gram of EPA, and perhaps some folic acid. Zinc too, can augment antidepressnat responces. You could always try inositol. It acts as a second messenger to the noradrenergic system.
I still have some fish oil, folic acid, and inositol in my box of rejects. The fish oil had some positive effect at first.
> (Although, inositol and nortryptaline might have mania writtain all over it!)
I wouldn't mind becoming manic because for me it is so easily treated with valproate or Zyprexa.
> How did you fair on SSRI's?
Zoloft produced a brief antidepressant response while I was taking imipramine and Lamictal. I think it would be justified to try it again with the Wellbutrin.
> The combination of sertraline and a nortryptaline would be like a triple uptake inhibitor.
I hope my doctor allows me to take all three antidepressants at the same time (nortriptyline, Wellbutrin, and Zoloft).
I tried Prozac, but only at 20mg. I also tried Paxil 30mg and Lexapro 20mg. I have not tried Luvox nor Celexa. I like Zoloft because it wasn't bad with side effects. I've also tried Effexor and Cymbalta. The pattern of response is always the same. I will start to improve during weeks 2-4 and relapse within a week.
You really think Zoloft + TCA is that potent? Hmmm. That might be a way to go. I would want to keep the Wellbutrin, though.
They say that if you throw enough sh*t against the wall, some of it is bound to stick.
- Scott
Posted by pseudoname on April 22, 2006, at 14:42:16
In reply to Another drug failure, posted by SLS on April 22, 2006, at 9:11:50
> I don't know how much more I can take. I don't know what there is left to try.
I'm so sorry about this latest outcome, Scott. Several times in the last 17 years, I *couldn't* take any more drug failures, and just gave up on them for years at a time.
But I'm now Johnny Appleseed for buprenorphine. It's not a 100% cure, but the benefit is stark to me. I'm pretty sure you haven't tried it yet, right?
Posted by SLS on April 22, 2006, at 14:42:22
In reply to Re: Another drug failure » SLS, posted by blueberry on April 22, 2006, at 13:40:52
> Hi Scott
Hi Blueberry.
Your post contains a wealth of ideas, some of which I haven't tried yet. Thank you.
You said, "It could be that dopamine receptors just get desensitized to any increase you give them,"
You might have hit the bullseye with that one. The problem is, what do you do to prevent that from happening?
- Scott-----------------------------
> You have been so helpful in trying to help me figure out my own problems. I feel pitifully inadequate in trying to help figure out yours. It saddens me how you are feeling, and it saddens me I don't have any magic ideas.
>
> Some off the wall thoughts though. Increasing wellbutrin to 450mg for 2 weeks and then even to 600mg for 2 weeks might be an idea. That's what they did back in the old days before seizures became a concern. You have lamictal to help protect from that.
>
> Maybe something to stimulate the release of neurotransmitters, rather than just damming them up. You could do a quick easy experiment to see if norepinephrine stimulation is an area to explore. Chromium picolinate. Take 400mg to 800mg. It mainly helps insulin response, but it also stimulates norepinephrine release. When I tried it at just 200mg, I definitely felt a noradrenergic boost of mood and energy, though the resulting anxiety was a bit much. But it is an easy experiment just to test noradrenergic stimulation response, versus noradrenergic reuptake inhibition.
>
> It could be that dopamine receptors just get desensitized to any increase you give them, and then you are right back where you started. On pubmed I saw a couple studies where siberian ginseng prevented dopamine receptors and opioid receptors from developing tolerance. Who knows. Just an idea.
>
> Maybe with the high focus on norepinephrine, serotonin has been squashed out of the picture. Except for the sexual side effects, you sound like the kind of person who might respond well to 200mg to 350mg zoloft, where the serotonin reuptake has long ago maxed out at lower doses and the dopamine reuptake is now significantly catching up at higher doses.
>
> But then again, you were on an maoi which boosted all of them. Something developed tolerance or immunity to the increased neuros. That's why I think maybe neuro stimulation, rather than neuro reuptake, might be an angle to consider. Maybe add in low dose prozac and zyprexa just to get some flow of all 3 neuros going. Ritalin maybe.
>
> And sometimes I think it makes some kind of unlogical sense to go for something that does not make sense. For example, it doesn't sound like you need xanax and it is unlogical to see how that might help you. But that's the point. Everything that is logical hasn't been quite right. Maybe a little prozac and a little xanax could do wonders, for some unexplainable reason we'll never know.
>
> And of course there is good ole low dose lithium. I've read several studies where when it was combined with noradrenergic agents, it stimulated the release of all 3 neuros, but not by itself, and only in the presence of a noradrenergic agent.
>
> Risperidone. It seems like a lot of treatment resistant things respond to low dose risperdal addition. Probably because it stimulates the flow and release of more dopamine.
>
> I'm just thinking. Wild ideas. I would sure like to wave a magic wand for me and you both.
Posted by SLS on April 22, 2006, at 14:52:24
In reply to bupe is still out there, right? » SLS, posted by pseudoname on April 22, 2006, at 14:42:16
Hi Pseudoname.
> But I'm now Johnny Appleseed for buprenorphine. It's not a 100% cure, but the benefit is stark to me. I'm pretty sure you haven't tried it yet, right?
Yes. You are correct. (Although I don't know how you would remember such a thing).
I've had buprenorphine on my list, but have been reluctant to bring it up with my doctor. I guess I should print out some stuff to give to him.
How do you administer buprenorphine? Route, dosage, schedule?
Thanks.
- Scott
Posted by Jay on April 22, 2006, at 15:05:27
In reply to Re: Another drug failure » linkadge, posted by SLS on April 22, 2006, at 10:30:13
> I have also wondered if any of my drugs are interfering with a positive response. That is one of the reasons why I discontinued Keppra.
>
> > What all are you taking currently?
>
> nortriptyline 100mg
> Wellbutrin 300mg
> Lamictal 150mg
> Abilify 10mg
>Scott....I am sorry to say but, this combo is just 'candy' to me. Let me give you some examples. First, in order to feel better, you need some SERIOUS additions. I don't know what exactly your DX is...I think I do a bit from other posts. Some of this is anecdotal, some from the research. I think now after reading over most 'cocktails', I take the most complicated, bizzare one on here..and you know what? It works! It covers everything. If you don't have insurance, it may cost you a bit more...but it is worth it...believe me. It will take some experimentation. So here goes my reccomendations:
-Add another mood stabalizer..possibly a good one, like depakote. The ER version is supposed to be excellent...fewer side effects because not dumped all into the bloodstream at once.
-You've got stimulating antidepressants, so add some Prozac, at a GOOD dose. (i.e. 80mg's)
-Add another atypical antipsychotic. Risperdal seems safest as far as diabetes goes, and don't be afraid to bump around the dose.
-I'd suggest maybe dumping the Wellbutrin, in place of some new Dexedrine.
-Add a PRN benzo if anxiety is still a problem.Just do some checking for any drug interactions....I have not had any problems...just need to be cautious with possibly the Depakote..and other m.s's...and if you are seizure prone might be some probs. Otherwise...my doc put me on two's of a.d.'s..a.p's...m.s's...all with fairly good success..way, way better than any little effect a single drug would have.
Good luck...you still have a long road to travel my friend.
Best,
Jay
Posted by Crazy Horse on April 22, 2006, at 15:11:44
In reply to Another drug failure, posted by SLS on April 22, 2006, at 9:11:50
> Another drug failure.
>
> The addition of Wellbutrin to my treatment produced a profound improvement in my depression during weeks 3 and 4. No more. I have relapsed. There is no vestige of an antidepressant response. I do not expect one to reappear regardless of how much time I remain on this drug.
>
> I don't know how much more I can take. I don't know what there is left to try. The logical part of me concluded quite some time ago that my brain will never respond to treatment. The emotional part of me masks the logical part and continues to have hope. I probably would not continue to live without it. I must therefore suppress and ignore my logic in order to survive.
>
>
> - ScottScott,
I don't know your med history as well as most of the others, and i probably won't come up with anything that you haven't already tried, but i'd still like to try to "help" if possible.
Have you been on Remeron? High dose Remeron 115mgs. helped me. Also a combo of Remeron and Paxil, both high dose help me for quite awhile. Also, how about Lyrica? For me, this was much more potent than neurontin. Mirapex was also helpful for awhile.
Before i started Parnate, i read that this formula below can be very effective for TR depression- Pindolol, Nefazodone and Tryptophan. 7.5 mg a day of pindolol, 300 mg. of Nefazodone, and 1 gram of Tryptophan. Pindolol stays the same for 20 weeks, gradually increase the nefazodone to 450 mgs. a day, and Tryptophan to 8 mgs. a day. This combo is believed to increase serotonin release and availability in TR patients.Hang in there Scott, I know there is a medication/cocktail that will help you...you deserve it Scott, you've suffered much too long.
-Monte
Posted by pseudoname on April 22, 2006, at 15:43:57
In reply to Re: bupe is still out there, right? » pseudoname, posted by SLS on April 22, 2006, at 14:52:24
> How do you administer buprenorphine? Route, dosage, schedule?
In my 5th month on bupe, I take:
Subutex 0.5mg sublingual tablet (Actually, I put it between the cheek & the gum, like chaw. Too much saliva under the tongue.)
I take the 0.5mg once or twice a day, depending on how the day is going. First dose anywhere from 5 AM to 10 AM; second dose 6-8 hours later.
But I had to get up to 1.0 mg, 3 times a day (6AM, 11AM, 4PM), in the first weeks, before I got the antidepressant benefit. For whatever reason, I just need less now.
I just posted a list of reported bupe doses I compiled last year, but it needs updating. Other Babblers have recently reported very small effective doses. http://www.dr-bob.org/babble/20060417/msgs/635901.html
For anyone considering bupe, I think these may be good pages to show your doc. I hope he/she won't think a special DEA waiver is needed to Rx it for depression. (It isn't.)
When you first start, do NOT take more than 0.1 or 0.2mg a day. Larry Hoover gave me advice on taking such small doses: http://www.dr-bob.org/babble/subs/20051106/msgs/580668.html
The main reference is this:
• J. Alexander Bodkin, MD, Gwen L. Zornberg, MD, Scott E. Lukas, PhD, and Jonathan O. Cole, MD. "Buprenorphine Treatment of Refractory Depression." Journal of Clinical Psychopharmacology, 1995, 15, pp. 49-57 http://balder.prohosting.com/~adhpage/bupe.htmlI just posted my transcript of this study:
• H.W. Emrich. "Antidepressant Effects of Buprenorphine." Lancet, 1982, Sep 25; 2(8300): 709 http://www.dr-bob.org/babble/20060417/msgs/635895.htmlAnd there's this:
• Enoch Callaway. "Buprenorphine for Depression: The Un-adoptable Orphan [Editorial]." Biological Psychiatry. 1996 Jun 15; 39(12):989-90. http://www.dr-bob.org/babble/20010625/msgs/67856.html
Posted by ed_uk on April 22, 2006, at 16:45:20
In reply to Another drug failure, posted by SLS on April 22, 2006, at 9:11:50
Hi Scott
Zeugma told me that Wellbutrin may raise the nortriptyline blood level. Perhaps it's now above the therapeutic window? I wonder whether it would help to reduce the dose of nortriptyline.
Regards
Ed
Posted by linkadge on April 22, 2006, at 19:05:00
In reply to Re: Another drug failure » SLS, posted by ed_uk on April 22, 2006, at 16:45:20
SLS, how is your sleep affected by these 2 week responses then relapses?
Linkadge
Posted by linkadge on April 22, 2006, at 19:08:48
In reply to Re: Another drug failure, posted by linkadge on April 22, 2006, at 19:05:00
Nortryptaline will supress REM greatly, but bupropion enhances it.
You might be a good candedate for voldoxan.
Linkadge
Posted by blueberry on April 22, 2006, at 20:02:59
In reply to Re: Another drug failure » blueberry, posted by SLS on April 22, 2006, at 14:42:22
Ya know Scott, I do not remember exactly where I saw it or exactly what it said. It was definitely at pubmed.com somewhere. Ginseng was able to prevent dopamine and opioid tolerance, and even reverse tolerance after it had already set in.
> > Hi Scott
>
> Hi Blueberry.
>
> Your post contains a wealth of ideas, some of which I haven't tried yet. Thank you.
>
> You said, "It could be that dopamine receptors just get desensitized to any increase you give them,"
>
> You might have hit the bullseye with that one. The problem is, what do you do to prevent that from happening?
>
>
> - Scott
>
> -----------------------------
>
> > You have been so helpful in trying to help me figure out my own problems. I feel pitifully inadequate in trying to help figure out yours. It saddens me how you are feeling, and it saddens me I don't have any magic ideas.
> >
> > Some off the wall thoughts though. Increasing wellbutrin to 450mg for 2 weeks and then even to 600mg for 2 weeks might be an idea. That's what they did back in the old days before seizures became a concern. You have lamictal to help protect from that.
> >
> > Maybe something to stimulate the release of neurotransmitters, rather than just damming them up. You could do a quick easy experiment to see if norepinephrine stimulation is an area to explore. Chromium picolinate. Take 400mg to 800mg. It mainly helps insulin response, but it also stimulates norepinephrine release. When I tried it at just 200mg, I definitely felt a noradrenergic boost of mood and energy, though the resulting anxiety was a bit much. But it is an easy experiment just to test noradrenergic stimulation response, versus noradrenergic reuptake inhibition.
> >
> > It could be that dopamine receptors just get desensitized to any increase you give them, and then you are right back where you started. On pubmed I saw a couple studies where siberian ginseng prevented dopamine receptors and opioid receptors from developing tolerance. Who knows. Just an idea.
> >
> > Maybe with the high focus on norepinephrine, serotonin has been squashed out of the picture. Except for the sexual side effects, you sound like the kind of person who might respond well to 200mg to 350mg zoloft, where the serotonin reuptake has long ago maxed out at lower doses and the dopamine reuptake is now significantly catching up at higher doses.
> >
> > But then again, you were on an maoi which boosted all of them. Something developed tolerance or immunity to the increased neuros. That's why I think maybe neuro stimulation, rather than neuro reuptake, might be an angle to consider. Maybe add in low dose prozac and zyprexa just to get some flow of all 3 neuros going. Ritalin maybe.
> >
> > And sometimes I think it makes some kind of unlogical sense to go for something that does not make sense. For example, it doesn't sound like you need xanax and it is unlogical to see how that might help you. But that's the point. Everything that is logical hasn't been quite right. Maybe a little prozac and a little xanax could do wonders, for some unexplainable reason we'll never know.
> >
> > And of course there is good ole low dose lithium. I've read several studies where when it was combined with noradrenergic agents, it stimulated the release of all 3 neuros, but not by itself, and only in the presence of a noradrenergic agent.
> >
> > Risperidone. It seems like a lot of treatment resistant things respond to low dose risperdal addition. Probably because it stimulates the flow and release of more dopamine.
> >
> > I'm just thinking. Wild ideas. I would sure like to wave a magic wand for me and you both.
>
>
Posted by zeugma on April 22, 2006, at 21:01:03
In reply to Re: Another drug failure » SLS, posted by blueberry on April 22, 2006, at 20:02:59
yes, Ed is correct that I said that Wellbutrin wil raise NOR plasma levels. Wellbutrin is a potent 2D6 inhibitor.
Can you get plasma monitoring of nortrip done on your insurance? I know it's awfully expensive when uninsured.
-z
Posted by Phillipa on April 22, 2006, at 21:07:20
In reply to Re: bupe is still out there, right? » pseudoname, posted by SLS on April 22, 2006, at 14:52:24
Scott I know I'm changing the subject a bit but I have been thinking not being the med expert. Yesterday I was talking to a man at Home Depot his nephew in his 40's has intractable depression he said he would get in a car and drive call home and have no iedea where he was. Well he received a rTMS implant and now his depression is basically cured he functions at 80-90%. Have you considered this love Jan
Posted by gardenergirl on April 22, 2006, at 21:28:26
In reply to New Idea Scott, posted by Phillipa on April 22, 2006, at 21:07:20
Scott,
I'm sorry you're experiencing this. It's so frustrating.You're getting some great advice here about meds, and I can't add to any of it. But something else...You may have already considered this, but has there been anything situational going on that could trigger a depression? I ask because I've had depression come back for me, and I've immediately looked to my drug regimen for tweaking. When I met with my pdoc, she pointed out that I had stopped doing some of the behavioral things that had been helping (yoga, light therapy, eating better, etc.) and that I had experienced a number of losses recently. No wonder I was depressed again, she said. So we didn't adjust any meds at that time. I made an effort to go back to doing the things that had helped before, and I tried to deal with the loss issues in therapy. And it eventually passed.
Of course it may truly be poop-out, and that always stinks. But if there's any chance there are psychosocial variables, I just wanted to raise my hand and say, "um..but?"
I share your secret wish.
gg
Posted by SLS on April 23, 2006, at 7:35:35
In reply to Re: Another drug failure, posted by linkadge on April 22, 2006, at 19:08:48
> Nortryptaline will supress REM greatly, but bupropion enhances it.
>
> You might be a good candedate for voldoxan.Antidepressants no longer suppress dreaming for me. Parnate once completely abolished it, now it doesn't affect me at all. All of my exposures to medication have definitely changed the way my CNS works.
I found it difficult to detect any differences in the way I slept during the time I was responding to medication this time around.
I would probably try agomelatine simply because it is different from anything I've yet tried.
I am getting depressed about being so ill. I was tempted to stay in bed all day because I would like to just give up.
- Scott
Posted by SLS on April 23, 2006, at 7:58:29
In reply to Re: Another drug failure, posted by zeugma on April 22, 2006, at 21:01:03
> yes, Ed is correct that I said that Wellbutrin wil raise NOR plasma levels. Wellbutrin is a potent 2D6 inhibitor.
>
> Can you get plasma monitoring of nortrip done on your insurance? I know it's awfully expensive when uninsured.I never thought of that. I guess it is possible that nortiptyline is too high and outside the therapeutic window.
Thanks.
- Scott
Posted by SLS on April 23, 2006, at 8:10:05
In reply to New Idea Scott, posted by Phillipa on April 22, 2006, at 21:07:20
> Scott I know I'm changing the subject a bit but I have been thinking not being the med expert. Yesterday I was talking to a man at Home Depot his nephew in his 40's has intractable depression he said he would get in a car and drive call home and have no iedea where he was. Well he received a rTMS implant and now his depression is basically cured he functions at 80-90%. Have you considered this love Jan
Hi Jan.
It sounds like you might be talking about VNS. I've been following its development, and have not been very enthused by its low success rate. The response rate is about 30% after 8 weeks. However, one must take into consideration that the study population is probably almost entirely treatment resistant. One thing that is important is that the literature indicates that some treatment failures at 8 weeks go on to improve at 6 months to a year.
I don't know what to think. The story you told is very interesting. I guess I'm not ready to have wires routed through my chest and neck with only a 30% probability of success.
As far as rTMS is concerned, if it is approved by the FDA, I will probably try it. They are getting closer to determining the optimal parameters of its application.
Thanks for your input. I guess I can't rule out VNS entirely.
- Scott
Posted by linkadge on April 23, 2006, at 8:38:03
In reply to Re: Another drug failure » zeugma, posted by SLS on April 23, 2006, at 7:58:29
Yeah, the voldoxan might offer a complementary effect to those taking other antidepressants.
If you're more "blue" then it might be a sign that you're one too many catecholamine enhancing drugs.
OTOH, Emsam might be an interesting option, though I don't know of the interaction with the drugs you're taking. Selegeline has a protective and restoritive effects on dopaminergicly mediated functions during aging, did you ever try selegeline?
Linkadge
Posted by SLS on April 23, 2006, at 8:43:28
In reply to Re: New Idea Scott, posted by gardenergirl on April 22, 2006, at 21:28:26
Hi GG.
> I'm sorry you're experiencing this. It's so frustrating.
Being given a taste of real life only to be denied is torturous.
> You may have already considered this, but has there been anything situational going on that could trigger a depression?
Not really. I've been taking advantage of some IP psychotherapy for about 6 months, and there doesn't seem to be anything getting in my way. I have also been using cognitive behavioral strategies to help manage my life for years.
Light therapy sounds like a viable option. A friend of mine who does not exhibit any seasonality to her depression has been benefiting from using it for 30 minutes each morning. I am so tired of investing myself in all sorts of different treatments.
When I respond to treatment, the effect is unmistakable. It is like adding color to a black and white world. This response was the real thing. Unfortunately, my relapse was a true poop-out (tachyphylaxis), and occured in the absence of significant psychosocial stress.
I am starting to get depressed about this treatment failure. I really don't want to be bothered trying to fight it. Having one depression stacked upon the other doesn't make for a pleasant combination. I was counting on this stuff to work. I thought I was on my way...
- Scott
Posted by SLS on April 23, 2006, at 8:50:27
In reply to Re: Another drug failure, posted by linkadge on April 23, 2006, at 8:38:03
> Yeah, the voldoxan might offer a complementary effect to those taking other antidepressants.
>
> If you're more "blue" then it might be a sign that you're one too many catecholamine enhancing drugs.
>
> OTOH, Emsam might be an interesting option, though I don't know of the interaction with the drugs you're taking. Selegeline has a protective and restoritive effects on dopaminergicly mediated functions during aging, did you ever try selegeline?I tried the oral preparation, Eldepryl. I took 30mg. I guess I should really consider the patch, despite my not responding adequately to Parnate and Nardil. I doubt my doctor would let me stay on nortriptyline and Wellbutrin, though.
I really don't feel blue, sad, or melancholy. It is more a loss of interest, anergia, and anhedonia. By what mechanisms do you think too many catecholaminergic antidepressants would produce feeling blue?
Thanks, Linkadge.
- Scott
Posted by ed_uk on April 23, 2006, at 9:43:45
In reply to Re: Another drug failure » linkadge, posted by SLS on April 23, 2006, at 8:50:27
Hi Scott
I hope Valdoxan is approved in Europe soon. Do you think it will be easy for you to obtain?
Regards
Ed
Posted by platinumbride on April 23, 2006, at 9:54:55
In reply to Another drug failure, posted by SLS on April 22, 2006, at 9:11:50
Scott,
I'm so sorry you are going through this again. I wish you the best.
Diane
Posted by bassman on April 23, 2006, at 10:10:50
In reply to Re: Another drug failure » SLS, posted by ed_uk on April 23, 2006, at 9:43:45
Is Valdoxan approved in the US? The only thing I could find on the net were Phase III trials..
Posted by SLS on April 23, 2006, at 10:53:47
In reply to Re: Another drug failure » SLS, posted by ed_uk on April 23, 2006, at 9:43:45
> Hi Scott
>
> I hope Valdoxan is approved in Europe soon. Do you think it will be easy for you to obtain?If the guy is still in business, I have used a pharmacy in the UK to procure sulpiride.
- Scott
Posted by ed_uk on April 23, 2006, at 11:22:46
In reply to Re: Another drug failure » ed_uk, posted by SLS on April 23, 2006, at 10:53:47
Hi Scott
What sort of pharmacy was it?
Ed
Go forward in 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.