![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 19 to 43 of 49. Go back in thread:
Posted by dewdropinn on July 24, 2007, at 0:20:04
In reply to Re: Patch decision - What to do?, posted by JohnSky on July 23, 2007, at 15:21:26
The dietary issues are largely theoretical. Bristol-Meyers worked very hard to induce tyramine reactions during initial clinical studies without any luck. They have lobbied with the FDA to get the black box warning removed, because all of their research suggests that the dietary precautions are unnecessary. The dietary risks are miniscule at best, but they are worth knowing about because of the severity of the possible side effect. Does this make sense?
Raising the dose may prove beneficial -- it made a huge difference for me. If bipolarity is an issue, it may make sense to try reducing the dose -- you can easily cut the patch and assess your response -- this would seem to be the most readily testable option. I wish that I could give you more definitive direction. Best of luck, and please let me know how everything goes.
Drew
> Thank you for the idea about going up to 9mg. At that dose I believe the dietary constraints come into play? That is the strategy I may need to go.
>
> I need to do something as I feel anxious and my mood is down. Over the last few days I just feel tired and "strange". Sort of a "out of touch feeling". This may be from feeling anxious alot of the time from the medication. Or from being over-medicated as I am also on Lithium and Seroquel. I just feel scared and that the EMSAM is making me worse. I have been on it 24 days. I will give it until Wednesday and then discontinue if I still feel so out of sorts.
>
> John
Posted by JohnSky on July 24, 2007, at 10:25:34
In reply to Re: Patch decision - What to do?, posted by dewdropinn on July 24, 2007, at 0:20:04
Thanks for the info. Why do you mention bi-polar and using a lower dose of EMSAM if so? I have recently been diagnosed bi-polar because Effexor caused a major manic reaction in me a year ago and my doc said I must be bi-polar because of the reaction. No other medication has caused that reaction in me and I have never had a manic reaction in my 49 years.
I read an FDA report that listed a manic reaction as possibility when taking Effexor.John
Posted by dewdropinn on July 24, 2007, at 12:33:00
In reply to Re: Patch decision - What to do?, posted by JohnSky on July 24, 2007, at 10:25:34
It sounds like we're in a very similar boat.
As you may know, there's a trend towards expanding the bipolar spectrum to include individuals who have never experience a true manic episode -- or whose manic episodes are purely medication induced. It's almost as if there's an underlying pattern that influences the overall course of the disease without manifesting overt symptoms. Among bipolar specialists, it is generally agreed that all antidepressants pose a risk of inducing mania -- SSRIs are the worst, MAOIs are arguably the best along with Wellbutrin, but all antidepressants have the potential to induce cycling, mania, etc.
When these specialists decide to use antidepressants, they typically select the drugs that pose the least risk -- e.g. EMSAM or Wellbutrin -- and they administer them at the lowest possible dose, so as to minimize the risk of exacerbating the bipolar features of the mood disorder. That's the theory, and that would be my reasoning for saying "lower the dose." But it sounds like you're really on the soft side of the bipolar spectrum which means that a more conventional approach to antidepressant dosing may work so long as you have a mood stabilizer on-board.
I actually assumed that you were classic bipolar 1 -- lithium is the bipolar 1 gold standard, and seroquel is the add-on for people who still have insomnia and anxiety in spite of being on a potent mood stabilizer. If you aren't bipolar 1, I could definitely see how this combo could cloud things up considerably.
Here's a snapshot of my history with bipolarity. I have taken any number of different drugs and combos of drugs -- some have worked for a time and then pooped out and at least one combo induced something that resembled a manic episode (freewheeling spending and a lot of partying.) My doctor at the time was a research psychiatrist who has been involved with major NIMH studies, and he's something of an expert on bipolar spectrum disorders. Based on my poop-out and hypomanic response to certain antidepressants, I was slapped with a bipolar diagnosis, and began one of the most excruciating phases of my psychopharmacological treatment. The doctor first determined that antidepressants were only an option of last resort, and that we would work to find an effective mood stabilizer and/or atypical anti-psychotic. We started with Lithium, and that was pretty brutal -- somewhat calming, but it made me dumber and number, and my job requires clarity -- it ultimately induced akathesia which ended that experiment; I then moved on to Depakote which was vicious in every respect; then Trileptal which was better than Lithium and Depakote but sent me into near suicidal depression; then Tegretol which was better than Trileptal, but still induced depression. Along the way, I took Seroquel, which resolved my insomnia but redered me incapable of functioning, regardless of the dose (I literally took crumbs of the stuff and it still made me instantly retarded.) To make a very long story a little bit shorter, I eventually consulted with another NIMH doctor -- one of the legendary research psychiatrists from back in the 70's -- and he was of the opinion that, while I had some bipolar features, I really wasn't truly bipolar and that my treatment would never succeed if it followed the strict guidelines proscribed for the treatment of bipolar disorders. Fortunately, he provided me with a pharmacological plan that proved effective. He suggested taking Lamictal and pushing the dose above 200mg -- at the higher levels it acts as a mood stabilizer but it also has true antidepressant qualities -- if Lamictal alone did not work, then he recommended adding Wellbutrin or an MAOI. I started on Lamictal, titrated up the dose, started feeling better around 300mg, and reached maximum benefits at 400mg -- I still had residual depression and cognitive problems. Because I had some success with selegiline in the past, my doctor selected EMSAM as the add-on. The 6mg patch increased my energy levels almost immediately, but it also induced anxiety and insomnia -- I tried cutting the patch, but it resulted in an increase of the depression and a decrease of energy, so I knew reducing the dose wasn't the answer for me. My doctor then raised the dose to 9mg, and I experienced almost total remission for the first time in ages.
So, if you were in fact bipolar 1, a reduction in dosage would seem to correspond with the prevailing theories of the day. If you are on the softer side of the bipolar spectrum, you almost certainly need some kind of mood stabilizer -- but your current combo may simply be too powerful -- great for classic bipolar, but the proverbial emotional and cognitive hammer for less severe varieties. Lamictal is becoming the gold standard for bipolar 2, 3, atypical bipolar and atypical depression. It is not as potent a mood stabilizer as Lithium or Depakote or Seroquel, but it is effective in this capacity none-the-less and it can also be an effective antidepressant if taken at high enough doses. In my experience, it's the kindest and gentlest of the available mood stabilizers -- so this may be worth exploring. Many psychopharmacologist like to resolve the mood stabilizer situation before adding antidepressants -- it's almost like the mood stabilizer lays the foundation for antidepressant therapy.
Once you find a livable mood stabilizer and/or mood stabilizing combo, then you can explore adding antidepressants. EMSAM @ 9mg would be my choice just based on my own experience -- there are other antidepressants and atypical anti-psychotics that may work as well -- most of them posed problems for me, but that doesn't mean they won't be effective for you.So that's my story -- your reactions may be totally different from mine, so I don't know if there are any definitive answers in this narrative -- but at the very least, there's a precedent. Hopefully this is helpful -- and let me know if you have any other questions.
Drew
> Thanks for the info. Why do you mention bi-polar and using a lower dose of EMSAM if so? I have recently been diagnosed bi-polar because Effexor caused a major manic reaction in me a year ago and my doc said I must be bi-polar because of the reaction. No other medication has caused that reaction in me and I have never had a manic reaction in my 49 years.
> I read an FDA report that listed a manic reaction as possibility when taking Effexor.
>
> John
Posted by aegle on July 25, 2007, at 2:39:13
In reply to Re: Patch decision - What to do?, posted by dewdropinn on July 24, 2007, at 12:33:00
<snipped>
Drew, thank you for your particularly cogent replay. Our histories have some substantive similariites and the description of your experience has been mimicked my own in some surprising ways.
I dislike putting you on the spot in a public forum such as this, but I must ask, may I babblemail you? I have some questions not addressed in your post.
Regardless of your answer, thank you for your participation here.
Regards,
aegle
Posted by aegle on July 25, 2007, at 3:45:26
In reply to Re: Patch decision - What to do?, posted by JohnSky on July 24, 2007, at 10:25:34
JohnSky, for what it's worth, I've found little value in a diagnosis reached by a psychiatrist backing into one based simply on your response to a specific medication. There are far too many uncontrollable environmental variables to slap a label of soft or Bipolar II on you if you've been asymptomactic for your 49 years simply because of your response to one medication.
I'd caution you to accept the foregoing as my personal perspective only. A simple Google search would help you find some quick and dirty diagnostic tools to help you evaluate your response to several bipolar II tests; if you have that "A ha!" response after relecting upon your response in an unmedicated state, you'll have quite useful information.
Again, FWIW, I was took Effexor ER at a dose of 375mg per day for 11 years. My own psychiatrist dabbled with the soft Bipolar diagnosis based on my reaction to that medication, though I'd been previously diagnosed as an Atypical Depressive (which includes the component of reactivity, a symptom frequently associated with Bipolar II.) I went through trials of Tegretol, Neurontin and Lamictal and others whose names I don't immediately recall to stabilize my moods while on Effexor.
Lamictal provided the best relief (a floor for depression and a cap for those rare times when the inability to sleep and wildly optimistic moods prevailed) for the longest period; the others had intolerable side effects. My point: even if you have no legitimate diagnosis of BP II, a mood stabilizer could be held in reserve as a useful adjunct to your medication regime. I'd wait until you see how you respond to the 9mg dose of Emsam, however.
I've been away from this group for the last two weeks due to outside commitments, but based on what I've read here over the last eight months and my own experience, there appears to be an inverse relationship between Emsam dosage and anxiety/agitation. An increase to the 9mg patch is certainly something worth trying to see if the anxiety is reduced.
Wishing you well with your decision.
Regards,
aegle
> Thanks for the info. Why do you mention bi-polar and using a lower dose of EMSAM if so? I have recently been diagnosed bi-polar because Effexor caused a major manic reaction in me a year ago and my doc said I must be bi-polar because of the reaction. No other medication has caused that reaction in me and I have never had a manic reaction in my 49 years.
> I read an FDA report that listed a manic reaction as possibility when taking Effexor.
>
> John
Posted by JohnSky on July 26, 2007, at 10:15:26
In reply to Re: Patch decision - What to do?, posted by dewdropinn on July 24, 2007, at 12:33:00
Thank you Drew for your very detailed reply and history. It helps. After talking with my Doc I have decided to stay with the 6mg patch but not cut it in half at night.. thus I will have the full 6mg throughout the day. I slept Ok this way last night. My doc felt with me cutting the patch at night to help with sleep I was ending up with say 4.5mg for the day which was just not a high enough dose to help me. I have decided to see if I can handle the anxiety at this dose until this Sunday. If not I will likely try the 9mg patch for a week. The anxiety I have felt has been very tough to deal with and it wears me down so much and makes me feel so hopeless. Two days ago was the most I've felt depressed in some time. Scared me as the dark thoughts came quickly and I thought the very worst.
I am on a medium dose of Lithium and Seroquel. Sometimes I wonder if the Lithium is depressing me.
Posted by JohnSky on July 26, 2007, at 10:27:38
In reply to Re: Patch decision - What to do?, posted by JohnSky on July 26, 2007, at 10:15:26
Forgot to ask. If I go up to 9mg does the preferred method seem to be to take it off at night? Also, Are most people abiding by the dietary restrictions or are they "soft".
John
Posted by dewdropinn on July 26, 2007, at 14:00:19
In reply to Re: Patch decision - What to do?, posted by JohnSky on July 26, 2007, at 10:27:38
Even though Lithium is sometimes thought of as having antidepressant qualities, I don't think it's particularly effective in this capacity -- it made me feel a bit stupid and spacey, and it certainly didn't help my mood. The anti-psychotics can have a whole range of effects and side effects -- I marvel at the extreme reaction people have to various atypical anti-psychotics -- from miraculous improvements to a rapid descent into total wackiness. So, I would say all bets are off as far as assessing what lithium and seroquel are doing for the overall picture. I would trust your doctor though -- he's prescribed you EMSAM, so he's clearly open to experimentation -- I would keep him appraised of your mood fluctuations.
The dietary precautions with the 9mg patch are definitely soft. I'm guessing that you're familiar with the mechanisms involved with the tyramine reaction. If not, it's associated with MAOI metabolism in the liver -- the theory behind the patch is that it largely bypasses the liver, and thereby bypasses the whole tyramine problem. During the clinical trials, they worked very hard to induce the tyramine reaction, and as far as I know, they were unable to -- the lack of dietary risks was supposed to be one of the major selling points of the drug, which is why Bristol-Meyers fought with the FDA to get these warnings removed -- it would seem they had the clinical evidence in hand, but the FDA was unyielding. The FDA decision was based on the fact that, even though the patch largely bypasses the liver, at the higher doses a sufficient amount of the drug could conceivably accumulate in the liver so as to pose a risk. So, that's the scoop on the dietary restrictions. The big risk with the patch is associated with drug-drug interactions -- over-the-counter drugs like Sudafed and any other decongestants can trigger a hypertensive reaction, so this should be the primary safety concern.
I removed the patch at bedtime both when I was at 6mg and now that I am at 9mg -- I literally could not sleep if I kept it on, unless I took klonopin or ativan. When I started removing the patch at bedtime, I found that I was able to fall asleep without any additional medication.
One final thought -- raising the EMSAM dose to 9mg should help the overall depression situation, so long as more serious bipolar issues are present. Lithium and seroquel may be needed, but the pharamocology of the 2 drugs may be compromising or altering the efficacy of EMSAM -- both drugs impact serotonin and dopamine (albeit in different ways), so it would seem to follow that they will at the very least impact the effect of EMSAM (for the better or worse.) I've already mentioned lamictal -- so that's an option. But an even easier option would be Klonopin, which would address any residual insomnia and anxiety. Some doctors -- particularly doctors under the age of 40 -- are ridiculously skittish about giving patients benzos for fear of addiction. They instead give non-benzo hypnotics, which are somewhat unpredictable, and APs like seroquel, which have no long-term track record and some worrisome potential side effects. One of my very old school pdoc pals said that, in all of his years of practice, the benzos were simply the greatest anti-anxiety/sedative drugs of all-time -- and the addiction risks vary considerably from one drug to the next -- halcyon being the most addictive, klonopin being the least. Having given all the non-benzos and most of the APs a whirl, I believe the old guy was right -- that's my personal opinion and the very old school doc's assessment, rather than any kind of universally excepted truth. In any event, I would definitely consider Klonopin -- it will help with the anxiety and insomnia, it will greatly simplify your regiment, and so long as you don't escalate the dose, the risk of long-term dependency is low.
That's my 2 cents -- just let me know if you have any other questions.
> Forgot to ask. If I go up to 9mg does the preferred method seem to be to take it off at night? Also, Are most people abiding by the dietary restrictions or are they "soft".
>
> John
Posted by JohnSky on July 26, 2007, at 16:59:03
In reply to Re: Patch decision - What to do?, posted by aegle on July 25, 2007, at 3:45:26
Thanks for your reply aegle. i am not sure about my bi-polar diagnosis with one manic episode in my entire life caused by a medication.
My doc said they think I am bi-polar because when I stopped taking the medication I continued to be manic for several weeks. I think the mania just runs its course no matter how started (bi-polar... or via a medicine).I plan to take the 6mg daily (including at night) until Sunday. If my anxiety doesn't back down I want to go to 9mg to give it a try to see if my anxiety drops off as others have experienced when they went to 9mg... and a decrease in depression. I just don't know whether to take the patch off at night. If I don't I think I would only get about 6mg in my blood stream daily???? Ideas and experience?? but I'm not sure wwh
Posted by dewdropinn on July 27, 2007, at 7:31:19
In reply to Re: Patch decision - What to do?, posted by JohnSky on July 26, 2007, at 16:59:03
As for removing the patch at bedtime. I do not believe that the patch delivers medication in a consistent pattern throughout the 24 hour day -- I suspect it releases the majority of the drug during the hours immediately following application, and the amount gradually diminishes throughout the day. While the 4.5mg calculation makes sense if you do straight arithmatic of the dose and hours taken, I pretty sure you're actually getting more than 4.5mg. Also, the efficacy of the drug is closely linked to sleep -- and I think you'll notice this trend with almost everyone who takes MAOIs -- the drug works far better when insomnia is under control. I would experiment with removing the patch because the sleep issue is at least as important as the dosage total.Here's my experience in a tiny nutshell --
1) Lithium and seroquel were just way to powerful -- they severely compromised cognition. Lamictal and klonopin were a much kinder and gentler solution to my low grade bipolar symptoms.
2) The true antidepressant benefits of EMSAM only kicked in at 9mg -- it vastly improved mood, and reduced anxiety.
3) In order for EMSAM to be effective at any dose, I need to sleep. In order to sleep, I need to remove the patch before bed.
Anectodal evidence, rather than scientifically verifiable and universally applicable -- so it may not hold true for you, but it's worked for me.
Drew
> Thanks for your reply aegle. i am not sure about my bi-polar diagnosis with one manic episode in my entire life caused by a medication.
> My doc said they think I am bi-polar because when I stopped taking the medication I continued to be manic for several weeks. I think the mania just runs its course no matter how started (bi-polar... or via a medicine).
>
> I plan to take the 6mg daily (including at night) until Sunday. If my anxiety doesn't back down I want to go to 9mg to give it a try to see if my anxiety drops off as others have experienced when they went to 9mg... and a decrease in depression. I just don't know whether to take the patch off at night. If I don't I think I would only get about 6mg in my blood stream daily???? Ideas and experience?? but I'm not sure wwh
>
Posted by JohnSky on July 27, 2007, at 14:20:38
In reply to EMSAM Dosage + Sleep, posted by dewdropinn on July 27, 2007, at 7:31:19
Thanks Drew for the comments and ideas. Right now I am back to 6mg all day and the anxiety is very harsh and I'm not sleeping well. My doc wanted me back up to 6mg all day. I will continue with this through Sunday and if I am still struggling with all the anxiety I go to the 9mg on Monday. I will give the 9mg one week to see if the anxiety goes down. If not, I'm done with EMSAM. If 9mg brings me more anxiety I just have had enough. Hopefully the anxiety will come down soon after I go to 9mg.
How long were you on 9mg before you noticed benefits?
While on 9mg I will likely take the patch off at night.
John
Posted by dewdropinn on July 27, 2007, at 17:30:01
In reply to Re: EMSAM Dosage + Sleep, posted by JohnSky on July 27, 2007, at 14:20:38
You should feel the difference between EMSAM doses almost immediately -- like within a week. So, on the upside, you should be able to determine whether or not EMSAM is for you in relatively short order. It's a great drug, but it's not necessarily for everybody.
If you noticed a significant benefit from lithium an seroquel, then this may suggest a direction for your next trial. There are APs that target depression more specifically than seroquel -- like Geodon for instance. Lamictal is commonly added to lithium for added mood stabilization and unresolved depressive symptoms -- klonopin can be added if insomnia and anxiety are still a problem. This would jive with the stanard mode of treatment for bipolar -- mood stabilizers first, then benzos and atypical anti-psychotics as needed -- antidepressants are added only when mood stabilizes.
Let me know how all goes,
Drew
> Thanks Drew for the comments and ideas. Right now I am back to 6mg all day and the anxiety is very harsh and I'm not sleeping well. My doc wanted me back up to 6mg all day. I will continue with this through Sunday and if I am still struggling with all the anxiety I go to the 9mg on Monday. I will give the 9mg one week to see if the anxiety goes down. If not, I'm done with EMSAM. If 9mg brings me more anxiety I just have had enough. Hopefully the anxiety will come down soon after I go to 9mg.
>
> How long were you on 9mg before you noticed benefits?
>
> While on 9mg I will likely take the patch off at night.
>
> John
>
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Posted by JohnSky on July 29, 2007, at 20:05:13
In reply to Re: EMSAM Dosage + Sleep, posted by dewdropinn on July 27, 2007, at 17:30:01
My anxiety has not settled down on 6mg patch so I will talk with my doctor tomorrow about what to do... The plan is to go to 9mg. The problem is I just don't feel right on EMSAM. I feel out of sorts and pretty tired at times. I just feel the medication is masking who I am somewhat. I feel strange and struggle for words at times... symptom of anxiety probably. Maybe that goes away with time. My main issue for months and months has been anxiety. I take Ativan to help with the anxiety but I just am not the generally relaxed person I used to be. Anxiety and depression dog me. I realize antidepressants normally work on the depression and then anxiety... I just haven't found a AD that works for me and I can say I have tried almost all of them. But I am not done with EMSAM yet. I would think the Lithium and Seroquel would help but I think they have just settled my mood down.
I am back meditating and doing many other things that should help me. The anxiety I may just have to deal with by accepting and working through the feelings.... that is after I get the EMSAM anxiety induced down.
Frustrated to say the least.
Posted by dewdropinn on July 30, 2007, at 11:25:59
In reply to Re: EMSAM Dosage + Sleep, posted by JohnSky on July 29, 2007, at 20:05:13
I look forward to hearing how everything goes -- it sounds like you've got your plan A established.
You know, there's an entire psychopharm. theory emerging based on the fact that a large percentage of people suffering from major depression are in fact contending with a bipolar spectrum disorder and antidepressants ultimately complicate and worsen the overall situation -- it explains why antidepressants don't work or work for a period of time and then poop out for many who suffer from long-term treatment resistant depression. This is the opinion of many bipolar experts.
If you fit into this group, your responses to lithium, seroquel and EMSAM all make perfect sense. Lamictal can act as both a mood stabilizer and an antidepressant, particularly at the higher doses -- Tegretol has antidepressive properties for some -- Geodon and Abilify have antidepressant properties -- and there other options as well. So, should things not work out with EMSAM, you have lots of options, and you will have completed an important step in targeting a viable treatment program for the future.
Best of luck!
Drew
> My anxiety has not settled down on 6mg patch so I will talk with my doctor tomorrow about what to do... The plan is to go to 9mg. The problem is I just don't feel right on EMSAM. I feel out of sorts and pretty tired at times. I just feel the medication is masking who I am somewhat. I feel strange and struggle for words at times... symptom of anxiety probably. Maybe that goes away with time. My main issue for months and months has been anxiety. I take Ativan to help with the anxiety but I just am not the generally relaxed person I used to be. Anxiety and depression dog me. I realize antidepressants normally work on the depression and then anxiety... I just haven't found a AD that works for me and I can say I have tried almost all of them. But I am not done with EMSAM yet. I would think the Lithium and Seroquel would help but I think they have just settled my mood down.
>
> I am back meditating and doing many other things that should help me. The anxiety I may just have to deal with by accepting and working through the feelings.... that is after I get the EMSAM anxiety induced down.
>
> Frustrated to say the least.
>
Posted by JohnSky on July 30, 2007, at 15:49:46
In reply to Re: EMSAM Dosage + Sleep, posted by dewdropinn on July 30, 2007, at 11:25:59
Thanks for the encouragement Drew.
My doctor and I have discussed this very issue. That if I am bipolar, medications like Lithium and Seroquel will help me but regular anti-depressants just aggrevate the situation. This is my experience so far in the last 1.5 years... but before that I was on a low dose of Prozac for 15 years and did fine.... I don't understand. This aggrevation issue is the case with my brother. He takes Lithium and is doing fine but he is still slowly getting off Paxxil that he says "messes him up".
I will give the EMSAM the 9mg try and then I am done. I am wired today at 6mg and it has been this way for nearly 5 weeks. Enough is enough.
I can't see how giving this 6mg another couple weeks would help... and I simply can't take any more.I hope the Lithium will kick in soon. I did try Abilify over a year ago with very bad results. I walked liked a 90 year old man. But as you mentioned there are other choices.
Maybe I may just need to wait for the Lithium to work. My brother says he feels wonderful and he has been on it 5 months. I have only been on it 2 months. It took a good 4 months for the Lithium to really show it's stuff.
John
Posted by dewdropinn on July 30, 2007, at 17:37:31
In reply to Re: EMSAM Dosage + Sleep, posted by JohnSky on July 30, 2007, at 15:49:46
I think you may have hit on a most likely answer. One of my very old school research doc friends once told me that if there's any family history with bipolar, then the diagnosis is easy -- you're bipolar or heading in that direction. And if a family member has responded well to a medication, then the chances are very good that other family members will get a good response from the same med.
There is supposedly a threshhold beneath which an antidepressant may not trigger mania -- so I suspect you were below the mania inducing dose of Prozac, but you may have been unwittingly setting the stage for the issues you are now contending with.
Just based on what I'm hearing, it sounds like it may be best to follow your gut instincts, ditch the antidepressants for now, and focus on optimizing your lithium dose. This would seem to jive with much of the latest research and a family precedent. I'll be interested in hearing how everything progresses.
Drew
> Thanks for the encouragement Drew.
>
> My doctor and I have discussed this very issue. That if I am bipolar, medications like Lithium and Seroquel will help me but regular anti-depressants just aggrevate the situation. This is my experience so far in the last 1.5 years... but before that I was on a low dose of Prozac for 15 years and did fine.... I don't understand. This aggrevation issue is the case with my brother. He takes Lithium and is doing fine but he is still slowly getting off Paxxil that he says "messes him up".
>
> I will give the EMSAM the 9mg try and then I am done. I am wired today at 6mg and it has been this way for nearly 5 weeks. Enough is enough.
> I can't see how giving this 6mg another couple weeks would help... and I simply can't take any more.
>
> I hope the Lithium will kick in soon. I did try Abilify over a year ago with very bad results. I walked liked a 90 year old man. But as you mentioned there are other choices.
>
> Maybe I may just need to wait for the Lithium to work. My brother says he feels wonderful and he has been on it 5 months. I have only been on it 2 months. It took a good 4 months for the Lithium to really show it's stuff.
>
> John
>
Posted by d0pamine on July 31, 2007, at 10:54:32
In reply to EMSAM Dosage + Sleep, posted by dewdropinn on July 27, 2007, at 7:31:19
Just to repeat what I mentioned in a previous post 600 mg or so of potassium CITRATE (has to be citrate) taken 300 in the morning and 300 at lunch COMPLETELY resolved the insomnia that I experienced with EMSAM
Posted by JohnSky on July 31, 2007, at 19:29:11
In reply to Re: EMSAM Dosage + Sleep, posted by dewdropinn on July 30, 2007, at 17:37:31
Thanks Drew. Rest assured I will post how my story plays out. My gut tells me the Lithium will help as it has helped my brother. It lifted his depression and anxiety but took some time to do it. I'm Ok with waiting if I am seeing some little progress forward from time to time.
John
Posted by JohnSky on August 1, 2007, at 9:21:27
In reply to Re: EMSAM Dosage + Sleep, posted by JohnSky on July 31, 2007, at 19:29:11
Today I started on the 9mg patch. If the anxiety comes roaring in this will be a short experiment. Yesterday on 6mg was one of the most anxious days ever. I decided to cut the patch down in the morning to something around 4mg and that seemed to increase the dose from how I felt... porbably just due to how much is built up in my system over 5 weeks. I was wired
all day, having anxiety attacks, and my chest hurt from the tension. I ended up taking the patch off at 1:00 in the morning because I kept waking up. The story goes that going up to 9mg the anxiety and agitation should come down. Sure hope so.. can't take any more days like yesterday.John
Posted by dewdropinn on August 2, 2007, at 10:20:02
In reply to Re: EMSAM Dosage + Sleep, posted by JohnSky on August 1, 2007, at 9:21:27
This is fantastic! You now have the opportunity to find out definitively whether or not your treament needs to follow the classic bipolar protocol, or if you are in fact among those with a much milder bipolar spectrum disorder, and will be best treated with a combination of mood stabilizers and antidepressants.
Best of luck and let us know how this all goes.
Drew
> Today I started on the 9mg patch. If the anxiety comes roaring in this will be a short experiment. Yesterday on 6mg was one of the most anxious days ever. I decided to cut the patch down in the morning to something around 4mg and that seemed to increase the dose from how I felt... porbably just due to how much is built up in my system over 5 weeks. I was wired
> all day, having anxiety attacks, and my chest hurt from the tension. I ended up taking the patch off at 1:00 in the morning because I kept waking up. The story goes that going up to 9mg the anxiety and agitation should come down. Sure hope so.. can't take any more days like yesterday.
>
> John
Posted by JohnSky on August 2, 2007, at 15:31:17
In reply to Re: EMSAM Dosage + Sleep, posted by dewdropinn on August 2, 2007, at 10:20:02
We'll I have to say I am thinking this higher dose of 9mg is causing less anxiety. Yesterday was my first day. I was very anxious in the evening for a couple hours for some reason... alot tension in my chest as well (no diet issues... I followed the guidelines). I cut the patch in half last night and slept Ok with the help of benzos. Today I feel less anxious again.... and tired as I'm not sure how well I slept... didn't feel very rested. We'll see how this goes. My fear is the medication is building in my blood level and anxiety will return. I hope the anxiety doesn't hit me as hard this evening... don't understand why that is happening. So I will give this experiment a few more days and hope the anxiety comes down and the depression gets better. The depression has lightened some since I started this EMSAM experiment 5 weeks ago... not sure how long it will take to get much better on this higher dose.
So I guess I should focus on what is going better.
Posted by JohnSky on August 3, 2007, at 15:15:49
In reply to Re: EMSAM Dosage + Sleep, posted by dewdropinn on August 2, 2007, at 10:20:02
I've seen this debated somewhat on the forum... I'm wondering if I really need to follow the dietary constraints if I am on the 9mg patch. I seen written that the answer is no but I would sure like to see more evidence and hear from some people that have not followed the dietary constraints.
Also, I went up to 9mg two days ago and I'm doing OK on this dose... meaning the anxiety isn't too bad. I was at 6mg for 5 weeks. The anxiety was bad for me at 6mg. I'm wondering how long before the 9mg is likely to kick in and help my depression?
Thanks
John
Posted by dewdropinn on August 4, 2007, at 15:36:16
In reply to Re: EMSAM Dosage - Dietary constraints?, posted by JohnSky on August 3, 2007, at 15:15:49
As I noted in an earlier post, the dietary risks associated with the higher doses of EMSAM are largely theoretical -- the theory is that, even though the patch enables selegiline to largely bypass the liver, some small modicum of the drug builds up in the liver, which in turn raises the risk of a tyramine induced hypertensive crisis. I would keep in mind that this is largely theoretical. During the clinical trials, independent and drug financed studies failed to produce any incidents of this tyramine reaction at any dose -- and they tried very hard to induce these reactions, because you can imagine the liability problems associated with releasing an MAOI that allegedly doesn't prose any risk of inducing tyramine related reactinos, and upon release patients begin experiencing this reaction en masse. In fact, one of the major delays in bringing the drug to market was due to Bristol-Myers desperate attempts to get the black box warning removed. So, there is a theoretical risk, and I would imagine there are isolated incidents of these reactions having occured, but in the real world setting, your chances of developing a tyramine reaction are incredibly remote and all clinical studies I am aware of demostrate that this is not a risk factor. The drug-drug interactions are where very real risks exist -- anti-histamines, narcotic pain killers, and many drugs commonly used in psychiatry are big no-no's (I'm sure your doctor is very aware of this.)
It's great to hear that your anxiety is decreasing -- this is totally consistent with my experience. I suspect that the true serotonergic effects of the drug start kicking in once you get to the higher doses, which should reduce anxiety and improve depression. As I mentioned earlier, removing the patch at bedtime can improve insomnia and the quality of sleep immeasurably -- and the vast majority of the drug is released during the course of the day, so you really aren't significanly reducing the dose by taking off the patch at night. I would at least experiment with removing the patch before bed -- it's such a simple thing to do, and you should know within a couple of days whether or not this procedure reduces the effect of the drug in any way. Sleep is essential to optimizing the response to almost any antidepressant, so even though you may be reducing the dose incrementally, you are probably also improving you capacity to respond to the drug. Does this make sense?
Best of luck,
Drew
> I've seen this debated somewhat on the forum... I'm wondering if I really need to follow the dietary constraints if I am on the 9mg patch. I seen written that the answer is no but I would sure like to see more evidence and hear from some people that have not followed the dietary constraints.
>
> Also, I went up to 9mg two days ago and I'm doing OK on this dose... meaning the anxiety isn't too bad. I was at 6mg for 5 weeks. The anxiety was bad for me at 6mg. I'm wondering how long before the 9mg is likely to kick in and help my depression?
>
> Thanks
>
> John
Posted by cumulative on August 5, 2007, at 19:21:53
In reply to Re: EMSAM Dosage - Dietary constraints?, posted by dewdropinn on August 4, 2007, at 15:36:16
Hello dr-bobbers, I'm cumulative.
Interesting about the help people have reported of removing the patch before bedtime.
Regardless of selegiline's half-life, at these dosages I believe the inhibition of MAOI is irreversible -- MAOI sticks around for about two weeks.
So I wonder what is at play? Subjectively the patch calms one down? Perhaps the l amphetamine isomers that are known to metabolize from selegiline are having some effect.
Just about to start on EMSAM + Ambien CR,
cumulative
Posted by JohnSky on August 6, 2007, at 10:53:45
In reply to Re: EMSAM Dosage - Dietary constraints?, posted by dewdropinn on August 4, 2007, at 15:36:16
Something is up with the 9mg patch. I started the higher dose on 8/1. I was having trouble sleeping so I cut the patch on 8/3 to 1/2. I slept better but still didn't feel rested. The last 2 nights I went to 1/4 of the patch and slept Ok but still not great. Today I feel down... more so than I have in a couple weeks or so. I probably am depressed about how long I have been dealing with depression but I wonder if the patch is causing a problem. I also have had some bouts of high anxiety that have me feeling down and losing hope... so that may be it.
Any guesses on when the higher dose will help with depression and bring the anxiety down?
Frustrated on what to do.
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