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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 18 of 18. This is the beginning of the thread.
Posted by CoutureMan on November 25, 2007, at 2:20:55
Hi Racer, how is the Emsam trial going? Is it starting to work as an antidepressant? Also, is there any increased anxiety or insomnia with the drug?
I really want to try this drug but I have such severe anxiety I don't know if I could tolerate it. I don’t do well on any stimulating meds.
Thanks,
-CM
Posted by Racer on November 25, 2007, at 2:39:06
In reply to Racer, how is the Emsam trial?, posted by CoutureMan on November 25, 2007, at 2:20:55
So far, no increased anxiety, no stimulation -- although I was taking Wellbutrin XL and Concerta when I started, so decreased stimulation isn't so surprising to me -- but there is finally some sign that it might be helpful as an antidepressant. The worst problem I'm having is constipation -- which is a side effect I get from most antidepressants, and one of the reasons I liked my WB/stimulant combination.
Insomnia is a bit of an issue, but my doctor warned me about it, so I wasn't surprised. It does mean that I'm taking more Sonata than I'm comfortable with. My sleep schedule is messed up right now, which bothers me a lot, and it's another thing I'll be talking to him about next week. Some of that is situational, though -- I just don't go to bed, but since I nap in the afternoon, that's not so surprising. I then beat myself up for the behavioral portion of the problem, which as we all know helps no end with depression. I suspect the insomnia wouldn't be so bad if I avoided napping, or if I went to bed at a reasonable time. I mean to, but...
I have an anxiety disorder to go with the depression, and can tell you now that there's no additional anxiety on it for me. It might even be anxiolytic, but I've still got enough depressive symptoms going to mask that a bit. I'm not crying every day anymore, though, so that might be a good sign. Still can't tell you that I feel as though living is worthwhile, but it's not as pressing an issue, if that makes sense. My obsessiveness has jumped up, which has provided a distraction for me -- that does tend to distract me from depression, which is a mixed blessing.
So far, I can't tell if it's a winner or not. My doctor doesn't want to go above the 9mg patch, because he says that every time he has, increased agitation has led to reducing back to 9mg. I suspect he'll want to discuss adding something, which I guess I'm willing to try -- although I'm not terribly enthusiastic about Lamictal, which I've tried twice now. I may ask about trying Provigil again -- it was my good and trusted friend, and might help with the GI problem.
I'm willing to continue the trial, which is about all I can say right now. Thank you for asking about me.
Posted by Phillipa on November 25, 2007, at 11:35:37
In reply to Thanks for asking » CoutureMan, posted by Racer on November 25, 2007, at 2:39:06
I didn't know you had anxiety as they is why my pdoc wouldn't let me go on it . I really would like to try emsam have since it came out. If anxiety still don't understand how concerta or a stimulating med helps. I know you know your neurotransmitters is there a simple way to explain? Thanks Phillipa
Posted by Racer on November 25, 2007, at 12:06:23
In reply to Re: Thanks for asking » Racer, posted by Phillipa on November 25, 2007, at 11:35:37
> I didn't know you had anxiety as they is why my pdoc wouldn't let me go on it . I really would like to try emsam have since it came out. If anxiety still don't understand how concerta or a stimulating med helps. I know you know your neurotransmitters is there a simple way to explain? Thanks Phillipa
The simple way to explain is that the neurotransmitters are not all that well understood, so a lot of what we discuss on this board is supposition, not accepted fact. Excessive serotinergic activity can be associated with anxiety, for example, and yet SSRIs are known to improve anxious symptoms. While it's easy to say, "Oh, I'm anxious, so I need more serotonin," or "I suffer from anhedonia, so I need more dopamine," it's just not that simple. What's more, the drugs don't increase neurotransmitters in a simple, direct manner, either. An SSRI affects the serotonin reuptake transporter, not serotonin itself -- that's indirect. If there's a problem with serotonin synthesis, inhibiting the transporter won't do a lot of good. And that brings up another issue: synthesis of the neurotransmitters. Dopamine is a neurotransmitter in its own right, but it's also a precursor to norepinephrine. That affects the whole metabolic picture in ways that can muddy the waters even more.
So, why do I do better on noradrenergic medications than on serotinergic meds? I don't know why, I only know that it's been true so far.
Depression is most likely related to the actions of the Big Three neurotransmitters we talk about on this board. No one knows, though, exactly what goes on. There is no test to show that this one or that one is the problem -- at least, no practical test. Even if research showed unequivocally that depression was caused by, say, low serotonin activity, that wouldn't necessarily prove that it was true in EVERY case of depression. Our neurochemistry is different, our metabolic chemistry is different -- even diet makes a difference. That's why what works for one person doesn't necessarily work the same way for someone else.
I've read your posts for a long time, and I'm curious about *why* you want to try EMSAM? If it's just because it's a new drug and people are talking about it a lot, or because a lot of people on this board have had good results from MAOIs, that's probably not a good rationale. As far as I recall, you haven't been able to get to a therapeutic dose of an SSRI, which would probably be a better choice for an anxiety-dominant depressive disorder. Frankly, I'd strongly suggest you try to do that, first, rather than moving on to EMSAM or another MAOI. If you really want to try an MAOI, Nardil is said to be very good for anxiety.
Regardless, though -- what works for one person won't necessarily work for another, even with the same general diagnosis. The fact that I do much better on stimulating medications, despite an anxiety disorder, is an example of that. It's all very individual, and the only way to see if a medication will work for you is to try it -- at a therapeutic dose for an adequate length of time -- and see if it works.
Posted by rskontos on November 25, 2007, at 15:32:12
In reply to Thanks for asking » CoutureMan, posted by Racer on November 25, 2007, at 2:39:06
Racer have you ever tried supplements for the constipation? rk
You seem so knowledgeable I hesitate to suggest anything and AD seem to give me the opposite effect but I have severe GI issues so that is something I am familiar with so I just wondered what you have tried to combat the symptoms and if effective? Unless this is a subject you would rather stay away from, is cool then.....I understand that the gi tract is more intuned with the central nervous system and brain than most realize.
Posted by Racer on November 25, 2007, at 16:57:37
In reply to Re: Thanks for asking, posted by rskontos on November 25, 2007, at 15:32:12
>
> You seem so knowledgeable I hesitate to suggest anything and AD seem to give me the opposite effect but I have severe GI issues so that is something I am familiar with so I just wondered what you have tried to combat the symptoms and if effective?
Thank you for the compliment, but I'm pretty ignorant about what to do for this problem. I've tried Metamucil, and that's about it. I just don't know of what else there is in the way of supplements? The Metamucil was not a great success -- if anything, I think it actually made the problem worse. I don't want to discuss details, but -- I think it made the problem worse...As far as the idea that the GI tract and the rest of the nervous system are linked, that's very true. Most of the serotonin in the body is actually found in the GI tract, not the brain or CNS. That's why so many serotinergic medications have GI side effects.
So, if you have any ideas, please let me know...
Posted by Phillipa on November 25, 2007, at 18:21:13
In reply to Re: Thanks for asking, posted by Racer on November 25, 2007, at 12:06:23
Racer that's pretty simple to answer. First long before babble or even people using computers much I went through the SSRI's at theraputic doses as they only for instance prozac was only in 20mg capsules at the time. Had been on benzos for so many years the SSRI's were added. I must say I regret not taking that Virginia pdocs advise and only taking prozac a couple days a week as the first day was great. But then all this was before the thyroid issue still not resolved. Anyway if I can see a med and since EMSAM is a patch psychologically knowing I can see the drug removed from me is reassuring. May seem stupid but not to me. I do know the med is in your body for days but the simple act of removing it is reassuring to me. Same as hormones the bioidenticle cream I could see and knew I could wash it off. Unfortunatedly I had great pdoc's in Connecticut and Virginia and trusted them. NC so far trust none. So that's the story. And if I could I'd be back in Virginia only the pdoc I had there went into employee assistance and I think he's now retired. My greatest in CT would be so upset to know what has happened to me. And he's still in practice but can't afford CT prices now. Phillipa
Posted by stargazer2 on November 25, 2007, at 19:37:26
In reply to I'm not sure what you have in mind? » rskontos, posted by Racer on November 25, 2007, at 16:57:37
Racer,
Here are some ideas I have used and given to others with constipation. If you are already constipated you can do a few things. First, you can take a dose (or two) of Milk Of Magnesia. Take it at bedtime and it should work overnight. Other things that can help once you are already constipated is a med called Dulcolax tabs (biscodyl). Take two of these if the MOM fails to do the job. This is a pretty powerful laxative despite the size of it. And lastly if those two things don't work, you can use a fleets enema which is very small or maybe a glycerin suppository.
To prevent constipation from occurring in the first place you have to take a stool softener (Colace), drink lots of fluids, eat dried fruit and take a fiber product like Metamucil which can be helpful to add bulk. By routinely doing these things you can avoid taking laxatives routinely which is never a good thing since that can lead to a "lazy" bowel, which makes you more reliant on daily laxatives.
Stools softeners can and should be taken a few times daily to start to get things moving along.
Once things are under better control, perhaps only one stool softener a day along with exercise, a good diet with lots of fiber will get things back on schedule and you will not need to take a laxative except for isolated situations.
Good luck, I hope these suggestions help you.
Stargazer
Posted by rskontos on November 25, 2007, at 20:45:37
In reply to I'm not sure what you have in mind? » rskontos, posted by Racer on November 25, 2007, at 16:57:37
I ask Racer because I have alot of experience and one of the best and easiest on your system is magnesium some people say they can't take it but the dosage is 1000 mg. Not only does it help constipation initally but it calms the central nervous system overall and aids in sleep which you also said you have problems with. Since you have the constipation problems then the 1000 mg. to start would be the best. My friend that is a doctor and nutrional supplementals are her secondary interest has had alot of people helped with this one. She said that mag has the least side effects so she likes it for that reason, There is another product I have found helpful too but I would only recommended if you don't get relief with maybe the mag first. If the 1000 mg isnt enough go up by 500. Some people might argue but I have found it to be very helpful. Now eventually your body will stabilze to the mag so the effects might go away. Another weird suggestion I heard at the ER was one 12 oz of dr pepper a day until regular. This was told by a ER doctor to a patient and when I questioned him he verified it. He stated that dr pepper does have enough prune juice in it to do the trick. Here are two suggestions. I like supplements if they work. I have a severe collitis issue and was told by my gastro specialist I would be on medication the rest of my life and I didn't like it as it had too many side effects. So I found something, a supplement that is working well. That is why I asked you. I would give the mag a try, I use magnesium oxide from a company called Nutraceutical Sciences Institute at www.gonsi.com or 800-776-2887. Their products are excellent and my friend the doctor/supplement specialist agrees. I order online. Let me know what you think. rk
Posted by Racer on November 25, 2007, at 21:02:20
In reply to Re: I'm not sure what you have in mind?/Racer, posted by stargazer2 on November 25, 2007, at 19:37:26
I appreciate the suggestions.
Right now, my doctor has prescribed Amitiza, and Miralax. Between the two of them -- I'm alternating between constipation and diarrhea. NOT pleasant, but with either one alone, it's pretty much just constipation.
Metamucil has made things worse for me in the past. The problem seems to be that nothing moves, and since nothing is moving, all the fluid is sucked out of it. Adding bulk doesn't help move things, for me at least. And drinking enough isn't the problem -- I drink too much water, which comes with a different set of problems.
All I can say is, "This really [emulates a Hoover]"
I have an appointment with a gastroenterologist in a couple of weeks, and will be having a colonoscopy. I hope that he'll have a nice fix for it. Or at least that he won't treat the problem as dismissively as one doctor did: "Oh, if you're constipated, it's a sign you don't drink enough water. Simple as that." Um...
Thanks for your suggestions.
Posted by Phillipa on November 25, 2007, at 23:27:32
In reply to Re: I'm not sure what you have in mind? » stargazer2, posted by Racer on November 25, 2007, at 21:02:20
Probably IBS and then the metamucil or citrocel. I like magnesium it works well. I also drink a lot of liquids too. Phillipa
Posted by Racer on November 26, 2007, at 1:52:29
In reply to Re: I'm not sure what you have in mind? » Racer, posted by Phillipa on November 25, 2007, at 23:27:32
> Probably IBS and then the metamucil or citrocel. I like magnesium it works well. I also drink a lot of liquids too. Phillipa
Probably caused by taking two different forms of laxatives for medication related constipation, I think. This is something which started with the EMSAM, and which has happened on other antidepressants -- it's not a coincidence that this happens to me while taking antidepressants known to cause constipation. That's a different phenomenon than IBS.
If you're suggesting that Metamucil is the answer, take another look at my posts -- Metamucil has worsened the problem.
Posted by Sigismund on November 26, 2007, at 3:10:37
In reply to I don't understand what you're trying to say? » Phillipa, posted by Racer on November 26, 2007, at 1:52:29
Perhaps digestive enzymes and probiotics could help (sort of) stabilize your guts while you work out what you need to do, and after?
Posted by CoutureMan on November 26, 2007, at 4:47:33
In reply to Thanks for asking » CoutureMan, posted by Racer on November 25, 2007, at 2:39:06
Racer,
Oh, how I can empathize with the constipation. I have to take high doses of Miralax daily along with prunes, prune juice and tons of water just to have 'incomplete' daily evacuation. Like you, any Metamucil etc. just makes the bloating, gas and peristalsis worse. It's misery and one of the main problems I am having with finding an antidepressant that will work. When I was younger I could tolerate the antihistaminic and anticholinergic side effects better. But at 52 and on multiple drugs that have not remitted my depression, I seem to be unable to handle these effects.In my case, I know that the depression is one of the main causes of the constipation. However, if I went off several of my current meds I would not need the Miralax but in short order I would not be able to tolerate the anxiety. I've been through the whole gastroenterologist route and there really is not much they have been able to do for me except prescribe Miralax and Zelnorm (before it was taken off the market).
I also had a surgery (nissen fundoplication) that has further complicated my GI distress. It's where your upper stomach gets wrapped around your lower esophageal sphincter to prevent acid reflux. I had a precancerous condition (barrett's esophagus) that necessitated this surgery because I could not tolerate acid reflux meds (they made me anxious!). Even though the barrett's esophagus is gone I wish I had never had the surgery because the bloating and gas are so much worse … Pure misery.
On a more hopeful note, if you normally don't have severe constipation, I bet if the Emsam were to kick in and fully remit your depression the constipation and related GI symptoms would go away. I hope I am right and in the next couple of weeks you get some relief. I know your suffering all to well. I wish you all the best.
Sincerely,
-CM
Posted by Phillipa on November 26, 2007, at 17:25:29
In reply to I don't understand what you're trying to say? » Phillipa, posted by Racer on November 26, 2007, at 1:52:29
Racer not at all the magnesium works. Phillipa
Posted by Racer on November 26, 2007, at 20:38:18
In reply to Re: Thanks for asking » Racer, posted by CoutureMan on November 26, 2007, at 4:47:33
> Racer,
> Oh, how I can empathize with the constipation. I have to take high doses of Miralax daily along with prunes, prune juice and tons of water just to have 'incomplete' daily evacuation.With both Amitiza and Miralax, I'm having my bouts of the icks about once, sometimes twice a week. Daily anything sounds much more manageable.... But I agree, it's harder and harder to put up with some of these side effects. Kinda like sexual side effects -- when I took Paxil, I had complete anorgasmia, just numb in that region. Since the doctor at that time said to stay on the Paxil for two years once I hit remission, I grumbled, but stayed on the drug. Now, with the doctor saying, "indefinitely," I wouldn't be as willing to put up with that. And now that I know not all psychotropic meds cause constipation, I have a much harder time putting up with this.
> On a more hopeful note, if you normally don't have severe constipation, I bet if the Emsam were to kick in and fully remit your depression the constipation and related GI symptoms would go away.At this point, since I have been on meds for so long, I have no idea what is "normal" for me, bowel wise. Honestly -- I don't remember what went on when I wasn't on medications, especially since I think you're right about depression slowing all that down anyway.
I'm not going to think about that right now. The EMSAM is not blowing the depression away, and I am still having the periods of wanting to give up most days. If I think about this problem, on top of some other practical life sorts of problems, I will just be that much more depressed. Gonna have to change my name to Scarlett, I guess. I see my psychopharmacologist tomorrow, maybe he'll have a scathingly brilliant idea for this...
By the way, do I remember correctly that you were in California? Or am I delusional?
Posted by ClearSkies on November 27, 2007, at 10:11:11
In reply to Yep, it's unpleasant, and hard to put up with » CoutureMan, posted by Racer on November 26, 2007, at 20:38:18
Racer, I can vouch for the laxative properties of taking a magnesium supplement, which I do for my anxiety. I don't know whether that would give you any relief, but it's worth a try. It's not as great a shock to the system if you take it after a meal, and I do find that it helps a lot to smooth out anxiety. Good luck at the doc's.
CS
Posted by Racer on November 27, 2007, at 11:24:48
In reply to Re: Yep, it's unpleasant, and hard to put up with » Racer, posted by ClearSkies on November 27, 2007, at 10:11:11
Thanks. I do take a magnesium supplement, to go with my calcium supplements, and it hasn't seemed to make a difference in this area. (Then again, I've taken it for years now, so maybe it did make a difference once upon a time...)
Thanks for responding. I hope you're doing well.
This is the end of the thread.
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