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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 23 of 23. This is the beginning of the thread.
Posted by jms600 on January 13, 2008, at 16:21:14
Hello everyone!
I need some advice on drug treatment for depression and anxiety - and know this is the best place to get it!
To cut a long story short, my depression returned with a vengeance over Christmas and I spent most of the holidays curled up crying.
I've gone back to my psychiatrist who has basically said that I've tried all the main antidepressants and there isn't many other medications left worth trying. I don't have much faith in his opinions and am sure there is plenty out there still worth trying.
Over the past five years I have been on:
30mg Seroxat/Paroxetine
60mg Prozac
100mg Lustral/Zoloft
225mg Efexor/VenlafaxineIve also taken a combination of 30mg Seroxat and 2mg of Stealzine about four years ago which helped more than any other medication - however when I came off the two drugs my depression and anxiety returned. When I went back on them they just didn't help the second time around.
My psychiatrist is now trying me on Mirtazipine (Remeron) - I'm currenelty on 45mg. Although I am better than I was, I am still far from good and don't think the Mirtazipine is helping that much. The only other thing that is getting me through the day is Valium.
So what I want to know is what else I could try? I have an appointment with my psychiatrist next week and want to go armed with some information - and ask him to try me on a new medication or combo.
My symptoms are:
General depression with morbid feelings/fears;
No interest in everyday things;
Panic disorder and feelings of shear dread and despair;
Generalised Anxiety Disorder;I am not sure whether combining an antidepressant with a low dose anti-psychotic would help as I had a good response to the Seroxat/Strelazine combo.
Could anyone offer some advice on what mediation I could try next?? Preferably something with a reasonable side effect profile that isn't just going to turn me into a zombie or make me extremely drowsy all day.
Thank you for your time an help - it's much appreciated!
Posted by Maxime on January 13, 2008, at 17:34:14
In reply to What else is there for me to try?, posted by jms600 on January 13, 2008, at 16:21:14
Hi
You have more choices than you know. You haven't tried an MAOI, or a tricyclic. Sometimes combining a tricyclic with an SSRI will work.
Good luck!
Maxime
Posted by Phoenix1 on January 13, 2008, at 18:05:47
In reply to Re: What else is there for me to try? » jms600, posted by Maxime on January 13, 2008, at 17:34:14
> Hi
>
> You have more choices than you know. You haven't tried an MAOI, or a tricyclic. Sometimes combining a tricyclic with an SSRI will work.
>
> Good luck!
>
> MaximeI agree with Maxime. Try a tricyclic (with serum monitoring to make sure you hit the right dose), then a tricyclic combo. (with an SSRI, etc. You may want to skip step 1 and just add a tricyclic). If this fails, you have the MAOI's. Sounds like you might consider finding a new pdoc if he thinks you've already tried all the options. You still have lot's more available for you. So don't give up. Demand something new. You deserve better!
Phoenix1
Posted by Phillipa on January 13, 2008, at 19:54:53
In reply to Re: What else is there for me to try?, posted by Phoenix1 on January 13, 2008, at 18:05:47
Even a mood stabalizer or Deplin to augment an ad. Phillipa
Posted by CareBear04 on January 13, 2008, at 23:35:51
In reply to What else is there for me to try?, posted by jms600 on January 13, 2008, at 16:21:14
hi! i agree with phoenix-- you have lots of options still to try, and if your current pdoc is set on being pessimistic or ignoring your suggestions, if you can, maybe you'd be better switching to someone else. it sounds like you're keeping a positive attitude about your options, though, which is great. seriously... i'm in the same place as you are, except that i've unsuccessfully tried many many more drugs than you have. sometimes i feel like i'm destined to be a treatment failure and there's no point in trying any longer, but from an objective standpoint, i know that there's probably some med or some combo for everyone; it's just a matter of finding it.
here's some thoughts from my experiences:(1) except for effexor, the other three ADs you've tried are all SSRIs. not everyone responds to them, although you said the paroxetine was effective the first time around. i had the same rebound depression/ineffectiveness experience with zoloft, and i don't want what to suggest. i would probably go with an AD from another class, which appears to be what you're doing with the mirtazapine. wellbutrin, either alone or with mirtazapine, might also help with the apathy and depression. on the other hand, it sounds like you've done better on more sedating meds, and wellbutrin is fairly activating. how long were you on 225mg of effexor? i think it's at about that dose that the NE effects start kicking in, so some people start feeling relief at 225mg or above. if you didn't stay on that dose long, you might try it again since Effexor is one of the few ADs found to be effective for both depression and generalized anxiety. cymbalta is another drug that, i think, works very much like effexor. i was on it briefly, but i was also on a million other meds at the same time, so i can't say how effective it was for me. i've heard some good things about it, though, so it might be one to think about. and i have no experience with TCAs or MAOIs, but like the others suggested, i would look into those, although they do tend to have more side effects than the newer drugs.
(2) Lithium augmentation-- even for people who are not bipolar, lithium can be effective in increasing an AD's mood effect. for me, lithium just really takes the edge off everything and maintains a baseline, allowing the other meds to work. as far as side effects, people react in different ways, and you'd have to try it to really know whether its benefits outweigh the side effects you experience. the side effects do generally correlate with the serum lithium level, so when you use it just to augment an AD and not as a mood stabilizer, you need a lower dose and are less likely to discontinue do to SEs. the downside is the need for periodic blood tests to check levels, but again, if you're on a low dose, you probably won't need to get the level checked often. i would really encourage considering lithium.
(3) how are you currently taking your valium? prn or on a schedule? if you're not already taking it regularly, maybe you could try that. if you're like me and anxiety and agitation underlie your depressions, it may be worth it to take the valium three times a day (or however often needed to keep a steady level) even if it increases your tolerance to it. maybe your pdoc would allow prescribe extra doses for you to take prn if you suddenly feel panicky or overwhelmed. i just think anxiety is so closely related to depression that, unless the anxiety is under control, it's not much use treating the depression. i haven't taken valium, but ativan, xanax, and klonopin have been lifesavers for me! also, you may keep haldol in the back of your mind as an option. for me, it did amazing things at low doses. i was reluctant to try it for a long time because i associated it with crazy institutionalized people, but it solved a lot of problems for me when i did. my thoughts tend to race almost all the time, and haldol just slowed them down, but not so much as to impair my thinking. since it's a high-potency antipsychotic, it's not very sedating, and i only needed a tiny dose to get the effects.
Anyway, those are just some initial thoughts. hope you start feeling better soon!
cb
Posted by cumulative on January 14, 2008, at 14:49:54
In reply to What else is there for me to try?, posted by jms600 on January 13, 2008, at 16:21:14
Completely incompetent. Try wellbutrin -- a commonly prescribed dopaminergic.
Posted by star008 on January 14, 2008, at 15:47:13
In reply to What else is there for me to try?, posted by jms600 on January 13, 2008, at 16:21:14
One of mine ssid the same thing..He wanted me to try ect or VNS and I kept saying no. I think he was frustrated.. He wasn't incompetent at all but we had been through many meds and I just didn't respond.. I hve a diffe4rent dco now and he hasn't aid it yet but i am waiting
Posted by gardenergirl on January 14, 2008, at 16:40:30
In reply to Your psychiatrist is incompetent., posted by cumulative on January 14, 2008, at 14:49:54
whether someone's physician is "competent" or not. You have a tiny amount of data here. And frankly, the construct of "competence" is not a single "is or is not" question. Competent or imcompetent at what is the key question. Even at that level, neither you nor I are in a position to judge a person's work based on a post on the internet.
But then, I'm sure you know this already.
gg
Posted by bleauberry on January 14, 2008, at 18:37:49
In reply to Your psychiatrist is incompetent., posted by cumulative on January 14, 2008, at 14:49:54
I agree. Not only have you not tried the full line of antidepressants (such as lexapro, effexor, cymbalta, wellbutrin, nortriptyline, desipramine) you also have not had much opportunity to experience the synergistic benefits of combinations, which is most common these days. I mean, psychiatrists hardly ever get someone well with one drug.
That being said, there was a metastudy that looked at the comparitive effectiveness of newer antidepressants. The two winners were Lexapro and Effexor, both showing statistical superiority over the others. That is very generally speaking of course and someone may do well on a drug that appeared inferior, such as me doing best on prozac.
Just thinking out loud. Prozac+Zyprexa. Effexor+Zyprexa. Celexa+Risperdone. I'm leaning in the antipsychotic combo direction because of the description of symptoms and because of prior decent response. Just need a different one this time.
It's pretty sad when strangers at a forum have to suggest things that good psychiatrists have dozens or hundreds of patients doing well on, when one's own psychiatrist didn't mention those things. So he thinks its the end of the road, eh? Sounds like he is already there but you are nowhere near the end. There are good options and tons of hope.
The only general piece of advice I can give is to embrace combinations, not single drugs, and keep an antipsychotic like zyprexa as one of them in the combo. Oh, and maybe call around for another doctor who has experience with MAOIs (just to weed out the wimps) and is willing to try things.
Posted by cumulative on January 14, 2008, at 23:24:03
In reply to There's not nearly enough info for you to judge... » cumulative, posted by gardenergirl on January 14, 2008, at 16:40:30
>whether someone's physician is "competent" or not. You have a tiny amount of data here.
Excuse me, this is more than enough:
"my psychiatrist who has basically said that I've tried all the main antidepressants and there isn't many other medications left worth trying."
"Over the past five years I have been on:
30mg Seroxat/Paroxetine
60mg Prozac
100mg Lustral/Zoloft
225mg Efexor/Venlafaxine">And frankly, the construct of "competence" is not a single "is or is not" question.
Competence/incompetence can certainly be viewed as a spectrum, but it can also be used quite usefully as a binary opposition -- for instance when someone in a professional, high-standards job that involves the life and death of patients, and where the member of the profession swears an oath to, among other things, to do no harm and to prescribe for the good of the patient, fails their profession and fails their oath in telling a vulnerable depressed patient that they have tried "most of the major antidepressants" when they have only taken a very narrow (albeit popular and well-advertised in doctor's offices) set of them. This is harmful both in the sense that there are many, many other drugs and some could help, and psychologically -- it damages hope, which is horrid.
>Competent or imcompetent at what is the key question.
Prescribing medication and knowing medication, which is one of the main functions of doctors. If a prescribing doctor is dysfunctional in these categories, he/she is incompetent in his/her profession. Plain and simple, right from the dictionary definition. This is the sort of behavior that leads some people to generalize things like "all psychiatrists are bad" and self-medicate (and note, I don't use this term "self-medicate" in an inherently negative context here).
>But then, I'm sure you know this already.
On the contrary, I think most people here are going to understand what I pointed out to be very reasonable. Thank you for helping me clear things up.
Posted by yxibow on January 15, 2008, at 0:01:50
In reply to Your psychiatrist is incompetent., posted by cumulative on January 14, 2008, at 14:49:54
> Completely incompetent. Try wellbutrin -- a commonly prescribed dopaminergic.
I would be wary of describing someone you do not know and their doctor-patient relationship as "incompetent."
First of all it can scare the **** out of someone who is in a precarious situation, and second of all unless you've got a medical degree as probably some of us wish we had, well I'll just leave it I would choose vocabulary a bit more carefully ---
--- such as general words such as, "why hasn't your doctor hasn't tried you on [fill in the blank], its a good combination. I think your doctor may not have given you a fair run?"
Posted by star008 on January 15, 2008, at 0:09:22
In reply to Re: Your psychiatrist is incompetent. » cumulative, posted by yxibow on January 15, 2008, at 0:01:50
No one can judge someone incompetent having never met them and only going by an internet post. My doc was not incompetent at all and is now a medical director.. but he once said the same thing. I didn't care for it but I realize how frustrated he had become when i failed to respond over and over again. I suppose some docs like a challenge more than others..
Posted by CareBear04 on January 15, 2008, at 0:30:38
In reply to Re: Your psychiatrist is incompetent., posted by star008 on January 15, 2008, at 0:09:22
i agree that no one can make the judgment that a doctor is incompotent based just on the information we have from this post, but i don't think it's necessary to have a personal relationship with the dr to come to such a conclusion, at least with respect to this particular patient. doctors, like everyone else, have a duty of reaosnable care, and in medicine, this expectation is defined by the standards and practices of the profession. most all of us who use this board know that psychiatry is by no means an exact science and that many treatments fail. when they choose this specialty, pdocs accept the challenge of treating even patients who seem not to respond well to medications and making reasonable effort to try all available options. there's also the doctor-patient relationship aspect and the duty not to make the patient's situation worse. although we would need more information, one could conclude from what we know that (1) whether or not he meant to be discouraging, the pdoc made comments that made a patient feel like they were out of options, and (2) he indicated reluctance to pursue other treatments. i don't think it matters if he was frustrated; that's part of the job he took on, if not when he chose psychiatry, then when he agreed to treat this particular patient. frustration doesn't authorize him to cause someone to lose hope or to minimize his treatment efforts. if he can't or won't live up to the standard required of him, he should discontinue treatment and refer her to another pdoc. so the way i see the issue isn't in terms of competence/incompetence but of whether this pdoc is exercising his abilities to provide reasonable care with respect to this person.
just my opinion...
Posted by Cecilia on January 15, 2008, at 3:15:23
In reply to Disagreed. » gardenergirl, posted by cumulative on January 14, 2008, at 23:24:03
Posted by Jay_BrAvEsT_FaCe on January 15, 2008, at 13:13:58
In reply to What else is there for me to try?, posted by jms600 on January 13, 2008, at 16:21:14
> Hello everyone!
>
> I need some advice on drug treatment for depression and anxiety - and know this is the best place to get it!
>
> To cut a long story short, my depression returned with a vengeance over Christmas and I spent most of the holidays curled up crying.
>
> I've gone back to my psychiatrist who has basically said that I've tried all the main antidepressants and there isn't many other medications left worth trying. I don't have much faith in his opinions and am sure there is plenty out there still worth trying.
>
> Over the past five years I have been on:
> 30mg Seroxat/Paroxetine
> 60mg Prozac
> 100mg Lustral/Zoloft
> 225mg Efexor/Venlafaxine
>
> Ive also taken a combination of 30mg Seroxat and 2mg of Stealzine about four years ago which helped more than any other medication - however when I came off the two drugs my depression and anxiety returned. When I went back on them they just didn't help the second time around.
>
> My psychiatrist is now trying me on Mirtazipine (Remeron) - I'm currenelty on 45mg. Although I am better than I was, I am still far from good and don't think the Mirtazipine is helping that much. The only other thing that is getting me through the day is Valium.
>
> So what I want to know is what else I could try? I have an appointment with my psychiatrist next week and want to go armed with some information - and ask him to try me on a new medication or combo.
>
> My symptoms are:
> General depression with morbid feelings/fears;
> No interest in everyday things;
> Panic disorder and feelings of shear dread and despair;
> Generalised Anxiety Disorder;
>
> I am not sure whether combining an antidepressant with a low dose anti-psychotic would help as I had a good response to the Seroxat/Strelazine combo.
>
> Could anyone offer some advice on what mediation I could try next?? Preferably something with a reasonable side effect profile that isn't just going to turn me into a zombie or make me extremely drowsy all day.
>
> Thank you for your time an help - it's much appreciated!
>Hi..
I am sorry you are going through, and have been through so much pain. Just to let us know which meds you have available to you, can you let us know which country you are located in?
For now, you may want to go back to paroxetine and an antipsychotic, likely the Stelazine. You could also look at the 'atypical' antipsychotics, such as Zyprexa, but a) they have not been proven any better in the long run and b) they carry a major danger of causing metabolic problems, diabetes risks, and major weight gain. Can you get the Valium, Stelazine, and paroxetine together? Please get back when you can...Best,
Jay
Posted by gardenergirl on January 15, 2008, at 15:40:10
In reply to Re: Your psychiatrist is incompetent. » cumulative, posted by yxibow on January 15, 2008, at 0:01:50
Posted by gardenergirl on January 15, 2008, at 15:42:01
In reply to Re: Your psychiatrist is incompetent., posted by CareBear04 on January 15, 2008, at 0:30:38
> so the way i see the issue isn't in terms of competence/incompetence but of whether this pdoc is exercising his abilities to provide reasonable care with respect to this person.
> just my opinion...That's a very good point. :)
gg
Posted by gardenergirl on January 15, 2008, at 15:45:58
In reply to Disagreed. » gardenergirl, posted by cumulative on January 14, 2008, at 23:24:03
> Prescribing medication and knowing medication, which is one of the main functions of doctors. If a prescribing doctor is dysfunctional in these categories, he/she is incompetent in his/her profession. Plain and simple, right from the dictionary definition. This is the sort of behavior that leads some people to generalize things like "all psychiatrists are bad" and self-medicate (and note, I don't use this term "self-medicate" in an inherently negative context here).
By "this sort of behavior", you mean your categorizing the pdoc as "incompetent" in your prior post, eh?
>
> >But then, I'm sure you know this already.
>
> On the contrary, I think most people here are going to understand what I pointed out to be very reasonable. Thank you for helping me clear things up.Snort! Thanks for that chuckle. With the writer's strike, The Daily Show is not quite there with the laughs so much, sigh.
gg
Posted by binarywoman on January 15, 2008, at 16:40:01
In reply to Your psychiatrist is incompetent., posted by cumulative on January 14, 2008, at 14:49:54
I didn't have any luck with SSRI's and valium.
Klonopin is better than valium and IMHO less addictive. It's long acting.
I'm not bipolar but I find a bit of lithium and seroquel help.
It's very hard to find the right med combo but it's out there for you. Just don't give up hope.
Karen in NY
Posted by bleauberry on January 15, 2008, at 18:31:02
In reply to Re: What else is there for me to try? » jms600, posted by Jay_BrAvEsT_FaCe on January 15, 2008, at 13:13:58
What else is there for you to try?
How about asking your doctor for a recommendation to someone else? Perhaps he knows of someone he respects as being of higher calibre.
How about another doctor? A second opinion and a fresh set of ideas might be a good thing.
When a doctor says there isn't much left to try when in fact you have tried only a narrow spectrum of things, I don't know. That says a lot. No more info needed.
Posted by bleauberry on January 15, 2008, at 18:33:08
In reply to Re: Your psychiatrist is incompetent., posted by binarywoman on January 15, 2008, at 16:40:01
> It's very hard to find the right med combo but it's out there for you. Just don't give up hope.
>
> Karen in NYI agree with Karen. Sometimes it isn't very hard though. Sometimes luck is on your side.
The important thing is that even though there is a good med combo out there for you, just based on what you have told us about your pdoc on this thread, I doubt he is the one who is going to find that combo for you.
Posted by FrequentFryer on January 15, 2008, at 23:47:45
In reply to What else is there for me to try?, posted by jms600 on January 13, 2008, at 16:21:14
> Hello everyone!
>
> I need some advice on drug treatment for depression and anxiety - and know this is the best place to get it!
>
> To cut a long story short, my depression returned with a vengeance over Christmas and I spent most of the holidays curled up crying.
>
> I've gone back to my psychiatrist who has basically said that I've tried all the main antidepressants and there isn't many other medications left worth trying. I don't have much faith in his opinions and am sure there is plenty out there still worth trying.
>
> Over the past five years I have been on:
> 30mg Seroxat/Paroxetine
> 60mg Prozac
> 100mg Lustral/Zoloft
> 225mg Efexor/Venlafaxine
>
> Ive also taken a combination of 30mg Seroxat and 2mg of Stealzine about four years ago which helped more than any other medication - however when I came off the two drugs my depression and anxiety returned. When I went back on them they just didn't help the second time around.
>
> My psychiatrist is now trying me on Mirtazipine (Remeron) - I'm currenelty on 45mg. Although I am better than I was, I am still far from good and don't think the Mirtazipine is helping that much. The only other thing that is getting me through the day is Valium.
>
> So what I want to know is what else I could try? I have an appointment with my psychiatrist next week and want to go armed with some information - and ask him to try me on a new medication or combo.
>
> My symptoms are:
> General depression with morbid feelings/fears;
> No interest in everyday things;
> Panic disorder and feelings of shear dread and despair;
> Generalised Anxiety Disorder;
>
> I am not sure whether combining an antidepressant with a low dose anti-psychotic would help as I had a good response to the Seroxat/Strelazine combo.
>
> Could anyone offer some advice on what mediation I could try next?? Preferably something with a reasonable side effect profile that isn't just going to turn me into a zombie or make me extremely drowsy all day.
>
> Thank you for your time an help - it's much appreciated!
>Try nardil maybe, your doc probably wont agree with me but all the SSRI / NRI / Trycyclics / Novels / lithium just fully zombified me and the tiny releif they did give me definatly didn't outweigh the side effects.
If ya have trouble sleeping maybe take Seroquel at night (I take a amall dose of it for a good night sleep and some 5ht antagonisation, it also has some antidepressant effects on some people and has the least weight gain of all antipsycotics (except abilify) you could look into that aswell)
But it didn't help me any.Freq
Posted by jms600 on January 16, 2008, at 15:32:59
In reply to Re: What else is there for me to try? » jms600, posted by FrequentFryer on January 15, 2008, at 23:47:45
Just a quick message to say thanks for your postings!
This is the end of the thread.
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