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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 20 of 20. This is the beginning of the thread.
Posted by CareBear04 on January 16, 2008, at 23:01:42
I'm at a point where I feel dead emotionally except that my anxiety response is still intact, and the stress I feel just makes me feel more hopeless and wanting even more to escape. The past few days I haven't even been able to drag myself to classes, which is a new low. Before, I might have felt very depressed, but at least I was outwardly functioning pretty well. Since I'm not able to stay on top of what I need to, and since being conscious of this failure is making me stressed and more depressed, I'd really just like something to make me a zombie so that I just don't care. Any suggestions?
I think the surest bet is an antipsychotic, probably one of the old ones. My old psychiatrist once described them on a spectrum from low potency to high potency, with the high end encompassing the strong but less sedating drugs. At the time, he prescribed Trilafon, which he put somewhere in the middle, and at 8mg or even 4mg at night, I just slept through each day. I think it might have been nice. I tried Thorazine very briefly last year. I took it at night like I was supposed to and slept through most of the next afternoon, when I got up to go to the bathroom and must have blacked out because I woke up on the floor. Can anyone comment on the other antipsychotics like Stelazine or Mellaril?
I don't think an atypical would do the trick for me right now. Abilify and Geodon didn't seem to do anything for anxiety. Risperdal just made me dumb, although it did sort of also make me numb. Hmm... I take 100-150mg of Seroquel for sleep at night, and it does nothing for me during the days. As for Zyprexa, the best use I had for it was as a prn-- when I felt overwhelmed, I would take a pill and sleep away the bad feelings. When I wasn't asleep, though, it didn't blunt my feelings or eliminate my anxiety at all; it just made me sluggish.
Have worked up a high tolerance to benzos and sleep meds... well, to just about everything for some reason.
Any suggestions?
CB
Posted by Justherself54 on January 16, 2008, at 23:46:19
In reply to what drugs would kill off my remaining emotions?, posted by CareBear04 on January 16, 2008, at 23:01:42
Are you on any type of antidepressant? Some are very good at handling anxiety..
Posted by CareBear04 on January 17, 2008, at 0:00:16
In reply to Re: what drugs would kill off my remaining emotion, posted by Justherself54 on January 16, 2008, at 23:46:19
i'm not on any antidepressants currently because they have tended to make me manic in the past. I'm on lithium and lamictal, which seemed to be working decently before, but not so much in the past week or so.
thanks,
cb
Posted by Jedi on January 17, 2008, at 2:25:29
In reply to Re: what drugs would kill off my remaining emotion » Justherself54, posted by CareBear04 on January 17, 2008, at 0:00:16
> i'm not on any antidepressants currently because they have tended to make me manic in the past. I'm on lithium and lamictal, which seemed to be working decently before, but not so much in the past week or so.
> thanks,
> cb
Hi cb,
Have you tried the atypical antipsychotics for your bipolar disorder?
JediReference:
Treatment of bipolar disorder: the evolving role of atypical antipsychotics.Perlis RH.
Harvard Medical School, 15 Parkman St, AC 812, Boston, MA 02114-3117, USA. rperlis@partners.orgManagement of bipolar disorder (BPD) may require multiple medications, including lithium, anticonvulsants, and antipsychotics (both conventional and atypical). Updated treatment guidelines reflect an expanded role for atypical antipsychotics (AAPs) in BPD treatment. Five AAPs--olanzapine, risperidone, quetiapine, ziprasidone, and aripiprazole--are approved by the US Food and Drug Administration (FDA) as monotherapy for first-line treatment of acute manic and (except for quetiapine) mixed episodes. Two AAPs--olanzapine (in fixed-dose combination with fluoxetine) and quetiapine--are also FDA approved for bipolar depression. For long-term maintenance therapy, one option is to continue effective, well-tolerated acute phase treatment; however, only olanzapine and aripiprazole are FDA approved for maintenance, based on evidence from randomized, placebo-controlled clinical trials. Although head-to-head comparisons are scarce, meta-analysis data suggest that olanzapine, risperidone, quetiapine, ziprasidone, and aripiprazole have similar antimanic efficacy; therefore, AAP selection for this indication should be guided by other considerations such as safety, tolerability, and cost. Safety and tolerability issues to consider when selecting an AAP include metabolic dysfunction (weight gain, type 2 diabetes, and dyslipidemia); hyperprolactinemia; extrapyramidal symptoms; QTc prolongation; and pharmacokinetic drug interactions.
PMID: 18041879 [PubMed - indexed for MEDLINE]
Posted by Squiggles on January 17, 2008, at 8:07:06
In reply to Re: what drugs would kill off my remaining emotion » CareBear04, posted by Jedi on January 17, 2008, at 2:25:29
You might want to check on the safety of
taking lithium along with antipyschotics.
Dr. Charles Nemeroff And Dr. Shatzberg,
in his "Recognition and Treatment of
Psychiatric Disorders: A Psychopharmacology
Handbook for Primary Care", p. 105, Table
62. Common drug interactions with lithium--
lists a number of drugs with low to high
safety risk. For antipsychotics, the table
describes the following:"May increase toxicity even with normal
lithium levels. Rare encephalpathic
syndrome (weakness, lethargy, fever,
increased Extrapyramidal Syndrome,
confusion) with irreversible brain damage
may be same as neuroleptic malignant syndrome;
may be more common with high-potency
antipsychotics (e.g. haloperidol).The atypical antipsychotics --
clozapine, olanzapine, quetiapine,
respiredone) (p. 136) are much safer than
the typical antipsychotics, causing minimal
EPS, little TD, and have great advantages
for the negative as well as positive symptoms
of schizophrenia, for which they are
commonly used. They also cause minimum
cognitive impairment.
Clozapine does pose a great risk of agranulocytosis,
especially in people of Jewish descent.Regarding the interaction of lithium with
atypical antipsychotics, i looked at the new
"Lithium in Neuropsychiatry: the Comprehensive
Guide" (eds., Bauer, Grof, Muller-Oerlinghausen)
recently published, and on p. 65 under Table 7.2
(A Company-initiated parallel group designed
randomized cotrolled trials designed for drug
approval using lithium as a internal standard
to validate assay sensitivity, published in
peer-reviewed international journals, listed by year of publication) --
authors Bowden et al, Tohen, Sachs,
Yatham et al). resutls are listed.This is what Licht, the author of this
chapter says, on p. 65:COMBINATION THERAPY TRIALS:
"Several drug companies have tested
their atypical antipsychotic in combination
with lithium or valproate (Table 7.2). In
these studies, lithium or valproate combined
with respiridone, haloperidol, quetiapine,
or olanzapine, were modestly more beneficial
in controlling manic symptoms than the
monotherapy alone....."So, it would seem that the antipsychotics
combined with lithium are not safe, and the
atypical antipsychotics are safe but introduced
as combination therapy by marketing initiatives.
This is the impression I get.Squiggles
Posted by Phillipa on January 17, 2008, at 10:28:45
In reply to Re: what drugs would kill off my remaining emotion, posted by Squiggles on January 17, 2008, at 8:07:06
Have you posted on the new neurotransmitter board? And please call your pdoc. Phillipa
Posted by Squiggles on January 17, 2008, at 11:47:05
In reply to Re: what drugs would kill off my remaining emotion, posted by Phillipa on January 17, 2008, at 10:28:45
> Have you posted on the new neurotransmitter board? And please call your pdoc. Phillipa
Hi Phillipa,
No, i have not posted there. But I noticed
that it's new.Why should i call my pdoc? If you are
concerned that i am taking antipsychotics
with lithium - I AM NOT - i declined
the offer.Hope your new year is going well.
Squiggles
Posted by rgb on January 17, 2008, at 15:03:22
In reply to what drugs would kill off my remaining emotions?, posted by CareBear04 on January 16, 2008, at 23:01:42
Hello CareBear,
I don't know you, but I'd probably argue that your anxiety about not going to classes is (to some degree) healthy, not dysfunctional.
You have my sympathy about your stressful situation and I can relate to your wish, but maybe a better strategy would be to change your medication and/or something else such that you are able to go to classes again. I think you know that heavy sedation will neither work forever nor make you content.
Maybe go back on a low dose antidepressant to increase motivation again? I have no experience with mania though.
Good luck,
rgb
Posted by bleauberry on January 17, 2008, at 20:27:46
In reply to what drugs would kill off my remaining emotions?, posted by CareBear04 on January 16, 2008, at 23:01:42
I usually find my gut instincts to be accurate. If your gut instincts are pointing you in the direction of antipsychotics, then maybe that is a meaningful hint. I think one thing to consider though is that there is some kind of synergy between ssris and aps that makes the combos special. Instead of just an antipsychotic, you should maybe consider an antipsychotic plus an ssri. For example, prozac + zyprexa is totally different than either prozac or zyprexa. The benefits are more profound, and they cancel out each other's side effects a great deal.
I don't know about the old aps. I do remember reading in a psychopharm book that low dose stelazine was similar to amisulpride.
In any case, ap + ssri. Whatever you past experience with aps was doesn't matter, and whatever you past experience with ssris was doesn't matter, because when they are combined it is a completely new ballgame.
Posted by CareBear04 on January 17, 2008, at 22:21:53
In reply to Re: what drugs would kill off my remaining emotion » CareBear04, posted by Jedi on January 17, 2008, at 2:25:29
thanks jedi for the suggestion. i've tried the big 5 atypicals (abilify, geodon, seroquel, risperdal, and zyprexa) all at some point, usually in combination with other meds, although I'm finding it hard to remember exactly what those combos were. In general, all give were effective in treating and preventing mania; none of them alone helped much with depression. At one point, my pdoc tried to increase my Seroquel from 100 to 300mg at night, but that made me so sluggish that i could hardly get out of bed the next day let alone function. my overall impression of the atypicals is that they seem to establish a ceiling on my mood but not a floor. or at least they don't help me get up from the floor. still if you have any ideas i'm missing, i'd appreciate them. Thanks! cb
Posted by CareBear04 on January 17, 2008, at 22:30:24
In reply to Re: what drugs would kill off my remaining emotion, posted by Squiggles on January 17, 2008, at 8:07:06
wow, i'm impressed by the research and knowledge everyone on this board contributes!
i'm open to combination therapy-- to anything that will help!-- but my impression is that the atypicals are more effective in treating mania than depression, and i happen to be lower than low right now. in a way, i'm already on a mood stabilizer-atypical combo, but i don't think either is at a therapeutic level. i was previously on 900mg of lithium, then got toxic last month, reduced to 600mg, still had symptoms, so cut back even more to 450mg. i haven't had a level since, but i sort of doubt my level is in the therapeutic range. and i take 100-150mg of seroquel at night, but i think the minimum effective dose for depression is 300mg.i'm willing to try anything with a good chance of working and am not so worried about developing these scary syndromes. i've been on some crazy combos before that could well have led to serotonin, anticholinergic, or neuroleptic malignant syndromes, but it has never happened.
CB
Posted by CareBear04 on January 17, 2008, at 22:41:13
In reply to Re: what drugs would kill off my remaining emotion, posted by rgb on January 17, 2008, at 15:03:22
hi rgb-- thanks for the suggestion and for your understanding. yeah, classes are one thing that is stressing me out-- with 5 or 6 classes a day, i know i need to be there, but i can't work up the energy, i know that once i fall behind, i won't be able to make up lost ground, so once i miss class, i'm even more disinclined to go back because i'm afraid of being caught unprepared. i guess it is a healthy anxiety in some ways, but it's also a vicious cycle making it all the harder to overcome this exhaustion.
i'm working on adding an antidepressant to my regimen but am not that hopeful about it helping. For one thing, I feel like I can't wait a month or however long it takes for these things to work! Equally important, though, is the fact that antidepressants, especially SSRIs, have tended to make me more anxious and agitated, at least in the beginning. i'm looking for something that will deaden my anxiety response, not enhance it.
blah... i feel stuck.
cb
Posted by CareBear04 on January 17, 2008, at 22:55:42
In reply to Re: what drugs would kill off my remaining emotions?, posted by bleauberry on January 17, 2008, at 20:27:46
thanks bleauberry-- through just a few posts, i know i can count on you to share a positive experience on zyprexa :).
i have tried an SSRI + atypical a few times, but the trial never lasted very long. First, I was on Paxil and added Risperdal. I had horrible side effects from the Paxil, so I switched to Effexor, which admittedly, is not an SSRI. i was also on lithium. so with the three drugs working, my mood improved some, but stabilized below baseline. the other time, i was on zoloft and was put on abilify. i felt really agitated and jittery, and once i was off the abilify and on something else (haldol?), the pdoc noted that i seemed much calmer and suggested that maybe the zoloft + abilify equaled serotonergic overdrive.
my pdoc is starting me back on prozac now. even though it has made me manic before, he thinks the risk of that happening this time is low since i'm on lamictal and lithium (therapeutic dose?) i guess this could count as an SSRI + atypical combo since I take seroquel at night, but for whatever reason, the seroquel helps only with sleep and doesn't seem to have any impact on my day to day functioning. i gave up on the low-dose Remeron earlier in the week when it didn't help with sleep or seem to have any effect at all. I'm curious as to whether Remeron played a part in my recent exhaustion and mood crash. Intuitively, it seems unlikely, but these states did emerge only after I started Remeron. Anyway, my pdoc wants me to increase to 30mg plus the Prozac. He cited some authroity or another in telling me this can be a very powerful combo. Again, I have my doubts and i dont' know if i can last until they start to work and what kind of a mess my life will be when i get there.
cb
Posted by linkadge on January 17, 2008, at 23:05:40
In reply to Re: what drugs would kill off my remaining emotions? » bleauberry, posted by CareBear04 on January 17, 2008, at 22:55:42
Posted by bleauberry on January 18, 2008, at 17:11:43
In reply to Re: what drugs would kill off my remaining emotions? » bleauberry, posted by CareBear04 on January 17, 2008, at 22:55:42
> thanks bleauberry-- through just a few posts, i know i can count on you to share a positive experience on zyprexa :).
>You gave me a grin. Seriously though, I know you've tried several aps. But unless you have tried zyprexa, you really haven't had a fair sample of the whole family. Zyprexa is different. Sure mileage varies and it doesn't help some people. The main complaint seems to be weight gain. Zyprexa just stands alone above the others in my opinion. Since you are on prozac, zyprexa just happens to synergize with it well. And there is more clinical study of that combination than any other ssri+ap combination I am aware of. Heck, the combination even made it past the FDA which is no small task.
Sounds like your doc has a gameplan. Don't let my bias favoring zyprexa get in the way. Keep it at the top of the list should the need arise to make another move.
Posted by Squiggles on January 18, 2008, at 17:19:06
In reply to Re: what drugs would kill off my remaining emotions? » CareBear04, posted by bleauberry on January 18, 2008, at 17:11:43
I just recently came across the subject
of different classes of drugs synergizing.
Would this be a topic for Dr. Bob's new site: Neurotransmitters?
I know nothing about this-- if there is
a synergy (chemically between say SSRIs and
Lithium) -- something which is denied btw,
in Bauer's book "Lithium in Neuropsychiatry",
is it determined by clinical response or
foreknowledge of psychopharmacology and
prediction of what *must* happen when two
different classes of drugs combine?Squiggles
Posted by jms600 on January 19, 2008, at 15:54:36
In reply to what drugs would kill off my remaining emotions?, posted by CareBear04 on January 16, 2008, at 23:01:42
Hi Carebear,
Sorry to hear that you are feeling so low and hope you return to the best of health soon!
You asked whether anyone could comment on Stelazine..?
I tried Stelazine about 5 years ago. At the time of taking it I'd been on Seroxat for four months which had helped but only a bit. My doctor decided the Seroxat needed a boost and so prescribed me Stelazine - 2mg per day, to be taken along side the 30mg of Seroxat I was on.
I had a great response to it - my depression lifted and the anxiety vanished. I did have side effects - however I'm certain they were from the Seroxat rather than the Stelazine.
I had such a good response from the new combo that my doctor decided I was better and gradually withdrew the Seroxat. I then suffered the now infamous withdrawal effects and the depression and anxiety returned. He then put me back on the combo but they just didn't seem to work the second time around.
I know you said that you had already tried Seroxat and couldn't take the side effects, but it's certainly worth trying the Stelazine with another antidepressant that you can tolerate better.
My psychiatrist also mentioned Haloperidol, the other day, to me. I'm currently on 50mg of Seroquel at the moment and if that doesn't work I think he's going to try me on a low dose.
It may be worth considering Haloperidol if you haven't yet tried it..?
Posted by CareBear04 on January 19, 2008, at 22:05:33
In reply to Re: what drugs would kill off my remaining emotion, posted by jms600 on January 19, 2008, at 15:54:36
thanks jms, i'm glad to hear more about stelazine; i don't know of many people anymore who have tried it or even many doctors who are still willing to prescribe it. i've actually tried haldol and, despite the rather bad rep it and other old APs have developed over the years, it probably helped me more than any of the newer atypicals. it didn't have much effect on my mood, but it was great for anxiety and went beyond helping with the physical jitters and actually slowed my thoughts from racing. but, unfortunately, i had to go off it after a short time of taking it regularly because my pdoc noticed the start of some facial twiching.
seroxat is paxil? i was only on it for a few weeks, and i think my experience was tainted by the side effects i developed when the pdoc doubled up to 40mg after just a few days on 20. but even having been on it so briefly, i had some withdrawal, too. i'm sorry it didn't work for you when you tried it again. it's really disappointing to be let down by a med you had faith in. as for seroquel, i can't give much of an opinion either way. i've been on it a number of times and have been taking it now for about a year. one pdoc i had once described it as "the world's most expensive sleeping pill." that's pretty much the experience i've had with it, but, as with other effects, i've worked up a pretty good tolerance to the sedation. i know 200+ lb men who are knocked out and hung over from 25 or 50mg, and i take 100-150mg and often still can't sleep through the night. but if i don't take it, i can't get to sleep at all. as for ongoing effects, i haven't noticed anything, good or bad. i don't feel sluggish anymore the next day, but i don't the seroquel affects my mood or anxiety. my pdoc once had in mind using seroquel for depression and increased it to 300mg. i think that's the minimum dose found to be effective for depression in studies, but i don't know anything its effect on anxiety.
thanks for responding, and i hope you feel better soon, too!
cb
Posted by Dr. Bob on January 20, 2008, at 3:26:08
In reply to Re: what drugs would kill off my remaining emotion, posted by Squiggles on January 18, 2008, at 17:19:06
> I just recently came across the subject
> of different classes of drugs synergizing.
> Would this be a topic for Dr. Bob's new site: Neurotransmitters?It would, thanks for thinking of that. Here's a link:
http://www.dr-bob.org/babble/neuro/20080114/msgs/807857.html
Bob
Posted by jms600 on January 20, 2008, at 15:31:34
In reply to what drugs would kill off my remaining emotions?, posted by CareBear04 on January 16, 2008, at 23:01:42
It's just a thought, but have you tried Memantine? I tried this drug a few years back. I was on a drug trial where they were testing the efficacy of Memantine for congenital Nystagmus. It didn't help my Nystagmus much, but it did have a great calming action on me (I was also taking Prozac at the time).
the only reason I came of the drug was because the drug trial finished, however I'm hoping to try Memantine again in the near future.
It may be worth considering/researching it if you haven't already tried it..?
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