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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 8 of 8. This is the beginning of the thread.
Posted by hansi555 on September 8, 2008, at 13:49:40
After almost 8 months of treatment with various "succes" in treating stress related unipolar depression, I am considering to alter from my present combo - Lexapro 20 mg and Remeron 30 mg - to something else.
I have most of the symptoms in Melancholic depression (morning worseness, early wake ups (somewhat prevented by the Remeron), loss of apetite during daytime, feeling better in the evening, off days w. crying spells).
What would be the best choice here? Have heard the TCA is or should be first choice but what about adding Lithium (and removing Remeron)?
Thanks!
Posted by Racer on September 10, 2008, at 10:27:17
In reply to Melancholic depression - what med is the best choi, posted by hansi555 on September 8, 2008, at 13:49:40
Hm... You don't say why you want to change, so I'm not sure how helpful this might be...
First, flip as it sounds, "the best med is the one that works for you," since we mostly react differently to meds. I also have classic melancholic features, and have found Wellbutrin a good choice, though it's never brought me to anything that could be called remission.
A TCA might be a good choice, depending on how well you tolerate it. The biggest appeal to the newer drugs is that they have fewer side effects than the TCAs and MAOIs. They're often more reliable than the newer drugs, though, so that's a good direction to look in.
What about Effexor, Cymbalta, or Pristiq? Those are very helpful for many people, and target multiple avenues for action.
Lithium is also a good choice for many, as is Lamictal. Lamictal has the benefit of fewer side effects, lithium is better known, since it's been used for a long time. It's a trade off -- which is a better choice to try first? Dunno -- they're both well worth discussing with your doctor.
I'm not sure what else to recommend, but thought I'd offer those thoughts. I hope they're helpful to you.
Good luck.
Posted by hansi555 on September 11, 2008, at 10:41:07
In reply to Re: Melancholic depression - what med is the best choi, posted by Racer on September 10, 2008, at 10:27:17
> Hm... You don't say why you want to change, so I'm not sure how helpful this might be...
I want to change because my good periods only lasts a few days or maybe a week before I become depressive (not deep deep but still very annoying) and in these periods have the melancholic features.
See I dont know how well I can expect meds to work since no one can really tell me. I am working 4-6 hours per day as a sales engineer, not doing many customers visits and also as few activities outside work since it was not work it self that brought me down but a HUGE load of things to do at the same time + 2 small kids - stress exhausted and then came depression together w insomnia.
> First, flip as it sounds, "the best med is the one that works for you," since we mostly react differently to meds. I also have classic melancholic features, and have found Wellbutrin a good choice, though it's never brought me to anything that could be called remission.
>
> A TCA might be a good choice, depending on how well you tolerate it. The biggest appeal to the newer drugs is that they have fewer side effects than the TCAs and MAOIs. They're often more reliable than the newer drugs, though, so that's a good direction to look in.Which one is the first choice for someone like me?
> What about Effexor, Cymbalta, or Pristiq? Those are very helpful for many people, and target multiple avenues for action.
Heard a lot scary things about Effexor...?
> Lithium is also a good choice for many, as is Lamictal. Lamictal has the benefit of fewer side effects, lithium is better known, since it's been used for a long time. It's a trade off -- which is a better choice to try first? Dunno -- they're both well worth discussing with your doctor.
What is Lacmital?
> I'm not sure what else to recommend, but thought I'd offer those thoughts. I hope they're helpful to you.
>
> Good luck.Thanks!
Posted by Racer on September 11, 2008, at 17:04:57
In reply to Re: Melancholic depression - what med is the best choi, posted by hansi555 on September 11, 2008, at 10:41:07
Quick and dirty, because I gotta get out the door:
Scary things about Effexor -- most of the scary things about Effexor have to do with the discontinuation effects. ("Withdrawal.") My doctor considers it to be an "old faithful," because it works reliably for so many of his patients. If you are one of those it works for, it's no more "scary" than any SSRI, really. It has a broader range of action, so it may be more effective for you than the SSRIs.
Cymbalta is like Effexor Lite -- same mechanism of action, same drug class, but with a slightly different "feel" to it. Of the two, I found it more friendly, but it was not effective on its own for me. (Nota Bene: I was not in a place that ANY medication could have treated effectively at that time, AND have not had a remission for about six years now. DO NOT think that my experience has any real predictive value for you. It almost certainly does not.) It was very good for some things for me, and I took it for about a year and a half. The side effects I did experience were milder FOR ME with Cymbalta than Effexor.
Lamictal is an anticonvulsant often used to treat mood disorders. I can't remember if it's officially approved as a mood stabilizer or not, but it's also used to treat depression. MANY people here have found it helpful.
I'm happy to answer questions, but I just realized I'll give better answers if I'm not also watching the clock and kicking my butt to get out the door! If you see this and have questions, please ask, otherwise I'll try to get back later tonight.
Posted by yxibow on September 11, 2008, at 19:35:31
In reply to Re: Melancholic depression - what med is the best choi » hansi555, posted by Racer on September 11, 2008, at 17:04:57
> Quick and dirty, because I gotta get out the door:
>
> Scary things about Effexor -- most of the scary things about Effexor have to do with the discontinuation effects. ("Withdrawal.") My doctor considers it to be an "old faithful," because it works reliably for so many of his patients. If you are one of those it works for, it's no more "scary" than any SSRI, really. It has a broader range of action, so it may be more effective for you than the SSRIs.For those who respond to stimulants that calm them, Effexor can be quite effective -- I'm not one of those people.
> Cymbalta is like Effexor Lite -- same mechanism of action, same drug class, but with a slightly different "feel" to it. Of the two, I found it more friendly, but it was not effective on its own for me. (Nota Bene: I was not in a place that ANY medication could have treated effectively at that time, AND have not had a remission for about six years now. DO NOT think that my experience has any real predictive value for you. It almost certainly does not.) It was very good for some things for me, and I took it for about a year and a half. The side effects I did experience were milder FOR ME with Cymbalta than Effexor.
I would concur, though always its just a personal experience. When I took Effexor years ago, it was like a magnitude of pitchers of coffee, and I couldn't sleep. Cymbalta partially worked for me up to 120 (Lilly does say that 60 or 120 does not make a difference) -- your insurance may not pay above 60.
Cymbalta has only a 6:1 average 5HT to NE dosage. One thing to remember, withdrawing from any SNRI is a slow process because if it is done fast it can be hideous for some. That's just information, not meant to discourage a trial.
>
> Lamictal is an anticonvulsant often used to treat mood disorders. I can't remember if it's officially approved as a mood stabilizer or not, but it's also used to treat depression. MANY people here have found it helpful.My doctor more classifies it as an antidepressant, but again that is also just for me, it may be different for you. It takes a long time to build up a dose because essentially it is a test for SJS (not the petit rash but the BIG internal rash).
Posted by hansi555 on September 12, 2008, at 14:52:46
In reply to Re: Melancholic depression - what med is the best choi » hansi555, posted by Racer on September 11, 2008, at 17:04:57
Thank you
So do you think Effexor/Cymbalta would be good against the Melancholic features?
Asked my psycologist today if she thought I did better, worse or the same as patients w similar depression but not on drugs, she said it was more or less the same...
Posted by yxibow on September 13, 2008, at 2:13:22
In reply to Re: Melancholic depression - what med is the best choi, posted by hansi555 on September 12, 2008, at 14:52:46
> Thank you
>
> So do you think Effexor/Cymbalta would be good against the Melancholic features?
>
> Asked my psycologist today if she thought I did better, worse or the same as patients w similar depression but not on drugs, she said it was more or less the same...Its hard to say -- some melancholic depression has early hour awakening and worsening in the morning, so if you're anxiety sensitive, it wouldn't be the best idea I imagine to take at night. Effexor could aggravate the sleep features.
But this is just hypothetical.
It also sounds from the DSM like a depression somewhat related to dysthymia which I have in a major fashion. But I am probably projecting.
Sometimes the best palleative for that is forcing oneself (which I find hard) to do things, a more psychodynamic approach. And through doing things that are positive and reinforcing for you, projects that you might enjoy even if you don't think you would, things that resonate with you, you discover you are more capable than you think.
But medication may be necessary too along with this so it is worth a trial. Remember that it does take time to build up -- Cymbalta I think takes a long time to kick in for a lot of people.I don't recall my impression of Effexor but I imagine you might feel something (good or bad as all psychotropics can do) sooner just because its very activating.
-- best wishesJay
Posted by azalea on September 14, 2008, at 0:49:10
In reply to Melancholic depression - what med is the best choi, posted by hansi555 on September 8, 2008, at 13:49:40
Replacing Lexapro with Effexor could be beneficial as there is hypothetical synergy between Effexor and Remeron. At doses above 150mg daily, Effexor blocks the reuptake of both serotonin and norepinephrine. Remeron, an alpha-2 blocker, promotes the release of serotonin and norepinephrine.
Are you experiencing any side effects from the Lexapro or Remeron?
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