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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 17 of 17. This is the beginning of the thread.
Posted by Four Feathers on September 8, 2008, at 9:04:00
I am currently taking Nardil at 22.5 mg per day and have been taking this at different doses (as high as 45mg) now for about 6 weeks. About 3 weeks ago I had written about how the effects were amazing. Unfortunately these were short lived. I am frustrated and was hoping someone may be able to shed some light on why meds may be initially successful and then quickly fall off for me? Here's the details:
I have seen these effects the most from Wellbutrin, Strattera, and Nardil. When starting, increasing, or decreasing any of these meds I will feel better (calmness, focus, organization, better time management, motivation, better mood) for a period of 4-7 days after the dosage adjustment (usually see effects the next day). Then literally, on about the 7-10th days I will feel myself sliding back into my unmotivated, unorganized, hypersomnia self. This has been very frustrating b/c I get this brief feeling of how it was years ago before my anxiety and depression reared its ugly head.
Does anyone have any thoughts on why I would see such a quick and obvious response that lasts for such a short period? I wondered if there may be a mild bipolar component to my case, but I can't identify any true "manic" phases? I should mention that I have also experienced the same thing when decreasing the dosage of Lexapro (not increasing).
Any thoughts are greatly appreciated as I see my pdoc this Wednesday. Thanks!
Posted by Racer on September 8, 2008, at 10:49:08
In reply to Brief immediate responses to meds?? - Advice Pls, posted by Four Feathers on September 8, 2008, at 9:04:00
This probably isn't something you want to hear, but I wonder if this might be -- at least in part -- a placebo response? They're very real, even if they are created in our brains rather than in our chemistry. And, as has been pointed out here before, they're rarely sustained for more than a few days.
In my case, I know I have a very robust and predictable placebo response -- both good and bad. If I am feeling a high degree of trust in my psychopharmacologist AND trying either a new drug or a drug that's been OK in the past, I'll feel some distinct improvement -- often in days. That's usually based on relief that I've found an opening in the wall of my cage, and have a doctor "taking care of" me. Once I've been on the drug for a bit, that goes away, and either I respond or don't respond, which usually takes several weeks.
On the other hand, if I am feeling distrustful or insecure with my doctor, and/or am taking a drug which has caused problems in the past, I'll often get worse. Sometimes, instead, I'll have an initial improvement -- which I think is an effort to please the doctor, to gain his approval. That sort of initial improvement, though, usually ends with a precipitous drop in mood once the placebo effect ends.
What makes all that so crazy-making is that I know it's a pattern I've experienced over and over again, and sometimes I even know I'm doing it -- and it's still "real" to me. Talk about feeling crazy!
The other possible answer, of course, is "no one really knows." Some medications used for multiple disorders have different courses with each of them. SSRIs for depression require weeks to work. SSRIs for premenstrual dysphoric disorder work within a couple of days, and only have to be taken for a few days a month. They may even be less effective if taken throughout the month. Same drug, different clinical pictures. And do you know why that is? No one else does, so I guess we write that up as another neurochemical mystery for now.
I guess what I'm saying is that there are a lot of possibilities, and no firm answers, but maybe a combination of mystery and psychological reaction.
Not so helpful, I'd bet, but I hope you do find a good answer for you.
Posted by Four Feathers on September 8, 2008, at 11:11:10
In reply to Re: Brief immediate responses to meds?? - Advice Pls » Four Feathers, posted by Racer on September 8, 2008, at 10:49:08
Thanks for the post Racer. I had considered the placebo effect and determined that this was not the case given the third-party comments I had received regarding my changes. Specifically, when the medication works (this is the case for all that I mentioned) I get unsolicited comments from third-parties regarding my mood, organization, etc. For example, I had three people in the course of two days (while I was feeling better) comment how organized my office and planning was, I had another comment on how I had been early (chornically a minute or two late) for meetings and calls. None of these people had any idea that I was taking medication.
I guess it could be argued that since I *think* I feel better (i.e. placebo effect) I am not so overwhelmed with daily tasks and these become much easier. However, I don't believe this to be the case given the changes that others have witnessed in me.
Thanks again for your input.
Posted by Racer on September 8, 2008, at 12:39:55
In reply to Re: Brief immediate responses to meds?? - Advice Pls » Racer, posted by Four Feathers on September 8, 2008, at 11:11:10
> Thanks for the post Racer. I had considered the placebo effect and determined that this was not the case given the third-party comments I had received regarding my changes.
Actually, when I said I "get better" due to the placebo effect, I meant that I can be seen to be better. It's not just that I perceive I feel better, but full on do, so people do notice it.
Then again, when I am feeling confident about my doctor, I don't get the beneficial placebo effect. That only happens when I am afraid the doctor will "be mad at me" if I don't respond. I think part of the reason I go so far down when it ends is the sense that I've got no where to turn, you know?
And there have been some medications that had an immediate and real effect -- like Lamictal. When I hit 150mg, and again when I hit 200mg, I had about three days of feeling pretty darned good. And then crashed badly after those three days. Such a tease. Or Provigil, which tends to help within days, even though full benefits take a while to stabilize.
I dunno. I just threw the placebo idea out there to see if that could be part of it. Sometimes just knowing that I'm doing something that might help is enough to boost me long enough for the med to kick in. And then there are times when it's real and transient. I don't have any definitive answer, just offering some thoughts.
Posted by Phillipa on September 8, 2008, at 12:47:27
In reply to Re: Brief immediate responses to meds?? - Advice Pls » Four Feathers, posted by Racer on September 8, 2008, at 12:39:55
Like Deplin helping on day three then the positive disappearing for 4-6 weeks according to Scott. Phillipa
Posted by bulldog2 on September 8, 2008, at 15:40:36
In reply to Brief immediate responses to meds?? - Advice Pls, posted by Four Feathers on September 8, 2008, at 9:04:00
> I am currently taking Nardil at 22.5 mg per day and have been taking this at different doses (as high as 45mg) now for about 6 weeks. About 3 weeks ago I had written about how the effects were amazing. Unfortunately these were short lived. I am frustrated and was hoping someone may be able to shed some light on why meds may be initially successful and then quickly fall off for me? Here's the details:
>
> I have seen these effects the most from Wellbutrin, Strattera, and Nardil. When starting, increasing, or decreasing any of these meds I will feel better (calmness, focus, organization, better time management, motivation, better mood) for a period of 4-7 days after the dosage adjustment (usually see effects the next day). Then literally, on about the 7-10th days I will feel myself sliding back into my unmotivated, unorganized, hypersomnia self. This has been very frustrating b/c I get this brief feeling of how it was years ago before my anxiety and depression reared its ugly head.
>
> Does anyone have any thoughts on why I would see such a quick and obvious response that lasts for such a short period? I wondered if there may be a mild bipolar component to my case, but I can't identify any true "manic" phases? I should mention that I have also experienced the same thing when decreasing the dosage of Lexapro (not increasing).
>
> Any thoughts are greatly appreciated as I see my pdoc this Wednesday. Thanks!I have heard that there is often a fast response to Nardil that fades away and than comes back later as the dose is increased. I think jumping around with your doses is not a good thing..Stay at a dose for awhile and than move up if there's no response.
Posted by Bob on September 8, 2008, at 15:57:10
In reply to Brief immediate responses to meds?? - Advice Pls, posted by Four Feathers on September 8, 2008, at 9:04:00
> I am currently taking Nardil at 22.5 mg per day and have been taking this at different doses (as high as 45mg) now for about 6 weeks. About 3 weeks ago I had written about how the effects were amazing. Unfortunately these were short lived. I am frustrated and was hoping someone may be able to shed some light on why meds may be initially successful and then quickly fall off for me? Here's the details:
>> I have seen these effects the most from Wellbutrin, Strattera, and Nardil. When starting, increasing, or decreasing any of these meds I will feel better (calmness, focus, organization, better time management, motivation, better mood) for a period of 4-7 days after the dosage adjustment (usually see effects the next day). Then literally, on about the 7-10th days I will feel myself sliding back into my unmotivated, unorganized, hypersomnia self. This has been very frustrating b/c I get this brief feeling of how it was years ago before my anxiety and depression reared its ugly head.
>
> Does anyone have any thoughts on why I would see such a quick and obvious response that lasts for such a short period? I wondered if there may be a mild bipolar component to my case, but I can't identify any true "manic" phases? I should mention that I have also experienced the same thing when decreasing the dosage of Lexapro (not increasing).
>
> Any thoughts are greatly appreciated as I see my pdoc this Wednesday. Thanks!I don't know if anyone can really answer this question, but I for one experience this. Years ago I would take these meds and experience a sustained response, sometimes for a couple months, then they would crap out. The durations of "response" got shorter and short and the years went by and now I'm lucky if I get a few hours let alone days or weeks of response. Its like my brain is burned out and can no longer be tricked by these pharmaceuticals.
- Bob
Posted by bleauberry on September 8, 2008, at 21:24:56
In reply to Brief immediate responses to meds?? - Advice Pls, posted by Four Feathers on September 8, 2008, at 9:04:00
I experience the same brief responses as you. While your timeframe is about 7 days, mine is about 3.
My own theory...the genetic programming tells the receptors how to respond to what the med is doing. They've gotten good at it with practice. For example, take an ssri, feel an immediate improvement, followed by worsening. My body liked the serotonin. And it was probably needed. But the autoreceptors, the governors, said "hey, no way, that's not how much serotonin there is supposed to be, so you guys over there making serotonin, slow down, and you guys over here squirting out serotonin, turn those hoses off". The genes always try to revert back to baseline programming, even when they are wrong.
If that theory of mine is true, then the receptors have to be tricked. Receptor blockers of various kinds, ranging from buspar to pindolol to remeron to antipsychotics, can fool the governors/genes so that the primary med can work as desired.
A few scientific studies hint that a good rapid response indicates a higher likelihood of robust response later on. So while the initial good response fades, it should slowly over weeks creep back in a subtle slow fashion.
And you may need a higher dose.
And some would say this is a sign of bipolar instead of depression. I disagree with that one, but hey. No one even knows what bipolar is anyway. Just a word to fit a description of symptoms, but no clue what is causing it or why.
So, take your choice. Just some ideas to ponder.
Posted by Four Feathers on September 8, 2008, at 22:57:54
In reply to Re: Brief immediate responses to meds?? - Advice Pls, posted by bleauberry on September 8, 2008, at 21:24:56
Thank you all for your responses.
Bleauberry, it sounds as though your experience, is very similar to mine. Your theory also may hold some validity with my experience. My best response to any AD was with a combination of Lexapro, Strattera, and Atenolol which had been initially prescribed before anxiety and depression was recognized for slight hypertension. I now fully believe that the HT is due to the anxiety/depressive disorder and I hope that it can ultimately be addressed if I can get the anxiety and depression adequately treated. When on Lex and Strattera (for about a year) I was able to decrease the Atenolol down to less than 25mg. If not for the severe constipation I would have likely never discontinued this.
While the Atenolol is cardio-selective, I noticed definite improvements in my peripheral physical "anxiousness" as well as a slightly improved mood and concentration for a short time after taking this. I was on Atenolol for about 10 years before switching to Lisinopril earlier this year to determine if it was exacerbating my depression. I have since seen that it did not cause depression to be worse and am considering going back on a beta blocker, perhaps Nadolol for its non-cardio selective peripheral action and decreased rate of crossing the blood brain barrier.
I don't know if I am going to give the Nardil more than another few weeks as I am beginning to see a number of side effects and no significant response on a consistent basis.
Given the above information, what would be your recommendation of other meds to try should my pdoc and I determine to discontinue Nardil? Would Nadolol be best for peripheral treatment or Pindolol as you mentioned (I am not very familiar with this BB). What about ADs to try at this point that would have a significant NE effect as this appears to be a major contributor in my case?
Posted by bleauberry on September 9, 2008, at 17:44:36
In reply to Re: Brief immediate responses to meds?? - Advice Pls, posted by Four Feathers on September 8, 2008, at 22:57:54
> Given the above information, what would be your recommendation of other meds to try should my pdoc and I determine to discontinue Nardil? Would Nadolol be best for peripheral treatment or Pindolol as you mentioned (I am not very familiar with this BB). What about ADs to try at this point that would have a significant NE effect as this appears to be a major contributor in my case?
It is so hard, impossible actually, to predict based on mechanism what meds would work good or not. They are so much more complicated than the simple mechanics we talk about. I am not well versed on beta or alpha blockers so I can't offer input on that.
Since you have identified that norepinephrine is somehow a key player, that narrows the field of choices down a lot and should make it less confusing in pondering what direction to go. There are the TCAs nortriptyline or desipramine, with desipramine being the strongest on norepinephrine. Both come with a host of other side effects which spare a few people but are problematic for many. You could research those. Returning to Strattera is an option maybe? Unless you are feeling like you been there done that and want something different? I can understand that.
My favorite pick in the norepinephrine category is Milnacipran. Popular successful AD around the world, it hits norepinephrine compared to serotonin at about a 3:1 ratio. Though it is not a stimulant, it has a feel to it, in my opinion, that reminds me sort of in a way of ritalin. A beta blocker used with it in literature is Flomax, usually intended for prostate issues. For tricking the genes, case studies indicate success outcomes in combination with Risperdal or Zyprexa. In Japan Milnacipran is commonly combined with SSRIs.
For pure norepinephrine, there is Reboxetine.
For the mailorder meds such as Milnacipran or Reboxetine, a google search with the words buy and whatever med you want will give you some sources. Only a few sell Milnacipran and they are all reliable and dependable. Customs allows a 90 day personal supply without a prescription.
Posted by Four Feathers on September 13, 2008, at 13:46:10
In reply to Re: Brief immediate responses to meds?? - Advice Pls » Four Feathers, posted by bleauberry on September 9, 2008, at 17:44:36
Thanks for all of the information Bleuberry.
I am continuing to do research on this and work with my pdoc to determine the next course of med trial. I had high hopes for Nardil and am bummed that it didn't provide for more than just brief results.
4F
Posted by azalea on September 14, 2008, at 0:02:46
In reply to Re: Brief immediate responses to meds?? - Advice Pls » Four Feathers, posted by bleauberry on September 9, 2008, at 17:44:36
I have also had rapid but transient response to SSRIs. With Lexapro, I was expecting 4-6 weeks to feel any effect, but in the first week I felt great. Didn't last though :(
Before reading this post, I didn't know anyone else had a similar experience.
Posted by Fra Angelico on September 21, 2008, at 4:32:13
In reply to Re: Brief immediate responses to meds?? - Advice Pls, posted by bleauberry on September 8, 2008, at 21:24:56
My theory is this: that the body is in a constant state of normalization and of attempting to restore the status quo. As with self-repair - healing - after a traumatic injury, there is a cogntive 'map' of some kind which tells the body just how it should be restored for normalcy and the status quo to be restored.
New medications may at first disturb the (depressive) status quo, allowing for the development of positive affect and well-being, but the normalization process perceives this change as an injury, and starts to restore or repair it, so reverting to the previous depressive state.
I have myself experienced wonderful - but very temporary - benefits from moclobemide - which quickly faded back into the status quo of dead-end dysthymia, and am now - sadly - experiencing the same thing again with phenelzine/"Nardil".
It is harder to see the good affect and liveliness go, than never to have experienced it at all.
Posted by Bob on September 21, 2008, at 11:51:58
In reply to Re: Brief immediate responses to meds?? - Advice P, posted by Fra Angelico on September 21, 2008, at 4:32:13
>
> It is harder to see the good affect and liveliness go, than never to have experienced it at all.
>
>
I've had the same sentiment as yours when I got a response to a med that allowed me to engage in life again only to see it drain away time and again. I'm really not sure in the end which is worse, having it and losing it, or never attaining it. They are both sh*&&y situations.
Posted by Bob on September 21, 2008, at 11:55:33
In reply to Re: Brief immediate responses to meds?? - Advice P, posted by Fra Angelico on September 21, 2008, at 4:32:13
> My theory is this: that the body is in a constant state of normalization and of attempting to restore the status quo. As with self-repair - healing - after a traumatic injury, there is a cogntive 'map' of some kind which tells the body just how it should be restored for normalcy and the status quo to be restored.
>
> New medications may at first disturb the (depressive) status quo, allowing for the development of positive affect and well-being, but the normalization process perceives this change as an injury, and starts to restore or repair it, so reverting to the previous depressive state.
>
> I have myself experienced wonderful - but very temporary - benefits from moclobemide - which quickly faded back into the status quo of dead-end dysthymia, and am now - sadly - experiencing the same thing again with phenelzine/"Nardil".
>
> It is harder to see the good affect and liveliness go, than never to have experienced it at all.
>
>
>How does this account for people who do respond to meds for years and years? My mother has been on the same SSRI for like 8 years and she's doing ok. I, on the other hand, get maybe a few hours response to a med, and can barely tolerate pharmaceuticals any longer.
- Bob
Posted by Phillipa on September 21, 2008, at 18:57:01
In reply to Re: Brief immediate responses to meds?? - Advice P, posted by Fra Angelico on September 21, 2008, at 4:32:13
I agree fully with that. Great point. Phillipa
Posted by Phillipa on September 21, 2008, at 19:03:05
In reply to Re: Brief immediate responses to meds?? - Advice P » Fra Angelico, posted by Bob on September 21, 2008, at 11:55:33
Bob although it your Mother still I feel different brain chemistry. Phillipa ps I am trying to wean off all meds and see who I am. Phillipa
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