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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 11 of 11. This is the beginning of the thread.
Posted by hansi555 on March 27, 2009, at 7:26:34
After more than 13 months of treatment w. ADs of unipolar stress-released depression, I am trying to make some kind of status on my situation.
I have had no permanent relief with ADs, only some weeks feeling normal here and there and other weeks of depressed feeling, no lust no joy, not happy etc. etc.
I have been through remeron, remeron + lexapro and now nortriptyline, (I will possibly combine nort w. lexapro later as this could be the best for me.)
In the beginning more than a year ago, I had a lot of psysical symptoms when feeling down; could not eat very much, vomitting, very poor sleep, nausea.
These symptoms continued until late 2008; around this time I started taking small dose Nortriptyline and almost all the psyscical symptoms went away. And they went away earlier than the Nort went into action, this is worth remebering.
So when I have my down periods now it is more or less only a mood thing meaning I can eat, sleep, f*ck, work normal (I have been working part time since febr. 2008, now almost back on full time).
And my down periods now are more like not being able to get normal happy, my normal me. As if the medicine is working too much or maybe not working.
After a period of not being able to be my own self me, not real happy, it gets too much and I crack and have a crying spell over it.
Before, when only on remeron or remeron/lexapro I could feel absolutely normal for 2-3 weeks, then things turned and was mixed, ups and downs for a couple of weeks, then I was good again etc.
I asked my psychologist (not my PD) if my depression with ADs had been any different to other patients of hers w. depression not taking ADs. She said that she couldnt really see any difference meaning i was struggling as hard as patients NOT on ADs...
She wants me to quit the ADs sometimes soon.
She claims that serotonine can not be produced in the brain when taking ADs as these "take over", is this really so...?So I am thinking that in the beginning of my treatment, the remeron had no AD effect, so when the good/normal periods came, these would have happended anyway - when the down periods came, remeron was no real help. I have later on learned
that remeron really aint worth much as an AD.
Things did not really improve when Lexapro was added, just a lot of SE, still ups and downs.The last 4 months w. Nortriptyline I have been more stable and I have more or less no psysical symptoms.
But is this really just because of the Nortriptyline or is this just because I am generally feeling better?Ever since I started the Nortrip at a dosage of 85 mg and above (now doing 125 mg) I can see from my dairy that my main problem is that I cannot get real happy, it is a struggle, I feel grey, not real sad and not real normal/happy, sometimes I feel I am in a "fog". This feeling is so frustrating because when I was on these less effective ADs, the good periods were really good.
So I am thinking if I am generally better now (the psysical symptoms are gone) and the Nort is not really helping me but instead keeping me away from recovering?
Posted by SLS on March 27, 2009, at 8:18:56
In reply to Stopping w. AD or not? I am feeling better?, posted by hansi555 on March 27, 2009, at 7:26:34
For a first time episode of Major Depressive Disorder (unipolar), the common recommendation is to remain on an effective treatment for 6-9 months after REMISSION is achieved. You have not yet achieved remission. Since you are already on nortriptyline, why not try adding the Lexapro now and then consider discontinuing treatment if that is what you wish to do.
I do not think nortriptyline is preventing you from recovering.
- Scott
Posted by Phillipa on March 27, 2009, at 12:37:40
In reply to Re: Stopping w. AD or not? I am feeling better? » hansi555, posted by SLS on March 27, 2009, at 8:18:56
Comment on the serotonin. It's my understanding that the serotonin in the ad bathes in the synapses longer hence cells get more serotonin. No my personal thought on this is like for example thyroid hormone if the organ is getting the same thing from say a pill then the body doesn't have to produce as much hence you're kind of back at the beginning. Now this is if you're sufficient with serotonin or thyroid. But if you're truly lacking it I guess that would provide what's missing hence feel better. If nortriptalline is pamelor boy it made me tired at l0mg. Sometimes I do agree with you on being happy is a state of mind and there are no pills to provide that. Has being back at work helped? Phillipa
Posted by bleauberry on March 27, 2009, at 14:36:10
In reply to Stopping w. AD or not? I am feeling better?, posted by hansi555 on March 27, 2009, at 7:26:34
I tend to agree with SLS.
More and more I am coming to my own beliefs, similar to the ones Dr Gillman at PsychoTropical.com, that most "selective" antidepressants on their own really aren't very effective, and that a mixture of both serotonin and norepinephrine yields best results. That can be done with either a SSRI+TCA combination, or a MAOI like Parnate. Clomipramine by itself fits the bill, but side effects are more.
I did not mention the so-called SNRIs like Cymbalta or Effexor, because it is bordering on falsehood to call them dual antidepressants. Their actions on NE are miniscule. And, you can't vary them individually as you could with a combination.
Remeron is not the dual antidepressant it is claimed to be. That's because it does not produce serotonin toxicity syndrome when combined with an MAOI. Whatever action it has on serotonin is miniscule. Its primary action by a long shot, way far above anything else, is a powerful antihistamine.
Two points:
Try a mixture first. As long as you are on Nortrip already, add either Zoloft or Lexapro to it.
Insist on brand. Lexapro is not generic, so it will be brand anyway. If you go with Zoloft, insist on brand and refuse generic. I only say this because of how stern my doctor was on that topic, and he knows what he is talking about. Though it is kind of a toss-up, my doctor does prefer Zoloft.
I like the way Dr Gillman phrased it. Think of a 4-wheel drive vehicle. Would you want one that puts 90% of its power to one wheel and 10% to the others? If you go with either a TCA or an SSRI alone, that is what happens. For true 4-wheel drive performance with equal power all around, A TCA+SSRI is better, or an MAOI.
Posted by hansi555 on March 28, 2009, at 4:22:35
In reply to Re: Stopping w. AD or not? I am feeling better?, posted by bleauberry on March 27, 2009, at 14:36:10
> I tend to agree with SLS.
>
> More and more I am coming to my own beliefs, similar to the ones Dr Gillman at PsychoTropical.com, that most "selective" antidepressants on their own really aren't very effective, and that a mixture of both serotonin and norepinephrine yields best results. That can be done with either a SSRI+TCA combination, or a MAOI like Parnate. Clomipramine by itself fits the bill, but side effects are more.
>
> I did not mention the so-called SNRIs like Cymbalta or Effexor, because it is bordering on falsehood to call them dual antidepressants. Their actions on NE are miniscule. And, you can't vary them individually as you could with a combination.
>
> Remeron is not the dual antidepressant it is claimed to be. That's because it does not produce serotonin toxicity syndrome when combined with an MAOI. Whatever action it has on serotonin is miniscule. Its primary action by a long shot, way far above anything else, is a powerful antihistamine.
>
> Two points:
>
> Try a mixture first. As long as you are on Nortrip already, add either Zoloft or Lexapro to it.
>
> Insist on brand. Lexapro is not generic, so it will be brand anyway. If you go with Zoloft, insist on brand and refuse generic. I only say this because of how stern my doctor was on that topic, and he knows what he is talking about. Though it is kind of a toss-up, my doctor does prefer Zoloft.
>
> I like the way Dr Gillman phrased it. Think of a 4-wheel drive vehicle. Would you want one that puts 90% of its power to one wheel and 10% to the others? If you go with either a TCA or an SSRI alone, that is what happens. For true 4-wheel drive performance with equal power all around, A TCA+SSRI is better, or an MAOI.Bleauberry, SLS
I too went to Dr. Gilmans site and I get the point and I also believe that combination treatment could be the answer in many cases, maybe especially in my case where nothing else have seemed to work properly so far.
So this coming tuesday I will go to my PD and suggest to start up the Lexapro (here it is sold under the name Cipralex, made by the patent-holding company Lundbeck) and increase it to around 10 mg and then go to around 100 mg of Nortrip. Later on I will remove the Remeron 15 mg that I take at bed time.
With all this said I am still not sure if medicine is the right thing for me but it is easier to make the trials now than later (as SLS wrote).
Thnaks everybody
Posted by 49er on March 28, 2009, at 12:15:04
In reply to Re: Stopping w. AD or not? I am feeling better?, posted by hansi555 on March 28, 2009, at 4:22:35
Hansi,
Due to insomnia, I didn't read your post very carefully but I think sharing my story is relevant.
I started on meds in 1995. In 2006, I made the decision to slowly taper off of a 4 med cocktail due to suffering a Remeron induced hearing loss and a worsening of learning disability issues that I feel were caused by the meds.
I am now down to 1 med and expect to be finished sometime next year.
When I am not dealing with withdrawal symptoms, which usually are 1 to 2 weeks after a med cut and I don't have insomnia, I feel very normal. And I was essentially told I would be on meds for life and so were many other people who have gotten off of the successfully.
The key if you decide to go off meds is to taper slowly at 10% of the current dose every 3 to 6 weeks. The reason alot of people aren't successful in coming off of meds is that many psychiatrists (not all) advocate a way too fast tapering schedule which is the equivalent of blunt trauma to the brain which needs time to adapt to less meds in the body.
As far as taking meds for another 6 months after you are in remission, I vehemently disagree with that as you are subjecting yourself to further unnecessary risks. And many times, those 6 months seems to extend to a lifetime as the psychiatrist (again, not all) never gets around to taking the patient off the meds.
I also think that if you taper the med very slowly and again, not at the fast rate the MD suggests, you will lessen the chance of a relapse.
While the drug companies and doctors aren't studying people who are living med free after getting off of meds, we are out there. Instead, we're referred to as crazy lunatic scientologists. Yeah, that is great way to advance debate isn't it?
Anyway, it is very possible to live a drug free life and not relapse. I have dealt with my mother's death, job instabilities, horrific insomnia, and I am still standing.
It does mean you have to seriously work on your thought pattern or see a therapist for help. I am not saying by the way that if you do this, you can live med free. But without examining your thought pattern, your chances of success will be less.
When I first started tapering off of meds, I was horrified to see how negative I was. With practice, it has gotten alot better although I am not perfect by any means.
Hope this helps and good luck with your decision
49er
PS - If you do decide to taper and want help with doing it slowly, I will be glad to help.
Posted by SLS on March 28, 2009, at 14:58:09
In reply to Re: Stopping w. AD or not? I am feeling better? » hansi555, posted by 49er on March 28, 2009, at 12:15:04
Hi 49er
It is not unexpected that you and I should have differing opinions from time to time. Your opinions are welcome and refreshing.
> As far as taking meds for another 6 months after you are in remission, I vehemently disagree with that as you are subjecting yourself to further unnecessary risks.
I believe that to allow someone to relapse unnecessarily by discontinuing an antidepressant prematurely, the risk of severe depression and suicide is too high to justify.
There are many studies demonstrating the need for 6-9 months of treatment after remission is achieved to prevent relapse. This is for someone's first depressive episode only. For the second and third episodes, 18 months is favored. For chronic of recurrent depressions, treatment may need to be indefinite.
I hope that you continue to feel better with your discontinuation of antidepressants. If I am not mistaken, though, you have been on antidepressants for longer than 9 months? I don't see that you can yet use yourself as an example of your contention.
Most relapses occur during the first 4 months after discontinuation, This often is an indication that longer periods of treatment are necessary. In other words, it might be premature to pass judgment on one's need for continued treatment based on how one feels immediately after discontinuation, especially since some people experience a rebound improvement just for lowering the dosage of the drug they are tapering or discontinuing.
It is sometimes difficult to avoid generalizing one's personal experiences onto the majority. I still have a tendency to do this.
- Scott
Posted by 49er on March 28, 2009, at 17:23:42
In reply to Re: Stopping w. AD or not? I am feeling better? » 49er, posted by SLS on March 28, 2009, at 14:58:09
Hi Scott
<<It is not unexpected that you and I should have differing opinions from time to time. Your opinions are welcome and refreshing.>>
I think I would die of shock if we agreed. In all seriousness, I appreciate your remark.
<<I believe that to allow someone to relapse unnecessarily by discontinuing an antidepressant prematurely, the risk of severe depression and suicide is too high to justify.>>
I think that assumption is based on the fact that meds are tapered way too quickly. I would love to see if that would hold up if people were tapered slowly at the rate I suggest. But psychiatrists will never do that.
<<There are many studies demonstrating the need for 6-9 months of treatment after remission is achieved to prevent relapse. This is for someone's first depressive episode only. For the second and third episodes, 18 months is favored. For chronic of recurrent depressions, treatment may need to be indefinite.>>
Again, that is based on the fact that withdrawal symptoms are confused as a return if the illness. That isn't just 49er's opinion as Joseph Glenmullen, suggests that.
<<I hope that you continue to feel better with your discontinuation of antidepressants. If I am not mistaken, though, you have been on antidepressants for longer than 9 months? I don't see that you can yet use yourself as an example of your contention.>>
And you can't validly assume you are right either as I feel those studies are based on false premises. And I am not the only one who is succeeding after being on meds for a long time which is 10 plus years.
<<Most relapses occur during the first 4 months after discontinuation, This often is an indication that longer periods of treatment are necessary. In other words, it might be premature to pass judgment on one's need for continued treatment based on how one feels immediately after discontinuation, especially since some people experience a rebound improvement just for lowering the dosage of the drug they are tapering or discontinuing.>>
Again, your premise is based on tapering schedules that are way too fast. Let me give you an example Scott.
Laurie Yorke, is an RN who runs the Paxil Progress Boards. Her son, Ryan, became psychotic due to a way too fast tapering schedule on Paxil. You would have assumed he needed to be on meds for life.
Well, 5 years post being off Paxil, he is doing great. Has no signs of mental illness whatsoever. There are plenty of Ryans but unfortunately, they don't have advocates like an RN.
<<It is sometimes difficult to avoid generalizing one's personal experiences onto the majority. I still have a tendency to do this.>>
>
Scott, I realize that just because I can get off meds, not everyone can do so. But to imply it is impossible and that people will commit suicide isn't accurate either.49er
Posted by Phillipa on March 28, 2009, at 20:18:17
In reply to Re: Stopping w. AD or not? I am feeling better? » SLS, posted by 49er on March 28, 2009, at 17:23:42
In real life my next door neighbor got off ad's over a year ago she had been on lexapro a lot of years then a doc here as she came from Florida put her on effexor. At 75mg she said no more and just stopped the med on her own. Still has her xanax. But after two weeks of withdrawal she made it and is only on the xanax which she decreased after elimination of ads' She said she just doesn't need as much. She's a teacher. Love Phillipa
Posted by desolationrower on March 28, 2009, at 21:54:31
In reply to Re: Stopping w. AD or not? I am feeling better?, posted by bleauberry on March 27, 2009, at 14:36:10
i disagree with gilman about this. lack of SS doesn't mean a drug can't affect serotonin; mirtazapine is a strong 5ht2 antagonist, which is probably the most important set of receptors for SS. balance of 1a and 2 is one possible serotonin effect.
the study to look at would be this one,but i don't have a fulltext.
Mirtazapine (Mir) is a novel antidepressant, reported to raise extracellular noradrenaline (NA) through blockade of !2-autoreceptors and serotonin (5-HT) output via (1) indirect activation of facilitatory !1-adrenoceptors on the cell bodies of ascending 5-HT neurones and (2) blockade of presynaptic release-modulating !2-heteroreceptors on 5-HT terminals in the forebrain. To further assess the effect of Mir on NA/5-HT system interplay, including putative regional differences in the effects of the drug on 5-HT release in rat forebrain, we used in vivo microdialysis in anaesthetised rats. Probes were implanted in the dorsal hippocampus (DH) and frontal cortex (FCx), representing median and dorsal raphe 5-HT projection areas, respectively. In the DH, Mir (10 mg/kg s.c.) completely blocked the 5-HT release-suppressing action of the selective !2-adrenoceptor agonist clonidine (0.1 mg/kg s.c.), but had no effect per se on the 5-HT output. Neither drug significantly changed the 5-HT levels in the FCx. Mir perfused locally (10 µM via reverse-dialysis) also failed to significantly elevate 5-HT output, and did not affect the clonidine response in either brain area. Thus, the data confirm the basic !2-adrenoceptor-blocking properties of Mir, but are only partly concordant with previous studies reporting an increase of 5-HT output after Mir alone. Moreover, we find no elevation in 5-HT by the reference !2-adrenoceptor antagonist idazoxan (0.3-1.0 mg/kg s.c.). The discrepancies encountered, and the potential ability of !2-adrenoceptor antagonists in general to raise the output of 5-HT, are discussed with particular reference to methodological and other factors that may influence the experimental outcome (e.g., brain regional aspects, different !2-adrenoceptor subtypes, potential differences in adrenoceptor tone under varying experimental conditions).
-d/r
Posted by SLS on March 29, 2009, at 10:34:27
In reply to Re: Stopping w. AD or not? I am feeling better? » SLS, posted by 49er on March 28, 2009, at 17:23:42
> <<I believe that to allow someone to relapse unnecessarily by discontinuing an antidepressant prematurely, the risk of severe depression and suicide is too high to justify.>>
> I think that assumption is based on the fact that meds are tapered way too quickly. I would love to see if that would hold up if people were tapered slowly at the rate I suggest. But psychiatrists will never do that.Well, depending on the length of time it takes to taper, you are still exposing someone to the drug for an extended period of time.
> <<There are many studies demonstrating the need for 6-9 months of treatment after remission is achieved to prevent relapse. This is for someone's first depressive episode only. For the second and third episodes, 18 months is favored. For chronic of recurrent depressions, treatment may need to be indefinite.>>
> Again, that is based on the fact that withdrawal symptoms are confused as a return if the illness.
This does happen. However, I don't believe that the majority of people whom develop depression and anxiety when discontinuing an antidepressant are suffering from a withdrawal syndrome. Unfortunately, I doubt we could find a scientific investigation of this issue. If in doubt, and with the patient's consent, I guess one can opt to persist through a discontinuation protocol despite the emergence of these symptoms.
How do you propose to tell the difference between depressive withdrawal symptoms and true relapse? The fact is, many people have discontinued antidepressants rapidly and remained in remission for a few months before encountering a relapse. The time in between is not one of depression or anxiety. No withdrawal symptoms persisted.
> That isn't just 49er's opinion as Joseph Glenmullen, suggests that.
Unfortunately, what he cannot do is quantify the percentage of people who discontinue antidepressants whom develop depression as a symptom of withdrawal. It is obvious that not everyone does.
> <<I hope that you continue to feel better with your discontinuation of antidepressants. If I am not mistaken, though, you have been on antidepressants for longer than 9 months? I don't see that you can yet use yourself as an example of your contention.>>
> And you can't validly assume you are right either as I feel those studies are based on false premises. And I am not the only one who is succeeding after being on meds for a long time which is 10 plus years.You are not an example of someone who has been on an antidepressant for a limited number of weeks or months to be able to deduce the rate of relapse after such a short course of treatment.
> <<Most relapses occur during the first 4 months after discontinuation, This often is an indication that longer periods of treatment are necessary. In other words, it might be premature to pass judgment on one's need for continued treatment based on how one feels immediately after discontinuation, especially since some people experience a rebound improvement just for lowering the dosage of the drug they are tapering or discontinuing.>>> Again, your premise is based on tapering schedules that are way too fast. Let me give you an example Scott.
And you are basing and comparing the success of the tapering schedules you suggest base upon what exactly?
> Laurie Yorke, is an RN who runs the Paxil Progress Boards. Her son, Ryan, became psychotic due to a way too fast tapering schedule on Paxil.What was he being treated for?
> You would have assumed he needed to be on meds for life.
I don't know what I would have done. It would depend on the length time and patterns spent in a state of illness previous to treatment. Treatment failures must also be taken into consideration. How long had he been taking Paxil before discontinuing it? Either way, it is guesswork at best based upon clinical experience and the studies revealing time until relapse for the several scenarios tested. What was the motivation for discontinuing Paxil in this case?
> Well, 5 years post being off Paxil, he is doing great. Has no signs of mental illness whatsoever. There are plenty of Ryans but unfortunately, they don't have advocates like an RN.For each Ryan out there, there might be many more whose treatments were indeed optimal and have also led lives free of mental illness after discontinuation. Although trite, I believe that it is true that the great majority of people going out of their way to write on the Internet regarding the treatment of mental illness do so as the result of an adverse experience rather than a pleasant one.
- Scott
This is the end of the thread.
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