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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 33. This is the beginning of the thread.
Posted by jono_in_adelaide on March 28, 2011, at 19:57:42
Hi, I am a sufferer of the holy trinity of depression, GAD and panic disorder.
Current meds are Sertraline (Zoloft) 100mg daily, reboxetine (Edronax) 4mg twice daily, and Xanax 1mg as needed, usualy twice daily.
I recently read that the BMJ had reviewed reboxetine and found it an "ineffective and thus dangerous antidepressant" (though it worked well for me, Zolfot alone did SFA for my depression, where as adding edronax had me feeling better within a fortnight) Given this poor rating, should I look at changing my NARI from reboxetine to nortriptyline (the only other reasonably clean NARI on the market in Australia, desipramine being discontinued some years ago)
What I am taking now works reasonably well, but wondering if Zoloft + Nortriptyline might work even better?
Posted by Phillipa on March 28, 2011, at 22:14:37
In reply to Nortriptyline vs reboxetine, posted by jono_in_adelaide on March 28, 2011, at 19:57:42
Australia is discontinuing some TCA'a is there a reason? I think the two are different hope some chimes in. Phillipa
Posted by jono_in_adelaide on March 29, 2011, at 2:53:36
In reply to Re: Nortriptyline vs reboxetine » jono_in_adelaide, posted by Phillipa on March 28, 2011, at 22:14:37
We arnt discontinuing all TCA's, the makers of desipramine decided to withdraw it because they werent getting enough sales to make a profit selling it here, I guesss because we are a small makert compared to the EU or US
Posted by ed_uk2010 on March 29, 2011, at 13:38:28
In reply to Nortriptyline vs reboxetine, posted by jono_in_adelaide on March 28, 2011, at 19:57:42
> Hi, I am a sufferer of the holy trinity of depression, GAD and panic disorder.
>
> Current meds are Sertraline (Zoloft) 100mg daily, reboxetine (Edronax) 4mg twice daily, and Xanax 1mg as needed, usualy twice daily.
>
> I recently read that the BMJ had reviewed reboxetine and found it an "ineffective and thus dangerous antidepressant" (though it worked well for me, Zolfot alone did SFA for my depression, where as adding edronax had me feeling better within a fortnight) Given this poor rating, should I look at changing my NARI from reboxetine to nortriptyline (the only other reasonably clean NARI on the market in Australia, desipramine being discontinued some years ago)
>
> What I am taking now works reasonably well, but wondering if Zoloft + Nortriptyline might work even better?I don't believe that Edronax is ineffective. I think it's effective for a subset of patients... just a smaller proportion than SSRIs and TCAs.
Nortriptyline is quite different to Edronax. It's much more likely to cause drowsiness and weight gain. Some other side effects may be less common, however.
I certainly don't think you should change meds because of what the BMJ said - it's your own personal response that counts, not how other patients respond.
Posted by Conundrum on March 29, 2011, at 15:06:32
In reply to Re: Nortriptyline vs reboxetine, posted by ed_uk2010 on March 29, 2011, at 13:38:28
> > Hi, I am a sufferer of the holy trinity of depression, GAD and panic disorder.
> >
> > Current meds are Sertraline (Zoloft) 100mg daily, reboxetine (Edronax) 4mg twice daily, and Xanax 1mg as needed, usualy twice daily.
> >
> > I recently read that the BMJ had reviewed reboxetine and found it an "ineffective and thus dangerous antidepressant" (though it worked well for me, Zolfot alone did SFA for my depression, where as adding edronax had me feeling better within a fortnight) Given this poor rating, should I look at changing my NARI from reboxetine to nortriptyline (the only other reasonably clean NARI on the market in Australia, desipramine being discontinued some years ago)
> >
> > What I am taking now works reasonably well, but wondering if Zoloft + Nortriptyline might work even better?
>
> I don't believe that Edronax is ineffective. I think it's effective for a subset of patients... just a smaller proportion than SSRIs and TCAs.
>
> Nortriptyline is quite different to Edronax. It's much more likely to cause drowsiness and weight gain. Some other side effects may be less common, however.
>
> I certainly don't think you should change meds because of what the BMJ said - it's your own personal response that counts, not how other patients respond.I agree, and most likely nortriptyline is more dangerous.
Posted by bleauberry on March 29, 2011, at 15:30:31
In reply to Nortriptyline vs reboxetine, posted by jono_in_adelaide on March 28, 2011, at 19:57:42
Wow that's a tough one. It's a balancing act between...1)be content significant improvement has happened and don't risk destabilizing that, or 2)Make the switch and see what happens in the hopes that it will be even better.
Nortriptyline has a good track record for a long time worldwide. Reboxetine hasn't been around that long and is only in limited parts of the world. No matter, all that really counts is what a drug feels like to each individual patient. And there is no way to know that without trying.
So yeah, it's tough. In your shoes I would probably lower the reboxetine dose slightly and add a small bit of nortriptyline to it, and then gently attempt a cross taper to see what happens along the way. That's the only way I would know. Would I go cold turkey? No way not me anyway. Suddenly stopping a potent NE med like that feels nasty.
Posted by desolationrower on March 30, 2011, at 12:51:06
In reply to Re: Nortriptyline vs reboxetine, posted by bleauberry on March 29, 2011, at 15:30:31
the 'danger' was reboxetine being ineffective. if there is a difference, nortrityline is more effective, and thus less 'dangerous' by that standard. i'm not interested in that article, though.
nortriptyline is a dirtier drug, specifically as an 5ht2 antagonist. good or bad depends on which of your two anxieties is more in need of help (change to nort if you want less GAD):
*******
Role of the amygdala and periaqueductal gray in anxiety and panicAbstract
The amygdala (AM) and the periaqueductal gray (PAG) represent the rostral and the caudal pole, respectively, of a longitudinally organized neural system, that is responsible for the integration of behavioral and physiological manifestations of defensive reactions against innate and learned threats. Microinjection of benzodiazepine (BDZ) anxiolytics, GABAA receptor agonists or 5-HT receptor antagonists into the AM has anxiolytic effects in conflict tests and other models of conditioned fear, while similar administration of 5-HT or of a 5-HT1A receptor agonist has anxiogenic effects. On the other hand, in the test of electrical stimulation of the PAG, microinjection of 5-HT, 5-HT mimetics, or of drugs that enhance the action of endogenous 5-HT into the same brain area has an antiaversive effect, like BDZ and GABAA agonists. Furthermore, microinjection of midazolam, of the NMDA receptor antagonist AP-7, or of the Image receptor blocker propranolol increased the exploration of the open arms of the elevated plus-maze, having therefore an anxiolytic effect. These results point to an inhibitory role of the GABA-BDZ system in both the AM and the PAG. In contrast, 5-HT seemingly enhances conditioned fear in the AM, while inhibiting unconditioned fear in the PAG. Thus, Image antagonists reportedly release punished behavior when injected into the AM, whereas they antagonized the antiaversive effect of 5-HT, zimelidine and Image receptor blockers in the PAG. Since reported clinical studies revealed that one of such compounds, ritanserin, relieves generalized anxiety but tends to aggravate panic disorder, a relationship may be established between the AM and anxiety and the PAG and panic.
*******-d/r
Posted by jono_in_adelaide on March 30, 2011, at 18:50:43
In reply to Re: Nortriptyline vs reboxetine, posted by desolationrower on March 30, 2011, at 12:51:06
Its all so confusing, found another articly in the BMJ which stated that reboxetine was equal to desipramine and fluoxetine as an antideopressant.
The 5HT2 blocking effect of the nortriptyline WAS part of my thinging, but I wonder wether, on sertraline 100mg/day, reboxetine 4mg twice a day and alprazolam 1mg twice a day, the effect would be significasnt enough to notice a difference.
Even on this regimen, I still get episodes of anxiety (though not panic)
Posted by mtdewcmu on April 2, 2011, at 0:05:48
In reply to Nortriptyline vs reboxetine, posted by jono_in_adelaide on March 28, 2011, at 19:57:42
Is Strattera (atomoxetine) available in Australia? Is there any difference in effect between reboxetine and Strattera?
Posted by psychobot5000 on April 3, 2011, at 0:01:28
In reply to Difference between reboxetine and atomoxetine?, posted by mtdewcmu on April 2, 2011, at 0:05:48
> Is Strattera (atomoxetine) available in Australia? Is there any difference in effect between reboxetine and Strattera?
I've taken both. For me, personally, neither was particularly useful, but the qualitative experience was very different. Reboxetine made me nervous, tense. Straterra made me (oddly), drowsy and mildly euphoric--but the euphoria passed very quickly, a couple hours after each dose, but progressively less and gone after a few days.
They're not the same at all, though their mechanism of action makes them sound similar. At least they weren't the same for me.
Posted by bleauberry on April 3, 2011, at 4:34:10
In reply to Re: Nortriptyline vs reboxetine, posted by jono_in_adelaide on March 30, 2011, at 18:50:43
There isn't time or space to explain it all, but just know that these things you (we) read cannot be trusted at face value. They are great for getting ideas and a general sense of things. But don't count on them for accurate details. And especially do not count on them to make any kind of prediction on how a particular med would work in your body.
Another one to consider is Milnacipran. I did not like reboxetine, somewhat liked nortriptyline, but really liked milnacipran. All very similar, but quite different as well. The one with the potent anti-anxiety, in addition to the most potent antidepressant, was Milnacipran. I couldn't take suggested doses though. I found lower doses much better, more effective, hardly any side effects.
> Its all so confusing, found another articly in the BMJ which stated that reboxetine was equal to desipramine and fluoxetine as an antideopressant.
>
> The 5HT2 blocking effect of the nortriptyline WAS part of my thinging, but I wonder wether, on sertraline 100mg/day, reboxetine 4mg twice a day and alprazolam 1mg twice a day, the effect would be significasnt enough to notice a difference.
>
> Even on this regimen, I still get episodes of anxiety (though not panic)
Posted by jono_in_adelaide on April 7, 2011, at 19:18:53
In reply to Re: Nortriptyline vs reboxetine, posted by bleauberry on April 3, 2011, at 4:34:10
The talk of 5ht antagonism got me thinking..... took 1mg of risperidone last night, and feel significantly better already, will try it for a week and see what happens.
Posted by jono_in_adelaide on April 11, 2011, at 17:43:03
In reply to Re: Nortriptyline vs reboxetine, posted by jono_in_adelaide on April 7, 2011, at 19:18:53
OK, after 5 days of rsiperidone 1mg at bedtime, I am feeling totaly different...... much less (almost no) anxiety during the day, only taking 2 x 1mg Xanax instead of three, less depressive, ruminating thoughts.
i feel weak for needing 4 (yes) 4 drugs to keep me stable (though truth be known, I dont think the Sertraline does anything for me, but it seems to be implied by my shrink that if i need Xanax, I have to take an SSRI as well)
Down side - the risperidone isnt from my doc, obtained from a "grey market" source. I'll keep taking 1mg at night for 3 months, then tail it off
Posted by mtdewcmu on April 11, 2011, at 20:08:27
In reply to Re: Nortriptyline vs reboxetine, posted by jono_in_adelaide on April 11, 2011, at 17:43:03
> i feel weak for needing 4 (yes) 4 drugs to keep me stable (though truth be known, I dont think the Sertraline does anything for me, but it seems to be implied by my shrink that if i need Xanax, I have to take an SSRI as well)That's the wrong way to look at it. You should feel fortunate that anything keeps you stable. A lot of people (including me) have been unable to find any combination of meds that works very well.
Posted by Phillipa on April 11, 2011, at 21:21:37
In reply to Re: Nortriptyline vs reboxetine, posted by mtdewcmu on April 11, 2011, at 20:08:27
Most definitely agree. A Benzo I was normal for about 30 years. Lucky I guess. Phillipa
Posted by SLS on April 12, 2011, at 5:03:40
In reply to Re: Nortriptyline vs reboxetine, posted by jono_in_adelaide on April 11, 2011, at 17:43:03
> Down side - the risperidone isnt from my doc, obtained from a "grey market" source. I'll keep taking 1mg at night for 3 months, then tail it off
You are obviously a very knowledgeable individual who understands much about psychopharmacology. I am surprised that you would purposely plan on discontinuing a drug that you feel is so helpful. For long-term remission, I should think that establishing homeostasis is an important contributor.
What do you think about using cyproheptadine (Periactin)?
- Scott
Posted by SLS on April 12, 2011, at 5:30:26
In reply to Re: Nortriptyline vs reboxetine, posted by mtdewcmu on April 11, 2011, at 20:08:27
>
> > i feel weak for needing 4 (yes) 4 drugs to keep me stable (though truth be known, I dont think the Sertraline does anything for me, but it seems to be implied by my shrink that if i need Xanax, I have to take an SSRI as well)
>
> That's the wrong way to look at it. You should feel fortunate that anything keeps you stable.Yes. That is my perspective as well. I feel fortunate to experience even a partial response on four drugs.
> A lot of people (including me) have been unable to find any combination of meds that works very well.
That is so sad. What choice do we have but to keep looking?
For me, I am having partial success with:
Nardil 90mg
nortriptyline 150mg
Lamictal 200mg
Abilify 10mgFor now, I am discontinuing lithium 300mg because I feel it was flattening me out. When I first started it, I felt a mood-lift. Thereafter, I felt that it was hurting more than it was helping. This is the type of thing that I find so demoralizing. Why should I have an atypical reaction to so many drugs? For now, I am going to remain on these four drugs and give it another 6 months to work better than it is now. I feel that establishing a homeostasis is important. The problem is, how do you know that you are using the right treatment to invest so much time in it?
For me, I simply combined those drugs that I had previously responded to briefly or partially. I am hoping that I got lucky. I am encouraged by what I had been experiencing prior to taking lithium. It took at least four months for the addition of Nardil to take effect. I have seen this before with Nardil in a few other people posting on PB. It is has been seven month, now, and I have been feeling the best I have in many years. I have a long way to reach full remission, though. I wouldn't be surprised if it took another year. My guess is that increased severity and increased chronicity indicate a longer period to attain remission. Why shouldn't we expect that it would take longer to recover? I imagine the brain of such a person has a lot of ground to cover in order to produce the type of neurogenesis and recovery of brain tissue that might be necessary under such circumstances.
Babble.
- Scott
Posted by SLS on April 12, 2011, at 5:35:17
In reply to Re: Nortriptyline vs reboxetine, posted by bleauberry on March 29, 2011, at 15:30:31
> Wow that's a tough one. It's a balancing act between...1)be content significant improvement has happened and don't risk destabilizing that, or 2)Make the switch and see what happens in the hopes that it will be even better.
>
> Nortriptyline has a good track record for a long time worldwide. Reboxetine hasn't been around that long and is only in limited parts of the world. No matter, all that really counts is what a drug feels like to each individual patient. And there is no way to know that without trying.
>
> So yeah, it's tough. In your shoes I would probably lower the reboxetine dose slightly and add a small bit of nortriptyline to it, and then gently attempt a cross taper to see what happens along the way. That's the only way I would know. Would I go cold turkey? No way not me anyway. Suddenly stopping a potent NE med like that feels nasty.
When I experienced a suicidal exacerbation of my depression with reboxetine, I suffered no such withdrawal effect when I discontinued it abruptly. Same thing with atomoxetine and desipramine. I found SSRIs and SRIs to be more difficult to discontinue. Perhaps I am atypical?
- Scott
Posted by SLS on April 12, 2011, at 5:39:58
In reply to Nortriptyline vs reboxetine, posted by jono_in_adelaide on March 28, 2011, at 19:57:42
> Hi, I am a sufferer of the holy trinity of depression, GAD and panic disorder.
>
> Current meds are Sertraline (Zoloft) 100mg daily, reboxetine (Edronax) 4mg twice daily, and Xanax 1mg as needed, usualy twice daily.
>
> I recently read that the BMJ had reviewed reboxetine and found it an "ineffective and thus dangerous antidepressant" (though it worked well for me, Zolfot alone did SFA for my depression, where as adding edronax had me feeling better within a fortnight) Given this poor rating, should I look at changing my NARI from reboxetine to nortriptylineI consider that to be a reasonable decision. Reboxetine sucks, in my opinion. Dangerous? Perhaps. For me, it produced an exacerbation of depression and anxiety such that I became suicidal within a week. I like the way I feel on nortriptyline much better - even better than desipramine.
- Scott
Posted by SLS on April 12, 2011, at 5:46:35
In reply to Difference between reboxetine and atomoxetine?, posted by mtdewcmu on April 2, 2011, at 0:05:48
> Is Strattera (atomoxetine) available in Australia? Is there any difference in effect between reboxetine and Strattera?
It is usually not a good idea to consider two different molecules pharmacologically or clinically identical. I found reboxetine to be more harmful than I did atomoxetine. They definitely felt different. Unfortunately, neither drug produced any benefit at all. Although not usually effective for Major Depressive Disorder, atomoxetine can be of great help when treating ADHD or ADD. It even treats the depressive mood that sometimes occurs with these disorders.
- Scott
Posted by mtdewcmu on April 13, 2011, at 18:46:57
In reply to Re: Nortriptyline vs reboxetine, posted by jono_in_adelaide on April 11, 2011, at 17:43:03
> Down side - the risperidone isnt from my doc, obtained from a "grey market" source. I'll keep taking 1mg at night for 3 months, then tail it off
How hard could it be to get your doctor to prescribe risperidone? Tell him or her that you tried it and it works. Acquiring risperidone without a prescription is not something they put people in prison for. Especially if it's for personal use.
Posted by mtdewcmu on April 13, 2011, at 19:02:51
In reply to Re: Nortriptyline vs reboxetine » mtdewcmu, posted by SLS on April 12, 2011, at 5:30:26
>
> That is so sad. What choice do we have but to keep looking?
>
> For me, I am having partial success with:
>
> Nardil 90mg
> nortriptyline 150mg
> Lamictal 200mg
> Abilify 10mg
>
> For now, I am discontinuing lithium 300mg because I feel it was flattening me out. When I first started it, I felt a mood-lift. Thereafter, I felt that it was hurting more than it was helping. This is the type of thing that I find so demoralizing. Why should I have an atypical reaction to so many drugs? For now, I am going to remain on these four drugs and give it another 6 months to work better than it is now. I feel that establishing a homeostasis is important. The problem is, how do you know that you are using the right treatment to invest so much time in it?
>
> For me, I simply combined those drugs that I had previously responded to briefly or partially. I am hoping that I got lucky. I am encouraged by what I had been experiencing prior to taking lithium. It took at least four months for the addition of Nardil to take effect. I have seen this before with Nardil in a few other people posting on PB. It is has been seven month, now, and I have been feeling the best I have in many years. I have a long way to reach full remission, though. I wouldn't be surprised if it took another year. My guess is that increased severity and increased chronicity indicate a longer period to attain remission. Why shouldn't we expect that it would take longer to recover? I imagine the brain of such a person has a lot of ground to cover in order to produce the type of neurogenesis and recovery of brain tissue that might be necessary under such circumstances.
>
> Babble.
>
>
> - Scott
>
>Do you think there could be something else that is standing in the way of you recovering from depression? I think in my case, I have spent the past 7 or so years treating my depression and anxiety on the premise that all of my symptoms came from those disorders, and I am concluding that my attention problems may be primary not secondary. A lot of my depression and anxiety come from my inability to successfully get through life, and my inability to get through life comes from me losing interest or succumbing to the inability to pay attention to whatever I need to be doing. It's very circular, because after the fact, you can always look at some failure and say, well, your depression and anxiety caused your lack of interest and attention. But I have been treating my depression and anxiety for 7 years and my attention issues are constant. I am very hopeful that if the pharmacy ever decides to fill my prescription for Dexedrine, I may be able to get a virtuous cycle going of having success in work projects, which will start to solve my financial woes, which will make me less anxious and depressed, and will lead to more success. Why does the pharmacy think I'm an effing criminal???
Posted by Bob on April 13, 2011, at 23:43:34
In reply to Re: Nortriptyline vs reboxetine » mtdewcmu, posted by SLS on April 12, 2011, at 5:30:26
>
> That is so sad. What choice do we have but to keep looking?
>
> For me, I am having partial success with:
>
> Nardil 90mg
> nortriptyline 150mg
> Lamictal 200mg
> Abilify 10mg
>
> For now, I am discontinuing lithium 300mg because I feel it was flattening me out. When I first started it, I felt a mood-lift. Thereafter, I felt that it was hurting more than it was helping. This is the type of thing that I find so demoralizing. Why should I have an atypical reaction to so many drugs? For now, I am going to remain on these four drugs and give it another 6 months to work better than it is now. I feel that establishing a homeostasis is important. The problem is, how do you know that you are using the right treatment to invest so much time in it?
>
> For me, I simply combined those drugs that I had previously responded to briefly or partially. I am hoping that I got lucky. I am encouraged by what I had been experiencing prior to taking lithium. It took at least four months for the addition of Nardil to take effect. I have seen this before with Nardil in a few other people posting on PB. It is has been seven month, now, and I have been feeling the best I have in many years. I have a long way to reach full remission, though. I wouldn't be surprised if it took another year. My guess is that increased severity and increased chronicity indicate a longer period to attain remission. Why shouldn't we expect that it would take longer to recover? I imagine the brain of such a person has a lot of ground to cover in order to produce the type of neurogenesis and recovery of brain tissue that might be necessary under such circumstances.
>
> Babble.
>
>
> - Scott
>Scott...
I thought I saw a post recently where you said that after an extended time on lithium it began to have an antidepressant effect that you had not expected?
Bob
Posted by jono_in_adelaide on April 14, 2011, at 0:06:54
In reply to Re: Nortriptyline vs reboxetine » SLS, posted by Bob on April 13, 2011, at 23:43:34
In Australia, risperidone is only avaliable under the national health schem for schtizophrenia, and as a private prescription, costs a lot of money.
I obtained 200 x 1mg tablets from an Indian generics manufacturer for $6.
I hve just moved to a new town, and will be seeing a new doctor, so I might bring it up ("my last doctor gave me a sample pack of Risperdal and it realy helped..."
Now been taking 1mg risperidone at night and I would say that I am as close to full remission as I will get.
Current regimen is
Sertraline 100mg in the morning
Reboxetine 4mg twice a day
Alprazolam 1mg twice a day (plus a 3rd 1mg pill during the day if needed, but i havent needed one since the risperidone)
Risperidone 1mg at night
No suicidal thoughts, almost no anxiety, I'm liking this.
Posted by SLS on April 14, 2011, at 4:59:40
In reply to Re: Nortriptyline vs reboxetine » SLS, posted by Bob on April 13, 2011, at 23:43:34
> I thought I saw a post recently where you said that after an extended time on lithium it began to have an antidepressant effect that you had not expected?
Yes. In fact, I began to improve within two days.
I must have hit a bump in the road this past week that was simply a worsening associated with the natural course of my illness rather than a lithium-induced worsening. I rechallenged myself with lithium 300mg and have recaptured the antidepressant effect. I like this drug (today). Interestingly, Harvard / Mass General determined that low dosages of lithium (300-600mg) act as an augmenter of antidepressants in MDD. Most patients whom responded did so at a dosage of 450mg. The antidepressant used in the study was fluoxetine. There is substantial indication in the medical literature that lithium added to a tricyclic can produce a rapid and robust improvement. It is nice to know that lithium can also augment a SSRI. Unfortunately, there are no studies I know of that compares the rate of response to an SRI versus a tricyclic when lithium is added.
- Scott
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Dr. Bob is Robert Hsiung, MD,
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