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Dr. Bob is Robert Hsiung, MD,
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Posted by schleprock on September 10, 2012, at 18:11:58
In reply to Re: Need out of the box suggestions » chicagokat, posted by SLS on September 10, 2012, at 17:36:41
You could always try a dopamine agonist(?) like mirapex. There's also pinoldol(>), a beta-blocker that I believe is being used off-label for depression.
And then, there's always another path...
Posted by jono_in_adelaide on September 10, 2012, at 18:30:16
In reply to Need out of the box suggestions, posted by chicagokat on September 10, 2012, at 10:42:19
Ask your doc about Lexapro combined with either Nortriptyline (75mg at night to start, then measure blood levels and adjust doseage up or down based on this) or Welbutrin 300mg-450mg/day
Adding an atypical antipsychotic (say Risperidone 0.5 - 1mg at bedtime) can offer a kick start to the antidepressant meds
Posted by SLS on September 10, 2012, at 18:38:46
In reply to Need out of the box suggestions, posted by chicagokat on September 10, 2012, at 10:42:19
Hi.
Ataxia is a frequent side effect with Ambien. If you do return to Nardil and the ataxia reappears, I would consider performing an experiment with Ambien by skipping one or two nights to see if the ataxia resolves.
- Scott
Posted by zazenducke on September 10, 2012, at 19:03:28
In reply to Re: Need out of the box suggestions » zazenducke, posted by SLS on September 10, 2012, at 14:40:53
> > > Where is Wellbutrin?
> >
> >
> >
> > >
> > > Have you ever tried Lamictal?
> > >
> >
> > SNRIs
> > TCAz
> > Atypical antipsychotics
> > Mood stabilizers (lithium, lamictal)
> >
> >
> > See original post above Mr S
> >
> > Never take advice from strangers on the internet :)
>
>
> You should really find a hobby.
>
>
> - ScottThanks for not suggesting I should really be medicated ;)
Posted by brynb on September 11, 2012, at 1:14:21
In reply to Need out of the box suggestions, posted by chicagokat on September 10, 2012, at 10:42:19
Hi Kat-
Push the Tramadol. I don't have any links right now to share, but google it and you'll find many hat you can show your pdoc.
It's an interesting drug (psychiatrically speaking); it's a weak NRI, a weak opiod agonist that works on the mu receptors and an NMDA antagonist. It pulled me out of my last depressive episode at only 100mg, and now I only take 50mg and it works great. I use i in combination with Lexapro (20mg) and lithium (300mg).
Nortyptiline with Lexapro is a good combo, but I couldn't really handle the Nortryptiline.
Good luck tomorrow and keep s posted!
Posted by SLS on September 11, 2012, at 2:06:03
In reply to Re: Need out of the box suggestions » chicagokat, posted by brynb on September 11, 2012, at 1:14:21
Hi Brynb
> Hi Kat-
>
> Push the Tramadol. I don't have any links right now to share, but google it and you'll find many hat you can show your pdoc.
>
> It's an interesting drug (psychiatrically speaking); it's a weak NRI, a weak opiod agonist that works on the mu receptors and an NMDA antagonist. It pulled me out of my last depressive episode at only 100mg, and now I only take 50mg and it works great. I use i in combination with Lexapro (20mg) and lithium (300mg).
>
> Nortyptiline with Lexapro is a good combo, but I couldn't really handle the Nortryptiline.
>
> Good luck tomorrow and keep s posted!
It is very good news to hear of your success with your current treatment. Lots of smiles.To what degree does tramadol inhibit the reuptake of serotonin?
- Scott
Posted by phidippus on September 11, 2012, at 4:30:42
In reply to Re: Need out of the box suggestions » phidippus, posted by chicagokat on September 10, 2012, at 14:55:58
>Prozac for years, Zoloft for months, Paxil for >years, Lexapro for many years
I can think of a couple you haven't tried: Luvox and Viibryd.
>as far as TCAs, I've tried Desipramine and >Amitryptiline
You could try Clomipramine.
>the others gave me akathisia
Akathisia is easily treated.
I would talk to your doctor about Tramadol and/or
consider going back on the Nardil.Eric
Posted by SLS on September 11, 2012, at 7:11:58
In reply to Re: Need out of the box suggestions » chicagokat, posted by phidippus on September 11, 2012, at 4:30:42
> I can think of a couple you haven't tried: Luvox and Viibryd.
What do you think of adding nortriptyline to the Viibryd? You'd be gaining NE reuptake inhibition and 5-HT2a receptor antagonism. The combination would be sort of like a more potent Geodon, but without the DA antagonism.
I would still be wary of the occurrence of serotonin syndrome with the addition of tramadol to Nardil. It would be a nice addition otherwise. I guess I would take the chance of adding small amounts to ongoing Nardil treatment, and titrate gradually as tolerated. One would want to have a list of SS symptoms to watch for. Hyperpyrexia is what usually kills people. Tramadol isn't that potent a SRI, but still...
http://www.ncbi.nlm.nih.gov/pubmed/10686795
- Scott
Posted by brynb on September 11, 2012, at 7:31:47
In reply to Re: Need out of the box suggestions » brynb, posted by SLS on September 11, 2012, at 2:06:03
> It is very good news to hear of your success with your current treatment. Lots of smiles.
>
> To what degree does tramadol inhibit the reuptake of serotonin?
>
>
> - Scott
Hi Scott,Thanks =). It's only been about three months, but I'm hopeful it'll keep up.
I'm not sure to what degree Tramadol inhibits the reuptake of serotonin. Less than Norepinephrine, I believe. I think it's structurally similar to Effexor.
Glad to hear you're responding well to Minocycline by the way! Fingers crossed...
-b
Posted by chicagokat on September 11, 2012, at 9:23:49
In reply to Re: Need out of the box suggestions » chicagokat, posted by SLS on September 10, 2012, at 18:38:46
> Hi.
>
> Ataxia is a frequent side effect with Ambien. If you do return to Nardil and the ataxia reappears, I would consider performing an experiment with Ambien by skipping one or two nights to see if the ataxia resolves.
>
>
> - ScottI'm already off the Ambien; it pooped out on me too. The only thing that helps me sleep now is Elavil, I take 25-50mg. Do you think I'd be able to stay on that if I went back to Nardil? I've heard talk of using TCAs with MAOIs.
Posted by chicagokat on September 11, 2012, at 9:29:49
In reply to Re: Need out of the box suggestions » chicagokat, posted by brynb on September 11, 2012, at 1:14:21
> Hi Kat-
>
> Push the Tramadol. I don't have any links right now to share, but google it and you'll find many hat you can show your pdoc.
>
> It's an interesting drug (psychiatrically speaking); it's a weak NRI, a weak opiod agonist that works on the mu receptors and an NMDA antagonist. It pulled me out of my last depressive episode at only 100mg, and now I only take 50mg and it works great. I use i in combination with Lexapro (20mg) and lithium (300mg).
>
> Nortyptiline with Lexapro is a good combo, but I couldn't really handle the Nortryptiline.
>
> Good luck tomorrow and keep s posted!Hi Bryn, I would really like to try Tramadol, but I'm worried about it leading to tolerance. I suppose if short holidays do reallly help with Tramadol I could handle it. I'm one that becomes physically addicted to drugs fairly easily (example: Ritalin, which really used to help but now does sqaut for me), but I don't seek to increase the dose to keep it going. I'm willing to do a drug holiday to bring back its efficacy. In fact, that's one of the things I'm thinking of trying, with my Ritalin. Because I really don't think my pdoc is gonna prescribe Tramadol for me :(
Posted by chicagokat on September 11, 2012, at 9:34:54
In reply to Re: Need out of the box suggestions » chicagokat, posted by phidippus on September 11, 2012, at 4:30:42
> >Prozac for years, Zoloft for months, Paxil for >years, Lexapro for many years
>
> I can think of a couple you haven't tried: Luvox and Viibryd.
>
> >as far as TCAs, I've tried Desipramine and >Amitryptiline
>
> You could try Clomipramine.
>
> >the others gave me akathisia
>
> Akathisia is easily treated.
>
> I would talk to your doctor about Tramadol and/or
> consider going back on the Nardil.
>
> EricHi Eric,
How is akathisia easily treated? fyi benzos are pretty much out for me as I've developed such a tolerance to thembtw, I have tried Viibryd, forgot to mention that one...and Luvox is not covered by my insurance and costs hundreds of dollars out of pocket.
I would love to try Tramadol, but my pdoc seems very nervous about it. I'm thinking more and more maybe the Nardil is the way to go
Thanks for your input
Kat
Posted by SLS on September 11, 2012, at 11:27:49
In reply to Re: Need out of the box suggestions » SLS, posted by chicagokat on September 11, 2012, at 9:23:49
> > Hi.
> >
> > Ataxia is a frequent side effect with Ambien. If you do return to Nardil and the ataxia reappears, I would consider performing an experiment with Ambien by skipping one or two nights to see if the ataxia resolves.> I'm already off the Ambien; it pooped out on me too. The only thing that helps me sleep now is Elavil, I take 25-50mg. Do you think I'd be able to stay on that if I went back to Nardil? I've heard talk of using TCAs with MAOIs.
Elavil shouldn't be a problem. I've combined it with Nardil once already at dosages above 100 mg/day. The dosage of Nardil was only 45 mg/day, though. Nardil is perfectly fine with desipramine and nortriptyline, as well as doxepin and perhaps trimipramine. The concern with these combinations is serotonin syndrome, not hypertensive crisis. I would say that amitriptyline and doxepin represent a slight risk of producing this in combination with Nardil. Nortriptyline and desipramine are the least likely tricyclics to produce SS. Steer clear of imipramine and clomipramine. Doxepin is good for sleep and anxiety. If I were you, and Elavil proved to be problematic, I would probably dump the whole Nardil + TCA idea.
The following combinations should be okay for depression and insomnia. SS would not be a problem. Hypertensive reactions are conceivable, but I couldn't find any descriptions of it ever happening.
Nardil + low-dose Seroquel
Nardil + low-dose Remeron
http://www.ncbi.nlm.nih.gov/pubmed/16342227
I would be curious to know what other people think.
- Scott
Posted by chicagokat on September 11, 2012, at 12:06:46
In reply to Re: Need out of the box suggestions » chicagokat, posted by SLS on September 11, 2012, at 11:27:49
> > > Hi.
> > >
> > > Ataxia is a frequent side effect with Ambien. If you do return to Nardil and the ataxia reappears, I would consider performing an experiment with Ambien by skipping one or two nights to see if the ataxia resolves.
>
> > I'm already off the Ambien; it pooped out on me too. The only thing that helps me sleep now is Elavil, I take 25-50mg. Do you think I'd be able to stay on that if I went back to Nardil? I've heard talk of using TCAs with MAOIs.
>
> Elavil shouldn't be a problem. I've combined it with Nardil once already at dosages above 100 mg/day. The dosage of Nardil was only 45 mg/day, though. Nardil is perfectly fine with desipramine and nortriptyline, as well as doxepin and perhaps trimipramine. The concern with these combinations is serotonin syndrome, not hypertensive crisis. I would say that amitriptyline and doxepin represent a slight risk of producing this in combination with Nardil. Nortriptyline and desipramine are the least likely tricyclics to produce SS. Steer clear of imipramine and clomipramine. Doxepin is good for sleep and anxiety. If I were you, and Elavil proved to be problematic, I would probably dump the whole Nardil + TCA idea.
>
> The following combinations should be okay for depression and insomnia. SS would not be a problem. Hypertensive reactions are conceivable, but I couldn't find any descriptions of it ever happening.
>
> Nardil + low-dose Seroquel
>
> Nardil + low-dose Remeron
>
> http://www.ncbi.nlm.nih.gov/pubmed/16342227
>
> I would be curious to know what other people think.
>
>
> - Scott
>Thanks Scott....If we go the Nardil route I'll ask my pdoc about the Elavil, and perhaps suggest Doxepin instead to him for sleep. I've had SS before, and believe me, I don't want to get it again!
Oh, and thanks for the info on Seroquel and Remeron, but Seroquel dosn't help me sleep and it gives me akatisia, and Remeron no longer makes me sleepy :(OK, I'm off to the doc! I'll let you all know how it turns out.
Regards,
Kat
Posted by bleauberry on September 11, 2012, at 13:05:31
In reply to Need out of the box suggestions, posted by chicagokat on September 10, 2012, at 10:42:19
Ok, cool, I saw a good clue in your post. Ritalin. That says something.
Right off the bat what pops into my head is Savella or Parnate. I mention Savella because even though it is an SNRI (the only true SNRI other than clomipramine), it has some mechanical similarities to ritalin.
I failed ECT too, and about a backpack full of meds that probably looks like your backpack full of meds. I responded nice to Savella within the first few days. That also happens to me on Ritalin, except the tolerance issue builds real fast, and it gets kind of nasty with agitation issues. It was a while ago, I read it on pubmed, there is some science showing some mechanical similarities between savella and ritalin.
have you combined SSRIs plus TCAs? Such as Zoloft+Nortriptyline, anything similar? If not, you should put that on the list too. It's totally different than either alone.
When you say you've tried SNRIs, if one of them was not savella, then you have not tried snris. That's because they are actually ssris with a marketing gimmic. Effexor for example is 30 parts serotonin to 1 part NE....almost pure serotonin. At highe doses the ratio changes to a little more of NE, but is still dominantly serotonin. Cymbalta is 9 parts serotonin to 1 part NE. Not exactly an snri there either. But it sure sounds good and makes sales go up. Prozac actually increases NE in the brain more than those two supposed snris do.
Interesting how you said you felt worse on ECT. From session 1 to session 10 I felt considerably worse too. It wasn't until the 12th session I actually improved a lot, but only for a couple days, and then it was gone, back to darkness. Thankfully I was so out of it during the ECT weeks the memory insults helped get through the rough times.
Parnate is sort of in the stimulant category, and may not have the same issues you had with nardil.
My lyme specialist said some of his patients present with only one symptom.....resistant depression. Now before anyone says there he goes again with that lyme crap, it just has to be put on the table for viewing. It's true. The underlying cause....not a deficiency of neurotransmitters, but rather a contamination of them. You would not believe how powerful the neurotoxins from stealth infections can be. They are....toxins. There aint no antidepressant on the planet gonna do anything about that. A few specialty herbs however are very specific for that. I'll mention the heavy weights if you want to learn more.....
Resveratrol made from polygonum cupsidatum (japanese knotweed), not resveratrol derived from grapes. Rhodiola Rosea. Smilax. As well as any vitamins/minerals known to mop up junk....mega dose vit c, high dose selenium, and overall a much higher intake of all vitamins/minerals. Therapeutic intake is different than normal healthy intake. Therapeutic requires much more.Grocery cart choices also can make a huge difference. There are so many people that have said the single best thing they did to improve their mood and symptom was.....(example) stopping dairy, stopping gluten, stopping whatever food they identified during challenge tests. Pretty simple. Just skip a suspect food for a couple weeks, then see what happens when you eat it again. No difference, cool. Big difference, you just found something no doctor was ever going to find. And other than that, is my standing that anyone with any kind of chronic symptoms needs to include careful food choices the same way they approach meds. Food really is powerful. We are not aware of that because we've been trained by consensus society habits that are different and do not take into account chronic illness. Just because something is called food and a lot of people eat it, does not mean it is good for you. Personally, when I read the ingredient label, if there is something there that is chemical not food, or something I don't recognize, or something I can't pronounce, forget it, I'm not eating it. Someone else can have that crap if they want. Eat to please your body, not your taste buds. Taste buds change to like whatever you eat. I used to love donuts everyday, a favorite. I've been gluten free for a few years now and I do not want a donut, they still taste ok, not great like they used to, and feel like rocks in my stomach. Every plate of food I eat has lots of colors in it....mostly from a variety of fresh or slightly cooked veggies and fruits. A lot of them I was not crazy about, but now I love them.
My biggest gains in mood improvement started when I began approaching it as lyme or lyme-like (lots of similar stuff out there) instead of depression. The depression was just a symptom of something else. No wonder the psych meds failed so often. Post ECT, the limited number of meds that offer me any potential include savella, ritalin, vicodin, parnate, nort+zoloft. Right now I am not on any meds. The antibiotic doxycycline for a few months probably got me the largest gains of all. Don't get me wrong, I'm not all that well, may never be, I'm just sayin, depression can and does respond to other stuff besides what is in the psych toolbox. And especially when the depression is strongly resistant, that is a huge clue the depression is not what we think it is.
Anyway, I hope you can get some ideas to work with.
Posted by phidippus on September 11, 2012, at 16:35:59
In reply to Re: Need out of the box suggestions » phidippus, posted by chicagokat on September 11, 2012, at 9:34:54
I think Nardil is your best bet. Is your doctor hesitant to prescribe Tramadol for addiction reasons?
Too bad you couldn't try Luvox. Its a unique antidepressant. Its the only SSRI that's monocyclic and it has a strong affinity for the sigma-1 receptor, a neuropeptide implicated in severe depression.
Eric
Posted by phidippus on September 11, 2012, at 16:54:58
In reply to Re: Need out of the box suggestions » SLS, posted by brynb on September 11, 2012, at 7:31:47
Tramadol is a serotonin releasing agent, rather than a seratonin reuptake inhibitor. Tramadol also acts a μ-opioid receptor agonist, NMDA receptor antagonist, 5-HT2C receptor antagonist, (α7)5 nicotinic acetylcholine receptor antagonist, TRPV1 receptor agonist, norepinephrine reuptake inhibitor, and M1 and M3 muscarinic acetylcholine receptor antagonist.
Eric
Posted by jono_in_adelaide on September 11, 2012, at 18:02:33
In reply to Re: Need out of the box suggestions » brynb, posted by phidippus on September 11, 2012, at 16:54:58
I took SR Tramadol, 200mg twice a day for a month after a back injury, and while it was an excelent analgesic, it didnt effect my mood one way or the other.
Posted by brynb on September 11, 2012, at 18:18:45
In reply to Re: Need out of the box suggestions » brynb, posted by phidippus on September 11, 2012, at 16:54:58
> Tramadol is a serotonin releasing agent, rather than a seratonin reuptake inhibitor. Tramadol also acts a μ-opioid receptor agonist, NMDA receptor antagonist, 5-HT2C receptor antagonist, (α7)5 nicotinic acetylcholine receptor antagonist, TRPV1 receptor agonist, norepinephrine reuptake inhibitor, and M1 and M3 muscarinic acetylcholine receptor antagonist.
>
> EricInteresting! Is it definitely a serotonin releasing agent? I've heard some say it releases it, and others claim it acts as a serotonin reuptake inhibitor. I'm confused :/. It's interesting, because I can't tolerate Cymbalta or Effexor. In fact, I've always done best on Lexapro, which leads me to think I'm a "serotonin" girl.
But, because of all the other ways Tramadol works (on mu/opiate receptors, on NMDA, etc.), it's probably got several things that are working in tandem to combat the depression.
What really pisses me off is that pdocs have this aversion to it when it works so well for so many people. I had no trouble stopping it (and NEVER abused it), have zero side effects from it, and have not become tolerant or dependent on it (I never increased the dose). And yet benzos, stims, opiates, heck, even anti-depressants are doled out as if they aren't habit forming. Ugh!
-b
Posted by jono_in_adelaide on September 11, 2012, at 18:22:04
In reply to Re: Need out of the box suggestions, posted by jono_in_adelaide on September 11, 2012, at 18:02:33
My out of box suggestions for you would be:
1. Effexor 150mg-300mg in the morning plus Remeron 30-45mg at night
2. Sertraline 100mg/day and Bupropion 300mg/day anda risperidone 0.5-1mg/day
3. Parnate plus Nortriptyline plus risperidone
4. Sertraline plus nortriptyline plus risperidone
Burenorphine and tramadol are options but a lot of doctors would be hesitant to prescribe them for depression (not nessecerily for any logical reason, the abuse liability of tramadol is virtualy nil)
The main thing is dont give up, keep trying different meds and combos in the hope that somthing that works will emerge
Posted by chicagokat on September 11, 2012, at 18:54:48
In reply to Re: Need out of the box suggestions, posted by jono_in_adelaide on September 11, 2012, at 18:22:04
Well, the verdiict is in, and it's.....Tramadol!
I gave my pdoc some information on it, and we had a discussion abour it, and I told him I was not desperate for it, that if he wanted to go the Nardil route I was fine with that...but he said with the Tramadol I'll know in days whether it works or not, so he said let's try it for a week.
I'll keep you guys updated on how it goes. And I really want to thank you all for your excellent suggestions and info. You all are great, and I'm really happy I stumbled upon this forum :)
All my best,
Kat
Posted by brynb on September 11, 2012, at 19:09:19
In reply to Re: Need out of the box suggestions, posted by chicagokat on September 11, 2012, at 18:54:48
> Well, the verdiict is in, and it's.....Tramadol!
>
> I gave my pdoc some information on it, and we had a discussion abour it, and I told him I was not desperate for it, that if he wanted to go the Nardil route I was fine with that...but he said with the Tramadol I'll know in days whether it works or not, so he said let's try it for a week.
>
> I'll keep you guys updated on how it goes. And I really want to thank you all for your excellent suggestions and info. You all are great, and I'm really happy I stumbled upon this forum :)
> All my best,
> KatGreat news! I really hope it works for you the way it's worked for me. If indeed it works, you can always speak to your pdoc about adding on the right AD to augment your response and prevent future depressive episodes.
I forgot--have you tried a low dose of Lithium? I like it with Tramadol.
Glad you're hopeful--keep posting about yur progress and hope you feel better soon.
-b
Posted by phidippus on September 11, 2012, at 21:57:56
In reply to Re: Need out of the box suggestions » phidippus, posted by brynb on September 11, 2012, at 18:18:45
"Is it definitely a serotonin releasing agent?"
Yes, indeed. Kind of like Stablon.
What are you taking? what's your diagnosis?
Eric
Posted by phidippus on September 11, 2012, at 22:02:02
In reply to Re: Need out of the box suggestions, posted by chicagokat on September 11, 2012, at 18:54:48
Congratulations! I hope in the end you get back on the Nardil and find the Tramadol a great way to augment your treatment with Nardil.
Eric
Posted by SLS on September 12, 2012, at 2:38:52
In reply to Re: Need out of the box suggestions » chicagokat, posted by phidippus on September 11, 2012, at 22:02:02
> Congratulations! I hope in the end you get back on the Nardil and find the Tramadol a great way to augment your treatment with Nardil.
>
>
> Eric
Just be careful and watch for signs of serotonin syndrome.
- Scott------------------------------------------
Mental status changes
Confusion (51%)
Agitation (34%)
Hypomania (21%)
Anxiety (15%)
Coma (29%)Cardiovascular
Sinus tachycardia (36%)
Hypertension (35%)
Hypotension (15%)Gastrointestinal
Nausea (23%)
Diarrhea (8%)
Abdominal pain (4%)
Salivation (2%)Motor Abnormalities
Myoclonus (58%)
Hyperreflexia (52%)
Muscle rigidity (51%)
Restlessness (48%)
Tremor (43%)
Ataxia/incoordination (40%)
Shivering (26%)
Nystagmus (15%)
Seizures (12%)Other
Diaphoresis (45%)
Unreactive pupils (20%)
Tachypnea (26%)
Hyperpyrexia (45%)
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