![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 35 to 59 of 76. Go back in thread:
Posted by jono_in_adelaide on December 27, 2012, at 2:24:48
In reply to thanks » SLS, posted by g_g_g_unit on December 27, 2012, at 0:47:24
GGG, can i suggest you look at treatment at the Black Dog Institute in sydney - they are reputed to be extremely good at treating depression and anxiety disorders
http://www.blackdoginstitute.org.au/
They do inpatient and outpatient treatment
And can I reiterate, you have a life threatening, life destroying condition, be prepared to put up with some minor side effects if your condition can sucsessfuly be treated
Posted by g_g_g_unit on December 27, 2012, at 3:06:42
In reply to Re: thanks, posted by jono_in_adelaide on December 27, 2012, at 2:24:48
> GGG, can i suggest you look at treatment at the Black Dog Institute in sydney - they are reputed to be extremely good at treating depression and anxiety disorders
>
> http://www.blackdoginstitute.org.au/
>
> They do inpatient and outpatient treatment
>
> And can I reiterate, you have a life threatening, life destroying condition, be prepared to put up with some minor side effects if your condition can sucsessfuly be treatedI can't afford to get to Sydney. If I do inpatient treatment, it will be at The Melbourne Clinic.
And for the record, I've never discontinued a med due to minor side-effects -- it's generally stuff that obstructs my quality-of-life or a case of the cure-being-worse-than-the-disease.
But I should probably start to accept I'm not going to get the life I want, which means devoting a lot of time to fighting this monstrous OCD.
Posted by SLS on December 27, 2012, at 7:15:29
In reply to thanks » SLS, posted by g_g_g_unit on December 27, 2012, at 0:47:24
> I just wanted to thank you all for your support and suggestions. I feel a little too overwhelmed to respond individually at this point, but I realize that I have quite a difficult decision ahead of me -- namely to continue with life, treatment and all the attendant hardship it brings -- or to surrender to my own nihilistic impulses. Right now, I feel like I'm in a hole that I'm not going to dig myself out of. I also realize that no one can make that decision for me.
This is absolutely true. I am a believer that people have a right to choose their own destiny, even if that means choosing death. I have reached the point on two or three occasions when I contemplated a "rational suicide", or what I like to call autoeuthanasia. They shoot horses, don't they? However, I would council you against making a decision to move in that direction while you are experiencing such a severe episode of depression and anxiety. I am sure you actually "feel" doomed. This usually passes in cases like yours. I don't think it would be rational for you to commit suicide while you are in this state. You can choose to leave life anytime. Why do it today? I lived many years believing that suicide was to be an inevitable conclusion to my life. However, on a daily basis I was able to rationalize living for just one more day. I have never made plans nor investigated methods. One would think that I would have researched the thing. Nope. I wanted to distance myself away from suicide as much as possible. I don't want to have the tools ready to act on impulse. As long as I chose to live that one more day, it made no sense to add to my morbidity by investigating suicide. I seem to always work to gain positive energy.
I know that I have said this before, but I find hope in uncertainty. If you can conceive of a treatment that you have not yet tried, there is hope that you might find therapeutic success. If you cannot conceive of such a treatment, then let other people do it for you. Hopefully, this will be your doctor who offers you untried alternatives. Perhaps you will find hope in treatments that are not pharmacological. Certainty can be a killer. I reached my only state of certainty a little over a year ago. I could not conceive of any treatment that I had not yet tried. In my mind, I had run out of alternatives. I was certain I was doomed to live in a chronic state of severe depression and the pain and ruination that accompanies it. Thus began my existential crisis. My thoughts were deep, intense, and destructive. It is not that the thoughts were without fact to justify them. It is that they were exaggerated by the depressive state. The depressed brain sees life through unrealistic filters. There are no positive thoughts. The brain simply does not generate them. What's worse, it seems that the brain generates and exaggerates negative thoughts. So, in the nomenclature of behaviorists, the result of these filters is a lack of reward and/or a preponderance of punishment. Before making any decisions, you may want to wait for the negativistic brain state to subside so that any choice you make will be the result of a more objective deliberation. If you wait, I am hoping that the world will seem different enough for you such that you don't choose death today nor tomorrow.
> It isn't so much the depression -- if it was depression alone, I could make some changes (maybe work, move out of home) which would help a lot; it's the relentless anxiety and OCD and agoraphobia which rule my life, and which I feel no reprieve from.
Depressed people commit suicide more often when anxiety or anger are present. Anxiety is an intergral part of OCD. It is often considered a type of anxiety disorder. You must be in a hellish state right now. You must be ruminating to the point of exhaustion. Do you feel the intense anxiety viscerally? Do you feel it in the pit of your stomach and experience heart palpitations? I experience these things when I am overwhelmed and are plagued by thoughts of inevitable doom. There seems to be a neurobiological substrate for the suicidal brain. Mine was created by a depressive rebound from discontinuing Viibryd (vilazodone) abruptly. It sure didn't feel biological, though. However, my doctor knew better. The beast will beguile you. I do not believe that your suicidal brain state will last for very long. However, you might need help to process your existential crisis - the thought content of which reflect real issues - until your suicidal state subsides.
Try not to feed the beast.
Anyway, let today not be the day that you act irrevocably. You will get through this. You will be okay.
Are there any crisis services available to you? Please keep reaching out.
- Scott
Posted by g_g_g_unit on December 27, 2012, at 8:41:23
In reply to Re: thanks » g_g_g_unit, posted by SLS on December 27, 2012, at 7:15:29
> This is absolutely true. I am a believer that people have a right to choose their own destiny, even if that means choosing death. I have reached the point on two or three occasions when I contemplated a "rational suicide", or what I like to call autoeuthanasia. They shoot horses, don't they? However, I would council you against making a decision to move in that direction while you are experiencing such a severe episode of depression and anxiety. I am sure you actually "feel" doomed. This usually passes in cases like yours. I don't think it would be rational for you to commit suicide while you are in this state. You can choose to leave life anytime. Why do it today? I lived many years believing that suicide was to be an inevitable conclusion to my life. However, on a daily basis I was able to rationalize living for just one more day. I have never made plans nor investigated methods. One would think that I would have researched the thing. Nope. I wanted to distance myself away from suicide as much as possible. I don't want to have the tools ready to act on impulse. As long as I chose to live that one more day, it made no sense to add to my morbidity by investigating suicide. I seem to always work to gain positive energy.
Thank you, Scott. I was hesitant to mention the "S" word, but I suppose it was implied in my post. I have no plans to leave this world today, tomorrow or in the foreseeable future, but it is certainly something that I have begun contemplate with greater openmindedness. I do not subscribe to the theory that all suicide, enacted in the context of mental illness, is by default irrational. You are right -- I feel doomed and imprisoned, both internally and externally. This has been a slow process of degradation that I have been undergoing for 5 years, with almost no signs of reprieve. It is the continual process of reality clashing with fantasy which produces the greatest despondency.
>
> I know that I have said this before, but I find hope in uncertainty. If you can conceive of a treatment that you have not yet tried, there is hope that you might find therapeutic success. If you cannot conceive of such a treatment, then let other people do it for you. Hopefully, this will be your doctor who offers you untried alternatives. Perhaps you will find hope in treatments that are not pharmacological. Certainty can be a killer. I reached my only state of certainty a little over a year ago. I could not conceive of any treatment that I had not yet tried. In my mind, I had run out of alternatives. I was certain I was doomed to live in a chronic state of severe depression and the pain and ruination that accompanies it. Thus began my existential crisis. My thoughts were deep, intense, and destructive. It is not that the thoughts were without fact to justify them. It is that they were exaggerated by the depressive state. The depressed brain sees life through unrealistic filters. There are no positive thoughts. The brain simply does not generate them. What's worse, it seems that the brain generates and exaggerates negative thoughts. So, in the nomenclature of behaviorists, the result of these filters is a lack of reward and/or a preponderance of punishment. Before making any decisions, you may want to wait for the negativistic brain state to subside so that any choice you make will be the result of a more objective deliberation. If you wait, I am hoping that the world will seem different enough for you such that you don't choose death today nor tomorrow.I hope so too. My personal psychiatrist has run out of treatment ideas -- our last appointment was a medication review, where he established that the priority should be to reign in the severity of my anxiety. He prescribed Xanax, which produced a paradoxical reaction, and is now on vacation, so I don't have access to him until the second week of January. As far as depression, the only thing that produced any significant gains, looking back, was Parnate (at 60mg) -- I became far more active, engaged, and motivated, though at the expense of insomnia, increased anxiety and agitation. Dexamphetamine also helps my amotivational and concentration issues (perhaps partly tied to ADD), though at the expense of anxiety and agitation as well.
I notice the bind I am in. I am suffering from such severe anxiety that I am effectively crippled, yet am so desperate to maintain some idealized quality-of-life. Maybe this is just a normal reaction to the whole process of medicating. But I fear that anything that produces a meaningful dent in my anxiety will come at the expense of apathy, anhedonia, etc. The last time I was referred to a Professor of Pharmacology for a consultation he had me on a high-dose of Lexapro and Zyprexa and I barely had the willpower to get out of bed.
>
> > It isn't so much the depression -- if it was depression alone, I could make some changes (maybe work, move out of home) which would help a lot; it's the relentless anxiety and OCD and agoraphobia which rule my life, and which I feel no reprieve from.
>
> Depressed people commit suicide more often when anxiety or anger are present. Anxiety is an intergral part of OCD. It is often considered a type of anxiety disorder. You must be in a hellish state right now. You must be ruminating to the point of exhaustion. Do you feel the intense anxiety viscerally? Do you feel it in the pit of your stomach and experience heart palpitations? I experience these things when I am overwhelmed and are plagued by thoughts of inevitable doom. There seems to be a neurobiological substrate for the suicidal brain. Mine was created by a depressive rebound from discontinuing Viibryd (vilazodone) abruptly. It sure didn't feel biological, though. However, my doctor knew better. The beast will beguile you. I do not believe that your suicidal brain state will last for very long. However, you might need help to process your existential crisis - the thought content of which reflect real issues - until your suicidal state subsides.To be honest, I live in such a constant state of fear that I don't even ruminate anymore. It's like my mind is frozen and barely able to think due to having to remain in such a constant state of hypervigilance. Perhaps my unconscious goal is to suppress thought since it seems so threatening; I spend my days in a constant state of meaningless distraction .. sleeping, playing video games, watching TV. I worry for my cognitive function. I don't see how it is possible to construct a meaningful future -- based on intellectual pursuit -- when I have basically fallen off the face of the planet. The circumstances that triggered my suicidal state (a relationship ending, Memantine failing me, diminishing med options) don't leave me in a state of 'chemical withdrawal' which somehow feels temporary -- I genuinely believe that it is no longer possible to etch out a meaningful future with my current malfunctioning brain, and sometimes it feels very tempting to just admit valiant defeat and put an end to things rather than face further humiliation.
>
> Try not to feed the beast.
>
> Anyway, let today not be the day that you act irrevocably. You will get through this. You will be okay.It won't be today. I will at least attempt inpatient treatment, though unfortunately have to wait until the end of February to be admitted.
>
> Are there any crisis services available to you? Please keep reaching out.
>
Well, there are things like lifeline etc. but I find them a little condescending. My last psychologist just left his practice to enter research but has said I am free to call him in cases of emergency.Anyway, I really appreciate your support and guidance.
Posted by schleprock on December 27, 2012, at 12:58:26
In reply to Re: feel finished » g_g_g_unit, posted by SLS on December 26, 2012, at 11:33:05
> > I had no idea that things could reach this point.
>
> Yes, they absolutely can.
>
> > I've found myself in the pits of depression, agony, despair and so on but always felt some sense of hope or reason to continue.
>
> You have a number of choices. All but one of them require that you remain alive.
>
> I won't go fishing for a treatment option for you at this time. You know that I would probably come up with something. If not me, someone else will. I'm sure it won't be easy, but you cannot be certain that you will never find a treatment that will work. You don't know for certain that you are doomed to live out your life in the altered state of depression. Fortunately, new and novel drugs are still being developed to treat it.
>
> Just over a year ago, I had reached the same point of despair and demoralization as you seem to have. I had reached the end of the line. There were no more treatments that I could come up with. Viibryd had been my last chance to get well. I experienced a major existential crisis for which I saw no escape. However, as my doctor had so accurately concluded, much of the origin of this intense episode was the result of discontinuing Viibryd too abruptly and experiencing a withdrawal depressive reaction with anxiety and suicidality. I insisted that he was wrong, however. It felt like my thoughts were the cause of my feelings of doom, and not some drug reaction. The content of my thoughts were certainly real enough and based upon my taking stock of my life and the prospect of being doomed to forever live a subhuman existence. The circumstances of my plight were real. As I learned afterwards, it was indeed Viibryd withdrawal depression that amplified my reaction to those very real life circumstances. As my doctor suspected, the suicidal state resolved despite nothing being different in my those circumstances. Still, I remained pessimistic. I don't know what I would have done had prazosin not produced a significant improvement in my condition a month later. It is possible that I would have come closer to suicide, even though the withdrawal depressive state had disappeared on its own.
>
> > Everything feels utterly pointless.
>
> I can totally understand this.
>
> > I feel lost, like my dreams are gone,
>
> My dreams died many years ago. I had quite a few.
>
> > there is nothing to direct myself towards anymore, no vision of a future .. nearly all of my 20s have been consumed by this horrible illness.
>
> It is a terrible loss. An important decade of your life is being stolen from you through no fault of your own. Many people try to help, but the illness is just too powerful and unrelenting. I am having a difficult time accepting the theft of my teens, 20s, 30s, 40s, and now my 50s.
>
> You are 27.
> 27 is old.
> 27 is young.
>
> When I reached age 32, I felt old. I felt that life had passed me by. I had missed everything. Older people insisted that I was still very young and had the better part of my life ahead of me. I didn't believe them. I sure didn't feel young. I was just too young to know any better.
>
> Take my word for it. You are still very young.
>
> > I don't know what to do anymore.
>
> I know what it is like to reach a wall at which there are no remaining treatment alternatives to break through it. You have exhausted all of them. There is no hope. I usually find hope in uncertainty. A year ago, I reached a point at which I became certain that I was to die ill. My greatest fear was to be realized: I was to die without ever having lived. At age 52, I had reached a seminal moment in my life.
>
> > I know there is only so much professionals can do, but the problem is I don't care about myself enough anymore to want to work with them.
>
> Do you feel as though you are always at odds with your doctors? If so, why?
>
> > My OCD has reached such a terrifying apex that I couldn't even begin to describe how much bizarre phobic avoidance etc. I go through.
>
> I do not have OCD. However, for many years while I was at my baseline severity of depression, I would hide whenever someone would walk or drive by the house. I didn't want to be seen through the window. I am not sure why. Avoidance was just part of the illness. What was particularly frustrating and confusing to me was that I really do love people. For some reason, I was just afraid of being around them. I found that when I reach remission or have a brief robust response to treatment, I become quite gregarious and don't mind being surrounded by a sea of people. I can tell that people genuinely like being around me. I am engaged. Depression disengages me. People are uncomfortable around me because I am mute and not very accessible. They can sense my discomfort to be in a social gathering. I have nothing to talk about. I just want to go home and be left alone.
>
> > Trying to piece together some semblance of a life at this point seems impossible. I don't want to live a compromised life, always battling this illness. I *know* that I could have been capable of so much more, and that thought -- what could have been -- eats me up.
>
> I have been devoured, regurgitated, and devoured again. This illness has pummeled me into submission. I reached this state about 10 years ago. I could no longer maintain my positive energy and enthusiasm. Much of me is now gone. I don't feel me inside me anymore. I don't think these parts of me will ever reappear. I can't think about these things anymore. They will never again exist. My best years have been forever stolen from me. My only desire now is to be able to actualize my remaining moments in life with peak experiences, despite my lack of achievement. This can only happen for me if I emerge from depression.
>
> > I guess this is kind of attention-seeking,
>
> No. It is a kind of help-seeking.
>
> > but I don't know what to do to help myself.
>
> Exactly.
>
> > I feel like I'm trying to destroy myself
>
> No. The illness is destroying your morale. Without morale, you are easy prey for the depression to cause you to:
>
> > .. I binge on junk food, I've stopped exercising and grooming, I sleep as much as I can, I've started abusing certain prescriptions just so I can socialize occasionally (which is something I never would have done in the past). My therapist gave me suggestions, but I don't even bother enlisting them. I feel like I've just been going round in circles in treatment for the past 6 years, and sitting in a park or listening to calming music isn't going to give me a life back.
>
> It is okay to allow yourself to feel defeated. Although entirely justified, it is still only a feeling. It does not mean that you are truly defeated. It just feels that way for the moment. The feelings will eventually subside. If you have indeed been defeated in your latest battle, there is still the war to be fought. If you win the war, life will become nirvana for you. It is worth fighting for. Your exhaustion will be replaced by enthusiasm.
>
> "The measure of achievement lies not in how high the mountain,
> but in how hard the climb.
>
> The measure of success lies only in how high one feels he must
> climb to get there."
>
> These are my words. They were meant for me. I wrote them at least 15 years ago as I struggled with my lack of success as it is usually defined. I need to be reminded of them every now and then. It is a hell of an achievement that you are still alive. However, you have achieved so much more than just survive. I'll let you make a list.
>
> This has been a rather rambling message. I hope some part of it makes sense.
>
>
>
> - ScottSLS, Could you please provide details on your experience with Prazosin? specifically it's effect on your depression and its suspected mechanism of action. I looked it up and noticed it was an alpha blocker. I was previously on beta blockers (atenolol and propranolol) and am thinking of going back to one (if I fail to have any progress with Buspar.) What are the advantages in choosing an alpha blocker over a beta-blocker?
Posted by SLS on December 27, 2012, at 14:18:03
In reply to Re: feel finished » SLS, posted by schleprock on December 27, 2012, at 12:58:26
Hi schleprock.
> SLS, Could you please provide details on your experience with Prazosin? specifically it's effect on your depression and its suspected mechanism of action. I looked it up and noticed it was an alpha blocker. I was previously on beta blockers (atenolol and propranolol) and am thinking of going back to one (if I fail to have any progress with Buspar.) What are the advantages in choosing an alpha blocker over a beta-blocker?
First of all, it is important to note that I was taking 5 other drugs before adding the prazosin. However, in studies of PTSD, prazosin monotherapy produced improvements in anxiety and depression. For me, prazosin feels like a very clean, robust, and broad-spectrum antidepressant. It reduces the severity of the entire scope of depressive symptoms. The one exception to this is sexual libido. Reduced libido is a side effect of prazosin, and it showed up immediately. However, the resolution of depression helps to offset this, as depression pretty much wiped-out my sex-drive to begin with.
NE alpha receptors and NE beta receptors are not interchangeable. Although they can both function as sympatholytics, they are not evenly distributed in the brain, and serve different circuits. Although three subtypes of receptor exist, my guess is that it is the NE alpha-1b receptors that are critical in modulating mood. Prazosin is more potent here than are other NE alpha receptor antagonists.
I am playing with the idea that blocking these receptors in the brain structure known as Brodmanns Area 25 produces antidepressant effects similar to deep brain stimulation (DBS), which seems to work by interfering (reducing) neurotransmission there. In addition, NE alpha-1b receptors exist in the amygdala, an area known to be responsible for producing fear and anxiety. They also exist in the nucleus accumbens, where they seem to antagonize incoming glutamatergic circuits. This would most likely result in an increase in dopaminergic activity there via disinhibition. There really isn't very much research into the pharmacological actions of prazosin to reduce PTSD and depression. I am left to offer only a lot of guesses.
Prazosin - NE alpha-1a/b/d receptor antagonist.
1. Reduce hyperactivity in Brodmann Area 25 (anterior subgenual cingulate).
2. Reduce hyperactivity in amygdala.
3. Increase dopaminergic activity in the nucleus accumbens.
You might want to check out the following thread. It is rather long, but might be worth a look. Here is a relevant post:
http://www.dr-bob.org/babble/20120202/msgs/1009565.html
To be honest with you, I haven't researched this thing very much. Nowadays, I am interested in doing the minimum amount of research that will facilitate my getting well.
- Scott
Posted by jono_in_adelaide on December 27, 2012, at 16:40:56
In reply to Re: feel finished » schleprock, posted by SLS on December 27, 2012, at 14:18:03
Sorry if my comments about side effects came across as me having a dig, it wasnt intended that way..... its just that you often get the side effects before you get any of the improvement, and its easy to say "this stiff is crap" and stop it.
I'd consider either a high dose SSRI (Sertaline 200mg/day) or Effexor 300mg plus mirtazapine to help with the depression, OCD and anxiety, with or without a benzo
other options are the parnate + nortriptyline i mentioned earlier with a benzo, or Nardil plus nortriptyline and a benzo, or a high dose SSRI with bupropion and a benzo, all of course depending on what you've tried in the past
Which drug or combination of drugs has come closest to giving you relief?
Posted by jono_in_adelaide on December 27, 2012, at 16:42:33
In reply to Re: feel finished » schleprock, posted by SLS on December 27, 2012, at 14:18:03
If you havent tried clomipramine 150mg per day plus a benzo, try it!
Clomipramine has more side effects than the SSRI's, but it is generaly the gold standard for OCD, is very effective in depression, and also is good for anxiety
Posted by SLS on December 27, 2012, at 17:07:43
In reply to Re: feel finished GGG oh, also, posted by jono_in_adelaide on December 27, 2012, at 16:42:33
> If you havent tried clomipramine 150mg per day plus a benzo, try it!
>
> Clomipramine has more side effects than the SSRI's, but it is generaly the gold standard for OCD, is very effective in depression, and also is good for anxietyThat's a great suggestion.
- Scott
Posted by schleprock on December 27, 2012, at 18:54:42
In reply to Re: feel finished » schleprock, posted by SLS on December 27, 2012, at 14:18:03
> Hi schleprock.
>
> > SLS, Could you please provide details on your experience with Prazosin? specifically it's effect on your depression and its suspected mechanism of action. I looked it up and noticed it was an alpha blocker. I was previously on beta blockers (atenolol and propranolol) and am thinking of going back to one (if I fail to have any progress with Buspar.) What are the advantages in choosing an alpha blocker over a beta-blocker?
>
> First of all, it is important to note that I was taking 5 other drugs before adding the prazosin. However, in studies of PTSD, prazosin monotherapy produced improvements in anxiety and depression. For me, prazosin feels like a very clean, robust, and broad-spectrum antidepressant. It reduces the severity of the entire scope of depressive symptoms. The one exception to this is sexual libido. Reduced libido is a side effect of prazosin, and it showed up immediately. However, the resolution of depression helps to offset this, as depression pretty much wiped-out my sex-drive to begin with.
>
> NE alpha receptors and NE beta receptors are not interchangeable. Although they can both function as sympatholytics, they are not evenly distributed in the brain, and serve different circuits. Although three subtypes of receptor exist, my guess is that it is the NE alpha-1b receptors that are critical in modulating mood. Prazosin is more potent here than are other NE alpha receptor antagonists.
>
> I am playing with the idea that blocking these receptors in the brain structure known as Brodmanns Area 25 produces antidepressant effects similar to deep brain stimulation (DBS), which seems to work by interfering (reducing) neurotransmission there. In addition, NE alpha-1b receptors exist in the amygdala, an area known to be responsible for producing fear and anxiety. They also exist in the nucleus accumbens, where they seem to antagonize incoming glutamatergic circuits. This would most likely result in an increase in dopaminergic activity there via disinhibition. There really isn't very much research into the pharmacological actions of prazosin to reduce PTSD and depression. I am left to offer only a lot of guesses.
>
> Prazosin - NE alpha-1a/b/d receptor antagonist.
>
> 1. Reduce hyperactivity in Brodmann Area 25 (anterior subgenual cingulate).
>
> 2. Reduce hyperactivity in amygdala.
>
> 3. Increase dopaminergic activity in the nucleus accumbens.
>
> You might want to check out the following thread. It is rather long, but might be worth a look. Here is a relevant post:
>
> http://www.dr-bob.org/babble/20120202/msgs/1009565.html
>
> To be honest with you, I haven't researched this thing very much. Nowadays, I am interested in doing the minimum amount of research that will facilitate my getting well.
>
>
> - ScottThanks SLS. Found this article:
http://www.ehow.com/facts_5695241_alpha-blocker-vs_-beta-blocker.html
So basically one class lowers norepinephrine while one lowers epinephrine. The article manages to make the side-effects of Alphas sound much worse than Betas. Atenolol (not over 12.5 mg) I know I've been able to tolerate. Not sure what to do...
Do you also believe bet blockers to be an effective adjunct treatment for anxiety\depression, or only alpha blockers?
Posted by g_g_g_unit on December 27, 2012, at 19:21:18
In reply to Re: feel finished - GGG, posted by jono_in_adelaide on December 27, 2012, at 16:40:56
> Sorry if my comments about side effects came across as me having a dig, it wasnt intended that way..... its just that you often get the side effects before you get any of the improvement, and its easy to say "this stiff is crap" and stop it.
>
> I'd consider either a high dose SSRI (Sertaline 200mg/day) or Effexor 300mg plus mirtazapine to help with the depression, OCD and anxiety, with or without a benzo
>
> other options are the parnate + nortriptyline i mentioned earlier with a benzo, or Nardil plus nortriptyline and a benzo, or a high dose SSRI with bupropion and a benzo, all of course depending on what you've tried in the past
>
> Which drug or combination of drugs has come closest to giving you relief?Unfortunately, I found nortriptyline stimulating rather than sedating, so don't think I'd be able to tolerate it with an MAOI. Same thing with clomipramine -- it produced a lot of akathisia and agitation and isn't something I'd be desperate to revisit.
As I said, the closest I came to relief was on Parnate, which helped my depressive symptoms (anergia, lack of motivation, rejection sensitivity) and, to a degree, my ADD (which no other AD has done), but which didn't relieve my anxiety, and in fact may have increased it. I was only permitted to try up to 60mg, which was the minimum dose necessary for an anti-depressant response. Nardil helped too, but the insomnia was terrible and it made me a little hypomanic.
Posted by SLS on December 27, 2012, at 20:29:37
In reply to Re: feel finished - GGG » jono_in_adelaide, posted by g_g_g_unit on December 27, 2012, at 19:21:18
> Nardil helped too, but the insomnia was terrible and it made me a little hypomanic.
Perhaps you could combine Nardil with a stimulant and Klonopin. Nardil is the ideal MAOI for your depression and anxiety. The stimulant would help with depression and ADD. The Klonopin would help with anxiety, insomnia, and possibly mania. The mania from Nardil usually starts early in treatment and is self-limiting. Trileptal can be used as a mood stabilizer if necessary. If insomnia is an obstacle to feeling great on Nardil, then it is incumbent on your doctor to treat that insomnia aggressively as if it were your primary illness. Failure is not an option. Use Halcion along with another benzodiazepine if you have to. Perhaps 25 - 50 mg of Seroquel? Find a way.
If I recall, you have problems with antipsychotics? Saphris and Latuda are interesting drugs. Saphris can actually be energizing along with being anxiolytic.
- Scott
Posted by jono_in_adelaide on December 27, 2012, at 20:37:44
In reply to Re: feel finished - GGG » jono_in_adelaide, posted by g_g_g_unit on December 27, 2012, at 19:21:18
In that case, it looks like your best options are either Nardil + a mood stabaliser and maybe doxepin or a benzo for sleep, or Parnate (perhaps in a higher doseage) plus a benzo for anxiety.
I'd decide which one you prefered, and push the envelope so far as dose and combinations go
What exactly do you mean by "a bit hypomanic", just more energy than usual, or somthing more serious?
Parnate (perhaps at 80mg) plus a long acting benzo such as Valium
or
Nardil plus a mood stabaliser (your guess is as good as mine here) plus either a benzo or doxepin for sleep
Dont give up, keep tryimg, keep hope
> > Sorry if my comments about side effects came across as me having a dig, it wasnt intended that way..... its just that you often get the side effects before you get any of the improvement, and its easy to say "this stiff is crap" and stop it.
> >
> > I'd consider either a high dose SSRI (Sertaline 200mg/day) or Effexor 300mg plus mirtazapine to help with the depression, OCD and anxiety, with or without a benzo
> >
> > other options are the parnate + nortriptyline i mentioned earlier with a benzo, or Nardil plus nortriptyline and a benzo, or a high dose SSRI with bupropion and a benzo, all of course depending on what you've tried in the past
> >
> > Which drug or combination of drugs has come closest to giving you relief?
>
> Unfortunately, I found nortriptyline stimulating rather than sedating, so don't think I'd be able to tolerate it with an MAOI. Same thing with clomipramine -- it produced a lot of akathisia and agitation and isn't something I'd be desperate to revisit.
>
> As I said, the closest I came to relief was on Parnate, which helped my depressive symptoms (anergia, lack of motivation, rejection sensitivity) and, to a degree, my ADD (which no other AD has done), but which didn't relieve my anxiety, and in fact may have increased it. I was only permitted to try up to 60mg, which was the minimum dose necessary for an anti-depressant response. Nardil helped too, but the insomnia was terrible and it made me a little hypomanic.
>
>
>
Posted by brynb on December 27, 2012, at 20:49:03
In reply to Re: feel finished GGG oh, also, posted by jono_in_adelaide on December 27, 2012, at 16:42:33
> If you havent tried clomipramine 150mg per day plus a benzo, try it!
>
> Clomipramine has more side effects than the SSRI's, but it is generaly the gold standard for OCD, is very effective in depression, and also is good for anxietyJono & Scott,
I feel like this could be helpful for me, too. (Sorry to make this about me, but I'm very curious.) I need something that obliterates (ok, rids) the depression and anxiety. I mentioned in a thread below that I'm contemplating Nardil (or an MAOI) cause nothing's cutting it and I've been back in bed without showering for the past week again.
OR, are there other SRIs that could be more effective than Lexapro? I've been on it forever and like how clean it is with serotonin and that it's weight neutral. What's with Viibryd and Pristiq?
I tend to get a lot more anxious and activated from meds that work on norepinephrine as well as Wellburin.
Thanks.
-b
Posted by SLS on December 27, 2012, at 20:50:54
In reply to Re: feel finished » SLS, posted by schleprock on December 27, 2012, at 18:54:42
> Thanks SLS. Found this article:
>
> http://www.ehow.com/facts_5695241_alpha-blocker-vs_-beta-blocker.html
>
> So basically one class lowers norepinephrine while one lowers epinephrine. The article manages to make the side-effects of Alphas sound much worse than Betas. Atenolol (not over 12.5 mg) I know I've been able to tolerate. Not sure what to do...
>
> Do you also believe bet blockers to be an effective adjunct treatment for anxiety\depression, or only alpha blockers?
Beta blockers seem to help some people with anxiety, but it is not as effective for PTSD and depression as is prazosin.As an analogy, think of beta blockers as working on norepinephrine and prazosin as working on serotonin and dopamine. They are totally different in the way they act in the brain.
Prazosin is generally benign. If beta blockers have not worked magic for you, I would consider trying prazosin. To minimize startup side effects, begin at 1 mg at night. You might feel somewhat dizzy and somnolent in the beginning, but these things usually disappear entirely. Studies using prazosin for PTSD with depression have used, on the average, 6 - 12 mg/day. You need to take prazosin 2 - 3 times a day. Right now, aside from the libido thing, I would never know that I was taking prazosin.
- Scott
Posted by jono_in_adelaide on December 27, 2012, at 21:22:30
In reply to @ jono + SLS, posted by brynb on December 27, 2012, at 20:49:03
Clomipramine would certainly be worth trying, as would nardil, with or without a benzo. hard to say which would be best as its so individual. neither is weight neutral, but given your current condition, I think you need an effective drug, regardless of weight gain etc.
Speak to your psych and see which one s/he thisnk would be best, its obvious that what you're doing now isnt cutting it.
Posted by Phillipa on December 27, 2012, at 21:51:08
In reply to Re: @ jono + SLS - brynb, posted by jono_in_adelaide on December 27, 2012, at 21:22:30
Bryn Jono is right it's getting this bad? Phillipa
Posted by brynb on December 27, 2012, at 23:35:40
In reply to Re: @ jono + SLS - brynb, posted by Phillipa on December 27, 2012, at 21:51:08
yes, it's bad--I've spent the week in bed. I can't even cry. I'm taking my Librium all day long to sleep. to make things worse, I lost my unemployment but gained two writing jobs, only I can't get myself to work on them even though I don't need to leave my apartment to do them!
I'm also pms-ing, which sends me into a tailspin. I don't want to quit & I have hope that things will get better but it seems so far away. I'm trying so hard to keep a brave face for my family but clearly when I'm holed up sleeping & not showering, it's a hard to maintain. my pdoc hasn't called me back & I think I'm going to embark upon the arduous task of finding someone new.
what's worse is I truly believe we create our own realities & that I could really push through this right now, BUT, I just don't have it in me at the moment. I have no strength right now.
Posted by g_g_g_unit on December 28, 2012, at 6:44:44
In reply to Re: feel finished - GGG » g_g_g_unit, posted by SLS on December 27, 2012, at 20:29:37
> > Nardil helped too, but the insomnia was terrible and it made me a little hypomanic.
>
> Perhaps you could combine Nardil with a stimulant and Klonopin. Nardil is the ideal MAOI for your depression and anxiety. The stimulant would help with depression and ADD. The Klonopin would help with anxiety, insomnia, and possibly mania. The mania from Nardil usually starts early in treatment and is self-limiting. Trileptal can be used as a mood stabilizer if necessary. If insomnia is an obstacle to feeling great on Nardil, then it is incumbent on your doctor to treat that insomnia aggressively as if it were your primary illness. Failure is not an option. Use Halcion along with another benzodiazepine if you have to. Perhaps 25 - 50 mg of Seroquel? Find a way.
>
> If I recall, you have problems with antipsychotics? Saphris and Latuda are interesting drugs. Saphris can actually be energizing along with being anxiolytic.
>
>
> - ScottThanks for the suggestions. Nardil + d-amphetamine is something I would love to try, but I have very little hope of having it prescribed. As I've mentioned before, I e-mailed a self-described specialist in treatment-resistant depression who claimed he was aware of studies indicating the usefulness of the combination, but considered it far too dangerous to utilize in practice.
There is a "professorial" unit at the hospital I would be going to, so I don't know if they would be more amenable to exotic treatment ideas, but the psychiatrist I contacted was also a professor at the same university with ties to the clinic.
As far as anti-psychotics go, Seroquel induced akathisia at the lowest possible doses (prescribed for sleep), Zyprexa and Risperdal increased anxiety.
Posted by g_g_g_unit on December 28, 2012, at 6:47:46
In reply to Re: feel finished - GGG, posted by jono_in_adelaide on December 27, 2012, at 20:37:44
> In that case, it looks like your best options are either Nardil + a mood stabaliser and maybe doxepin or a benzo for sleep, or Parnate (perhaps in a higher doseage) plus a benzo for anxiety.
>
> I'd decide which one you prefered, and push the envelope so far as dose and combinations goI suppose it would ultimately depend on how far the psychiatrist in question would be willing to push things. Liberal psychiatrists seem to be a rarity in Australia.
>
> What exactly do you mean by "a bit hypomanic", just more energy than usual, or somthing more serious?More energy, a little euphoric, acted slightly out-of-character (reconciled with brother I hadn't spoken to for 4 years, though perhaps that's a good thing?) ..
>
> Parnate (perhaps at 80mg) plus a long acting benzo such as Valium
>
> or
>
> Nardil plus a mood stabaliser (your guess is as good as mine here) plus either a benzo or doxepin for sleep
>My only worry is Nardil would have no benefit on ADD (most ADD patients seem to report in exacerbating their attentional difficulties).
> Dont give up, keep tryimg, keep hope
>
>
> > > Sorry if my comments about side effects came across as me having a dig, it wasnt intended that way..... its just that you often get the side effects before you get any of the improvement, and its easy to say "this stiff is crap" and stop it.
> > >
> > > I'd consider either a high dose SSRI (Sertaline 200mg/day) or Effexor 300mg plus mirtazapine to help with the depression, OCD and anxiety, with or without a benzo
> > >
> > > other options are the parnate + nortriptyline i mentioned earlier with a benzo, or Nardil plus nortriptyline and a benzo, or a high dose SSRI with bupropion and a benzo, all of course depending on what you've tried in the past
> > >
> > > Which drug or combination of drugs has come closest to giving you relief?
> >
> > Unfortunately, I found nortriptyline stimulating rather than sedating, so don't think I'd be able to tolerate it with an MAOI. Same thing with clomipramine -- it produced a lot of akathisia and agitation and isn't something I'd be desperate to revisit.
> >
> > As I said, the closest I came to relief was on Parnate, which helped my depressive symptoms (anergia, lack of motivation, rejection sensitivity) and, to a degree, my ADD (which no other AD has done), but which didn't relieve my anxiety, and in fact may have increased it. I was only permitted to try up to 60mg, which was the minimum dose necessary for an anti-depressant response. Nardil helped too, but the insomnia was terrible and it made me a little hypomanic.
> >
> >
> >
>
>
Posted by SLS on December 28, 2012, at 7:11:39
In reply to Re: feel finished - GGG » SLS, posted by g_g_g_unit on December 28, 2012, at 6:44:44
> > > Nardil helped too, but the insomnia was terrible and it made me a little hypomanic.
> >
> > Perhaps you could combine Nardil with a stimulant and Klonopin. Nardil is the ideal MAOI for your depression and anxiety. The stimulant would help with depression and ADD. The Klonopin would help with anxiety, insomnia, and possibly mania. The mania from Nardil usually starts early in treatment and is self-limiting. Trileptal can be used as a mood stabilizer if necessary. If insomnia is an obstacle to feeling great on Nardil, then it is incumbent on your doctor to treat that insomnia aggressively as if it were your primary illness. Failure is not an option. Use Halcion along with another benzodiazepine if you have to. Perhaps 25 - 50 mg of Seroquel? Find a way.
> >
> > If I recall, you have problems with antipsychotics? Saphris and Latuda are interesting drugs. Saphris can actually be energizing along with being anxiolytic.
> >
> >
> > - Scott
>
> Thanks for the suggestions. Nardil + d-amphetamine is something I would love to try, but I have very little hope of having it prescribed. As I've mentioned before, I e-mailed a self-described specialist in treatment-resistant depression who claimed he was aware of studies indicating the usefulness of the combination, but considered it far too dangerous to utilize in practice.Perhaps he needs more practice?
Have you found and printed material indicating the safety of such combinations to show your doctors? Being on Parnate + TCA + stimulants hasn't killed me. I wish I had the name of a good doctor for you. Where do you live? Which universities are close to you? I might be able to come up with some names for you. Perhaps you can arrange for a consultation with another doctor who would then have a conversation with your current doctor?
Do you have the antipsychotic, asenapine (Saphris), there?
- Scott
Posted by g_g_g_unit on December 28, 2012, at 7:30:18
In reply to Re: feel finished - GGG » g_g_g_unit, posted by SLS on December 28, 2012, at 7:11:39
>
> Perhaps he needs more practice?I imagine so. I remember a comment from Chairman_MAO on here about how European-trained psychiatrists are far more willing to take risks, and that was the only way he managed to get an MAOI + stimulant prescribed. There is a Russian woman I saw when I first moved here who seemed extremely competent and well-researched, but she was so aggressive and confrontational that I found her impossible to work with. I've always imagined that she might be willing to try the combination, though I'm far too scared to return to her (I just left halfway through treatment and never returned).
>
> Have you found and printed material indicating the safety of such combinations to show your doctors?No, I didn't bother. It took an incredible amount of convincing to get my psychiatrist to exceed the daily threshold of 30mg of Parnate per day permitted here, so I doubt he would add a psychostimulant into the mix (plus Parnate was stimulating enough). That said, if I go inpatient, he won't be treating me.
>Being on Parnate + TCA + stimulants hasn't killed >me. I wish I had the name of a good doctor for >you. Where do you live? Which universities are >close to you? I might be able to come up with >some names for you. Perhaps you can arrange for a >consultation with another doctor who would then >have a conversation with your current doctor?
I live in Melbourne, Australia. We have Melbourne University, Monash University and Deaken University here. If you could come up with any names, that would be great. I have done my best -- emailing heads of departments etc. -- though typically I don't receive a response.
My psychiatrist did, at one point, refer me to a professor he frequently utilizes for second opinions. The doctor in question recommended a high dose SSRI + high dose anti-psychotic (despite my lackluster response to both) and said I couldn't possibly have ADD (though I don't know how he discerned that after a single one-hour interview). He also recommended ECT over MAOIs. I kind of lost faith in other specialists after that. My own psychiatrist has been extremely accommodating a pleasure to work with, but doesn't, I think, have the research background to toy with more exotic combinations. He tends to treat fairly straightforward ADHD cases, from my understanding. I stick with him for his patience and goodwill and unparalleled bedside manner.
>
> Do you have the antipsychotic, asenapine (Saphris), there?
>A cursory google search seems to suggest we do ..
>
> - ScottThanks, as always.
Posted by g_g_g_unit on December 29, 2012, at 1:41:32
In reply to Re: feel finished - GGG » g_g_g_unit, posted by SLS on December 28, 2012, at 7:11:39
Hey SLS, I'm not sure whether you'll be able to answer this or not, but I'm not currently on any meds -- and my psychiatrist only returns from vacation in three weeks -- so I kind of have some room to experiment.
Anyway, I have a bunch of Memantine lying around. I tried it in doses varying from 2.5 - 15mg, but found that it increased my anxiety/OCD and caused agitation.
I read a post from phiddipus stating that 5-HT3 affinity increases at 20mg, and thus it enhances GABA activity and becomes more anxiolytic. I can't find anything that confirms that and haven't read of anyone noticing a subjective difference in effect with different doses -- in fact, my adverse reaction seems to be quite out of the ordinary. Overall, from studies etc., it seems to be a really well-tolerated drug, which is why my response confused me.
That said, do you think it would be worth experimenting with taking 20mg a day for a little while and seeing how I respond? Do you know of many people who have experience with the drug and possibly responded better at a higher doses? Is it possible to speculate whether the increased NMDA antagonism etc. could possibly be more beneficial?
It's hard to know whether attempting to self-medicate when feeling so out-of-control etc. might be worse for me -- and whether it might be better to just secede control over to the hospital -- but I also thought I might get lucky (for once) and didn't have anything to lose, other than some transient discomfort.
Posted by SLS on December 29, 2012, at 7:44:17
In reply to question for SLS » SLS, posted by g_g_g_unit on December 29, 2012, at 1:41:32
I spent about an hour researching 5-HT3 receptors and am now more confused now than before I started. I had begun to write a long-winded explanation, but quickly found that the subject would require more study to offer any meaningful understanding at this time. 5-HT3 receptor function and dynamics are complex and variable, and depends upon the neuroal circuits they appear in and the species being studied.
As far as I can see, memantine acts as an antagonist of serotonin 5-HT3 receptors at concentrations comparable to those producing NMDA antagonism. However, any small difference in the numbers observed in the lab might translate to a significant difference in therapeutic dosage. Phiddipus might be right. I can't be sure. However, because memantine can help with OCD, I think this might be reason enough for you to try it again. I don't think you can evaluate memantine until you can establish a dosage of 20 mg/day. If anxiety prevents you from doing this, I would discontinue it. From what I gather, antagonism of 5-HT3 receptors in the amygdala can lead to a reduction in the activity of GABA neurons there. This might account for the anxiety you experience. It might dissipate with continued treatment, though, as I believe the presynaptic membrane becomes desensitized quickly. If it doesn't dissipate, this may be a clue into what is going on with you - amygdala hyperactivity. How do you react to Neurontin (gabapentin)? Perhaps prazosin would help.
What if you were to attack the ADD, anxiety, and OCD first? Do you think the depression would resolve?
As always, it would be nice to have your doctor support you during a treatment experiment. However, if it were me, I would probably try the memantine again and push the dosage to 20 mg/day or higher. Take things one step at a time, though. See if the startup anxiety is tolerable using the recommended titration schedule. If the inceased anxiety persists for two weeks or is otherwise intolerable, I would stop taking it. Your amygdala might be hyperactive. If you do manage to establish a dosage of 20 mg/day without adverse effects, you might as well leave it on board as you try adding Nardil, Viibryd, or clomipramine.
Nardil + Focalin + memantine might be interesting.
Recommended NAMENDA dosing schedule:Week 1: Starting on Day 1. Take one 5 mg tablet in the morning, each day.
Week 2: Starting on Day 8. Take one 5 mg tablet in the morning and one 5 mg tablet at night, each day.
Week 3: Starting on Day 15. Take one 10 mg tablet in the morning and one 5 mg tablet at night, each day.
Week 4: Starting on Day 22. Take one 10 mg tablet in the morning and one 10 mg tablet at night, each day.
- Scott
Posted by g_g_g_unit on December 29, 2012, at 21:46:10
In reply to Re: question for SLS » g_g_g_unit, posted by SLS on December 29, 2012, at 7:44:17
Thanks so much for your reply Scott.
For the record, I *did* recently try Memantine in a dose range from 2.5mg-15mg and only experienced an increase in anxiety and agitation. At 10mg, and again 15mg, I gave each dose two weeks to adjust, but the increased anxiety never dissipated, which is what forced me to discontinue.
I thought perhaps that 20mg might yield some alternate effects, so was considering just starting directly at 20mg without titrating, though if I reacted badly to lower doses, perhaps it isn't worth my time?
> I spent about an hour researching 5-HT3 receptors and am now more confused now than before I started. I had begun to write a long-winded explanation, but quickly found that the subject would require more study to offer any meaningful understanding at this time. 5-HT3 receptor function and dynamics are complex and variable, and depends upon the neuroal circuits they appear in and the species being studied.
>
> As far as I can see, memantine acts as an antagonist of serotonin 5-HT3 receptors at concentrations comparable to those producing NMDA antagonism. However, any small difference in the numbers observed in the lab might translate to a significant difference in therapeutic dosage. Phiddipus might be right. I can't be sure. However, because memantine can help with OCD, I think this might be reason enough for you to try it again. I don't think you can evaluate memantine until you can establish a dosage of 20 mg/day. If anxiety prevents you from doing this, I would discontinue it. From what I gather, antagonism of 5-HT3 receptors in the amygdala can lead to a reduction in the activity of GABA neurons there. This might account for the anxiety you experience. It might dissipate with continued treatment, though, as I believe the presynaptic membrane becomes desensitized quickly. If it doesn't dissipate, this may be a clue into what is going on with you - amygdala hyperactivity. How do you react to Neurontin (gabapentin)? Perhaps prazosin would help.
>
> What if you were to attack the ADD, anxiety, and OCD first? Do you think the depression would resolve?
>
> As always, it would be nice to have your doctor support you during a treatment experiment. However, if it were me, I would probably try the memantine again and push the dosage to 20 mg/day or higher. Take things one step at a time, though. See if the startup anxiety is tolerable using the recommended titration schedule. If the inceased anxiety persists for two weeks or is otherwise intolerable, I would stop taking it. Your amygdala might be hyperactive. If you do manage to establish a dosage of 20 mg/day without adverse effects, you might as well leave it on board as you try adding Nardil, Viibryd, or clomipramine.
>
> Nardil + Focalin + memantine might be interesting.
>
>
> Recommended NAMENDA dosing schedule:
>
> Week 1: Starting on Day 1. Take one 5 mg tablet in the morning, each day.
>
> Week 2: Starting on Day 8. Take one 5 mg tablet in the morning and one 5 mg tablet at night, each day.
>
> Week 3: Starting on Day 15. Take one 10 mg tablet in the morning and one 5 mg tablet at night, each day.
>
> Week 4: Starting on Day 22. Take one 10 mg tablet in the morning and one 10 mg tablet at night, each day.
>
>
> - Scott
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