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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 19 of 19. This is the beginning of the thread.
Posted by Snell on January 11, 2014, at 7:07:49
Hi, everyone. I looked for an existing thread to hook this to but could not find one.
Ths short story is after trying everything except TCAs other than desipramine I forced my shrink to prescribe Parnate. I take 60 mg/d. It only works when augmented with an SGA (currently using Fanapt). I have the typical sleep fragmentation. I'm not in abyss-mode but I'm so, so sad--it's like the Parnate facilitates the movement of sadness and desperation through me, so I cry all the time. Hell, I was watching reruns of "Friends" and crying at *those.*
While I am somewhat preserved from total anhedonia I have almost complete anergia. I cannot do anything except surf the web and go to doctor's appointments. The government provides a "homemaker" to come for two hours per week and that is a godsend--having her here helps to motivate me to clean alongside her.
The pdoc and therapist have prescribed a dog (an "emotional support animal") to help with my loneliness and isolation, which is crushing.
So I take the 60 mg Parnate, 8 mg Fanapt, 150 mg lamotrigine, and 4 mg clonazepam. I would dearly love to go back on Adderall but it's contraindicated with Parnate (though many pdocs use it) but it makes my blood pressure soar.
We are looking into Provigil (modafinil) as a means to prevent the absolute necessity of taking a three-hour nap every afternoon.
My pdoc mentioned marijuana, which is medically legal in Massachusetts, my home state. Maybe ... in greater than moderate doses it takes away my motivation even more, but in low doses it might help with the anxiety and the tears.
Could I raise the lamotrigine? Sometimes switching the atypical works for a bit--I've also had success with Seroquel, Latuda, and Zyprexa. The problem is that Seroquel and Zyprexa make me eat like a fiend.
Ideas, ideas?
Posted by Phillipa on January 11, 2014, at 9:28:04
In reply to Desperation -- even with (whoo) Parnate, posted by Snell on January 11, 2014, at 7:07:49
I'm sorry I don't have an answer but was struck by the fact that your doctor suggested marijuana. So legal in MA now too? Phillipa
Posted by bleauberry on January 11, 2014, at 9:40:07
In reply to Desperation -- even with (whoo) Parnate, posted by Snell on January 11, 2014, at 7:07:49
I'm so sorry Snell. What a hard war. You have extraordinary strength and endurance and you are a fantastic special person for that!
When MAOIs fall short, it seems like the end of the road? Trapped? Scary? Yeah. I think we all hit that wall at some point. Multiple times for some of us.
Do you believe in the Bible? Even if you don't....talk to this imaginary guy named Jesus, challenge Him that if He is real, show it, and be authentic about it. I've never seen the miracles of the Old Testament occur in present day, but strange things can happen.....things people would call "good luck", "good timing", "coincidence"....Jesus is real, is alive, and at your heart felt request will take over the steering wheel for you. He wants to actually. Waiting on you. If you are a Jesus believer, keep talking to Him. He rewards the faithful, those who believe even though they have not seen.
I say that because I believe it and have seen it multiple times, enough times that I could no longer shrug it off as imagination or nonsense.
There is something great and grand in your sufffering. What is it? There is a purpose. It is not punishment. What is the purpose in all this evil? What good could possibly come out of it all. How could God take such badness Satan threw in our path, and somehow transform that to good? Well, it happens all the time. You may already know what it is, you maybe don't know what it is, but through all this crap you will be a huge, unique, and special blessing, to other people. Your strength and endurance alone are an inspiration to others who may be ready to give up and die.
I don't know about add-ons. I mean, you are apparently already aware of what your choices are.
Here's what happened when I tried Parnate. At the proper doses, it made me feel exactly like you described. At lower doses, I actually felt better. Even though I do not strongly believe your dose is too high, it could be. Too high of a dose of any of our meds can and will make symptoms worse. Just a random thought to mull over.
The loneliness and isolation. Yeah, sucks. I have found only one way out of that, and it is work. It doesn't just happen. With a treatment that works good, yeah, it can happen by itself. But in a treatment that is falling short, it can be tackled but it takes purposful forceful work and time.
Here is an example. Patient XYZ just got out of the hospital. ECT failed. Thinking about suicide. Dragged into a church service. The rock band was pretty good. Almost felt goose bumps in the midst of all the tears. The Pastor's message was ok, didn't resonate very well due to the depression, and it was hard to concentrate. Felt so damn lonely with all these apparently happy well-to-do people sitting around. This happens again the next Sunday, and the next, and the next. Somewhere along the line you are invited to a picnic or something. Oh no! The last thing you want to do! Well, you suck it up, take a deep breath, another one if needed, and you go. It isn't fun because everyone else is having fun but you are not. You feel so lonely. And time goes on like this. A few months into, something is changing. You actually feel a distant connection with someone in that church. You actually were looking forward to asking a particular person a question or talking to them about something. The shell around you is cracking, the real you is trying to get out and see sunshine again. All the purposeful forceful activity is doing that. It is actually retraining the brain receptors, genes, and nerve endings, on what you want them to do. Now, the same MAOI, well, it's not working as bad as it used to, not great, but it is not as dark as it used to be. Something has changed. The more you keep going, the more promise and progress there is.
Stay at home, none of that happens. We have at least the comfort of our own solitary comfort zone...the dungeon...but that's it. The brain has absolutely nothing to zap it, spank it, slap it, steer it, guide it, nothing. It will continue to deteriorate unless it gets outside stimulation. That's the hard part. Simply thinking about going out the front door is a monumental task, right? It is. But in reality, it is only as difficult as putting one foot in front of the other, then direct the other foot forward, then back to the other foot. The mind does not have to play. The feet do the work. They don't care if you are depressed and they will walk where you point them no matter. So it's really a matter of instructing the feet to go that way, and depression be damned.
I look at depression as my enemy. Satan in emotional form that I can feel. I am NOT going to just let my enemy have his way with me. I AM going to fight back. I mean, me, not my drugs, me, I am going to fight back, depressed as hell, you aint gonna beat me without a fight! I'm going out that door because you don't want me to! Screw you enemy, I'm going to the mall, I'm going to church, I'm going to the park, I'm going to do anything besides this couch! It's gonna feel bad and suck, but each time I do, I WIN! Lots of little battles, win them.
I've never had behavioral psychology, but it has to do with retraining the brain. I guess my above example is sort of similar. A Neurologist once explained to me how our emotions, just like drugs, shape the way our receptors and messengers operate. Drugs and purposeful activities together do that better than either alone. imo. Most of empirical and anecdotal evidence supports that.
Medical marijuana is usually dosed in small controlled doses. For example, 2 puffs in am, 2 puffs pm, 2 puffs evening, something like that. Medical marijuana MD offices sometimes have instructional videos. In those videos they make it clear that if the right amount of mj is consumed, symptoms improve. Low doses are good for motivation and wanna-do-something, and actually even have a little pleasure doing it! Washing the sink full of dishes? Well, yeah! Haven't felt like doing that in months! But on the other hand, doses that are too high will worsen symptoms. For each patient, it is important to experiment to find the right dose size, the right timing of the doses, and the right method of consumption. Pipes, papers, tinctures, culinary....they have different effects. MJ MDs usually have a lot of information to help guide your decisions.
Personally I would be a bit cautious with MJ because while I do believe it can help you in the ways you want it to, actually maybe better than any other prescription I can think of, there is not enough known on its mechanisms to be able to definitely say it is, or is not, safe with Parnate. Does it dramatically increase serotonin like some people have claimed? Does it boost NE and DA as claimed? Since your doctor is ok with it, I'm thinking then it probably is ok, but with an extra dose of caution while starting up.
I know two people personally who have a long history of decades of depression and failed treatments and are now doing quite well, not cured, never will be, but quite well on just marijuana and no more drugs! Marijuana alone did for them what all those decades of prescriptions did not. For one of those people, it even included ECT. Marijuana ended up being remarkably more effective than ECT in that person.
Forget the dog thing. You need PEOPLE in you life, not dogs. The forced thing I was talking about. I don't think a dog is going to take you to a good outcome, just the same outcome except with a 4 footed friend. The interaction of the spirits of other humans needs to be interjected into your life. Probably by force. That's ok. The world's greatest success stories were born from intense pain and work. They would not have been great otherwise.
Somebody told me this years ago, I did not believe, but remembered it. They said the day would come when God would give me bumper crops following the years of locusts ravaging my crops. That came true. When it was said, all I saw was a cold dark dungeon.. What they said was, impossible. But alas, it was not impossible. It was the Word of God and it happened. And I had nothing to do with it! Somebody else prayed that for me. Again, the reason we need people instead of a dog.....people can pray for you, even when you can't pray for yourself. Ask them to. I used to tell people, "I am in such bad shape, wow, could you please just pray for me?" Simple as that. God does the rest. Years later when things are considerably better, you might look back and realize it was God directing the doctor's decisions and it was God orchestrating every little detail the whole time. But without prayers, not likely to happen. He is waiting to be asked because He does not force Himself upon someone. It is their will to invite Him or not. We are not puppets on a string.
I really want to give some medication advice, but I'm stuck. I almost want to say the parnate itself, or the lamictal itself, or likely the klonopin, are the ones causing the emptiness, not the depression itself causing that. Hard to tell. We get so far down the road on our meds it's hard to back up and see what's really going on. I can say, anyone I've ever known that took 4mg or more of klonopin had bad depression as one of their complaints, a certain version of depression a bit different than the one they were treating, a darker one, a more hopeless trapped one. So I dunno, I think you'll have to weave thru the maze with your doc and try to figure out the next move. I am actually more suspicious of the meds themselves than I am of your actual underlying depression. Could be wrong.
Marijuana medically prescribed and dosed low. Adderall. On the table at this very moment those look like good choices to me. Hopefully someone else here can chime in with some creative ideas to add to the discussion.
> Hi, everyone. I looked for an existing thread to hook this to but could not find one.
>
> Ths short story is after trying everything except TCAs other than desipramine I forced my shrink to prescribe Parnate. I take 60 mg/d. It only works when augmented with an SGA (currently using Fanapt). I have the typical sleep fragmentation. I'm not in abyss-mode but I'm so, so sad--it's like the Parnate facilitates the movement of sadness and desperation through me, so I cry all the time. Hell, I was watching reruns of "Friends" and crying at *those.*
>
> While I am somewhat preserved from total anhedonia I have almost complete anergia. I cannot do anything except surf the web and go to doctor's appointments. The government provides a "homemaker" to come for two hours per week and that is a godsend--having her here helps to motivate me to clean alongside her.
>
> The pdoc and therapist have prescribed a dog (an "emotional support animal") to help with my loneliness and isolation, which is crushing.
>
> So I take the 60 mg Parnate, 8 mg Fanapt, 150 mg lamotrigine, and 4 mg clonazepam. I would dearly love to go back on Adderall but it's contraindicated with Parnate (though many pdocs use it) but it makes my blood pressure soar.
>
> We are looking into Provigil (modafinil) as a means to prevent the absolute necessity of taking a three-hour nap every afternoon.
>
> My pdoc mentioned marijuana, which is medically legal in Massachusetts, my home state. Maybe ... in greater than moderate doses it takes away my motivation even more, but in low doses it might help with the anxiety and the tears.
>
> Could I raise the lamotrigine? Sometimes switching the atypical works for a bit--I've also had success with Seroquel, Latuda, and Zyprexa. The problem is that Seroquel and Zyprexa make me eat like a fiend.
>
> Ideas, ideas?
Posted by vbs on January 11, 2014, at 10:04:08
In reply to Re: Desperation -- even with (whoo) Parnate, posted by bleauberry on January 11, 2014, at 9:40:07
bleauberry, your post struck a chord with me. Overcoming depression takes more than just prescription drugs. I think too many of us rely on the establishment of psychiatry. Put one foot in front of the other despite the desire to remain stagnant in one's comfort zone.
Thank you for your thoughtful post. :-)
Posted by linkadge on January 11, 2014, at 10:57:45
In reply to Desperation -- even with (whoo) Parnate, posted by Snell on January 11, 2014, at 7:07:49
Have you ever tried a sleep enhancing antidepressant only (amitriptyline, remeron, trazodone, surmonitil etc.)?
parnate can definitely fragment sleep (I could only sleep from 1-6 on the stuff)
lack of sleep can increase emotionality
Linkadge
Posted by bleauberry on January 11, 2014, at 11:41:14
In reply to Re: Desperation -- even with (whoo) Parnate » bleauberry, posted by vbs on January 11, 2014, at 10:04:08
Thank you VBS. I would like to take credit for the idea but it is not mine. For sure though, it works toward good outcomes.
The whole process of coming to realize it would take more than a drug molecule to fix me was about a 3 year slow discovery process, following 20 years of faithful med trials and failures.For most of my time here at psychobabble, 20-25 years, I too was in the frame of mind that totally trusts the doctor, the med, and the fact that psychiatry is the only way to deal with mood issues. Many years later, I realized only a few doctors can be trusted, meds never trusted for longterm anyway, and that the psychiatric toolbox is too limited considering the complexity and scope of human physiology.
Your open mind is going to save your life. The locusts will one day be gone and your crops will be bountiful, so bountiful in fact that they will more than make up for all the destruction.
> bleauberry, your post struck a chord with me. Overcoming depression takes more than just prescription drugs. I think too many of us rely on the establishment of psychiatry. Put one foot in front of the other despite the desire to remain stagnant in one's comfort zone.
>
> Thank you for your thoughtful post. :-)
Posted by Willful on January 11, 2014, at 11:54:51
In reply to Desperation -- even with (whoo) Parnate, posted by Snell on January 11, 2014, at 7:07:49
It could be that your dose is a bit too low. I was extremely exhausted at 60 mg of parnate, so I took more, which somewhat relieved the sleepiness, although not completely. It did have fairly significant blunting and mental blurring effects on me-- but I had a very atypical response on many levels.
You could certainly add modafinil, which I also used. and which was definitely helpful.
For me, Parnate wasn't a very satisfactory AD, but I"ve done well with another maoi, Emsam, which I find doesn't disrupt my sleep as much (it does a bit) and is activating, as is parnate. If your insurance covers it, and the parnate doesn't work out, even with modafinil, etc, I would definitely recommend it.
I do think if Parnate is making you that sad, you need to modify the dose, or use some additional meds to improve sleep. That might really help-- along with the modafinil.
I'm sorry to hear that you're struggling so much, and hope that you'll find a combination of meds that gives you what you need.
Willful
Posted by johnLA on January 11, 2014, at 19:38:57
In reply to Desperation -- even with (whoo) Parnate, posted by Snell on January 11, 2014, at 7:07:49
hi snell-
i can comment on the marijuana bit a bit. ;)
you can also search the archives for my trial diary on using it.
my pdoc at the time suggested it. i was quite surprised. the key is the right strain and to use as little as possible. i did help me sleep and reduced my klonopin usage.
but, in the end i ended-up smoking too much and just didn't feel right. so, i ditched it.
again, according to my pdoc at the time she had patients that were helped by it. mostly for anxiety and sleep though.
john
Posted by jono_in_adelaide on January 12, 2014, at 4:09:38
In reply to Desperation -- even with (whoo) Parnate, posted by Snell on January 11, 2014, at 7:07:49
You could add a TCA (Nortriptyline for example, 75-150mg an hour before bedtime) to your cocktail, it would help sleep, and might well increase your energy and reduce the depression
Posted by Dr. Bob on January 16, 2014, at 23:10:38
In reply to Re: Desperation -- even with (whoo) Parnate, posted by bleauberry on January 11, 2014, at 11:41:14
> my time here at psychobabble, 20-25 years
20-25 years means you joined between 1989 and 1994?
Bob
Posted by Snell on January 22, 2014, at 7:11:05
In reply to Re: Desperation -- even with (whoo) Parnate » bleauberry, posted by vbs on January 11, 2014, at 10:04:08
Yes:
> Thank you for your thoughtful post. :-)When I was in my twenties, I was a Zen Buddhist, as much as you can "be" a Zen Buddhist. I went to the temple twice a week to do meditation three hours at a time. I found that Zen Buddhism (ZB) offered the same answers to the questions that other religions did, yet was more in keeping with my beliefs.
It helped, somewhat. My depression wasn't as bad then, but the basic ideas of tolerance, even welcome, of suffering did end up reducing that suffering.
When I was in graduate school in California, where the weather is wonderful, I used to run. I was extremely anxious then--anxiety was my first psychiatric symptom, as I think is the case with many people. I ran and ran; it made me feel a little better. But not much, and not for long. I was running about eight miles every other day and was amazingly fit but I was still extraordinarily anxious.
I think of these two things when people suggest religion or exercise. The only things that have *really* treated my depression have been medicine and psychotherapy. I think the emotional support animal--the dog--will help me feel less lonely and isolated and more connected.
I very much appreciate your writing
Posted by Snell on January 22, 2014, at 7:15:23
In reply to Re: Desperation -- even with (whoo) Parnate, posted by linkadge on January 11, 2014, at 10:57:45
> Have you ever tried a sleep enhancing antidepressant only (amitriptyline, remeron, trazodone, surmonitil etc.)?
>
> parnate can definitely fragment sleep (I could only sleep from 1-6 on the stuff)
>
> lack of sleep can increase emotionality
>
> LinkadgeYes, I've taken both Remeron and trazodone, both alone and in combination with others. Thank you for reminding me of this. It's just that with Parnate, my pdoc is unwilling to prescribe any other antidepressants. Some of the SGAs are sleep-enhancing, specifically Zyprexa and Seroquel. I would love to have access to Seroquel but my pdoc and I made a contract for me never to take it again because it makes me stuff sugar and carbohydrates into my face. I'm thirty pounds overweight (I'm six feet tall and weigh 230 lbs) and that is all due to the Seroquel-gorging. The Zyprexa *does* help for sleep.
>
>
Posted by Snell on January 22, 2014, at 7:19:10
In reply to Re: Desperation -- even with (whoo) Parnate » Snell, posted by Willful on January 11, 2014, at 11:54:51
I tried going up to 80 mg/d for a week with no effect. Do you think higher than that?
What is that last drug in your signature?
Yes, modafinil. My insurance is extremely loath to pay for modafinil unless it's for narcolepsy. I mean, they want a polysomnogram *showing* narcolepsy before they will authorize it. But my pdoc is trying to make the case that--look, he's exhausted all the time, he can't take amphetamines, he's taken modafinil before with good effect (I have, when I've had other insurance). So we'll see.
Posted by Snell on January 22, 2014, at 7:23:09
In reply to Re: Desperation -- even with (whoo) Parnate » Snell, posted by johnLA on January 11, 2014, at 19:38:57
> my pdoc at the time suggested it. i was quite surprised. the key is the right strain and to use as little as possible. i did help me sleep and reduced my klonopin usage.
>
> but, in the end i ended-up smoking too much and just didn't feel right. so, i ditched it.
>
> again, according to my pdoc at the time she had patients that were helped by it. mostly for
anxiety and sleep though.
>I think that would be exactly my response. At low doses (someone mentioned only two puffs TID) I think it would help anxiety and sleep. Any more than that and it would sap my motivation and make me depressed. I know; I used to smoke constantly. MJ is legal in my home state of Massachusetts (USA) but one must *buy* it, and I don't have the money to do that. They are working on a subsidy for people in my position.
Then there's always Marinol (dronabinol) pills, but oddly, after my pdoc recommended MJ, he backed off and said it wouldn't work. Sometimes he's inconsistent like that.
I *would* like to try the dronabinol at a very low dose just to see, but I don't think it's in the offing.
Posted by Snell on January 22, 2014, at 7:25:29
In reply to Re: time here » bleauberry, posted by Dr. Bob on January 16, 2014, at 23:10:38
Well, Dr. Bob, I remember becoming aware of this site when I was in graduate school, which would have been in 1996. So what's that--eighteen years for me.
> > my time here at psychobabble, 20-25 years
>
> 20-25 years means you joined between 1989 and 1994?
>
> Bob
Posted by Dr. Bob on January 23, 2014, at 2:34:54
In reply to Re: time here, posted by Snell on January 22, 2014, at 7:25:29
> Well, Dr. Bob, I remember becoming aware of this site when I was in graduate school, which would have been in 1996. So what's that--eighteen years for me.
Maybe it was something I did online before Psycho-Babble?
Bob
Posted by Willful on January 23, 2014, at 10:39:38
In reply to Willful's suggestion » Willful, posted by Snell on January 22, 2014, at 7:19:10
I took 100 mg but it really in retrospect, I really can't recommend it.
If you didn't feel any effect on 80, I doubt 100 will make a dramatic transformation.
Rilotek, or generic name rilozole, is a different class of drug-- it was originall for ALS, but it turned out not to help the ALS that much-- but to elevate the mood of sufferers.
Typical story of how anti-depressants are found.
I think it's an incredibly good drug-- but unfortunately, it's pretty expensive-- and not used that often as an adjunct to other drugs.
I would recommend trying it--if you can get it-- because it does help with energy and is also calming, and noticeably improves my mood, without emotional flatness.
My insurance just switched to Express Scripts, which I think is pretty awful-- Emsam is not on their formulary so I have to pay a lot more for it-- but it's still of course less expensive than the open market--. I"m waiting to see if they'll cover rilozule for depression-- or will refuse, because of the off-labelish use. I'm not toally optimistic.
But-- I do highly recommend it-- it really helped me.
Posted by Snell on January 24, 2014, at 10:08:38
In reply to Re: Willful's suggestion, posted by Willful on January 23, 2014, at 10:39:38
It sounds like a dopamine agonist, such as the drugs used for Parkinson's. I've heard of people taking Mirapex (pramipexole) and Requip (ropinirole) to augment. Is your drug in that family?
Posted by Willful on January 24, 2014, at 13:06:58
In reply to Re: Willful's suggestion / Dopamine agonist?, posted by Snell on January 24, 2014, at 10:08:38
It's not like any other AD but seems to have anti-depressant andaxiolytic effects as well--. So far its effects aren't really understood but are thought to be dependent on its glutamate antaonism.
From:
"Review of the Use of the Glutamate Antagonist Riluzole in Psychiatric Disorders and a Description of Recent Use in Childhood Obsessive-Compulsive Disorder" (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2958461/)~~~"Riluzole inhibits the release of glutamate at the presynaptic nerve cell terminus, most likely by blockade of voltage-gated sodium channels, and this effect may be achieved at low riluzole concentrations (demonstrated most recently by Urbani and Belluzzi 2000). It also likely reduces glutamate neurotransmitter vesicle fusion with the presynaptic cell membrane, either directly by opening voltage-gated calcium channels (Wang et al. 2004) or indirectly by altering G-proteinmediated signaling (Huang et al. 1997). Riluzole's effects on potassium channels have also been measured, but possibly not at clinically meaningful riluzole concentrations (Ahn et al. 2005; Mathie and Veale 2007).
Downstream effects of riluzole have been noted as well, but clinical significance remains unclear. These effects are stimulation of growth factor synthesis, including brain-derived neurotrophic factor (Fumagalli et al. 2006), and promotion of neuritogenesis, neurite branching, and neurite outgrowth (Shortland et al. 2006)."
This is the end of the thread.
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