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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 21 of 21. This is the beginning of the thread.
Posted by Anita on March 6, 1999, at 22:07:40
Anybody find a med good for atypical depression besides
Nardil, Parnate, Prozac, moclobemide, Marplan, Effexor, Wellbutrin, or stimulants?
Not much left, is there :-(
Posted by George O. on March 7, 1999, at 1:07:49
In reply to Atypical depression? already tried MAOIs & Prozac, posted by Anita on March 6, 1999, at 22:07:40
> Anybody find a med good for atypical depression besides
> Nardil, Parnate, Prozac, moclobemide, Marplan, Effexor, Wellbutrin, or stimulants?
> Not much left, is there :-(
>I had a similar experience, eventually couldn't even leave my bedroom for a year and my doc was doing nothing. To make a long story short, antidepressants often don't work because of problems with the receptor sites. Meds which tunes the receptors can drastically increase the effectiveness of antidepressants, I'm getting a strong boost from one which was previously a total washout. I'm taking Seroquel, a new atypical antipsychotic which is pretty easy to tolerate, as well as Buspar and several tricyclics, can't say my head is all that clear but I'm feeling great for the first time in years. Hope this is coherant, my night time meds are kicking in. George
Posted by Wayne R. on March 7, 1999, at 6:01:45
In reply to Yes , posted by George O. on March 7, 1999, at 1:07:49
I am not sure what you mean by atypical depression. If you mean you do not get satisfactory results with the ADs by themselves, then this may be worth a shot. I tried nearly every AD in the book over 30 years and nothing would stick. Recently we augmented an SSRI with Naltrexone and it has changed my life. I chose to augment Prozac but understand that any SSRI can be effective. Best wishes... Wayne
Posted by MA on March 7, 1999, at 11:34:46
In reply to Atypical depression..., posted by Wayne R. on March 7, 1999, at 6:01:45
> I am not sure what you mean by atypical depression. If you mean you do not get satisfactory results with the ADs by themselves, then this may be worth a shot. I tried nearly every AD in the book over 30 years and nothing would stick. Recently we augmented an SSRI with Naltrexone and it has changed my life. I chose to augment Prozac but understand that any SSRI can be effective. Best wishes... Wayne
Wayne, is there any information on why this wroks? I mentioned this to my doctor and he hadn't heard of Naltrexone used to augment SSRI's.
I have an atypical depression also, whatever that means, but most of the AD's except Marplan did not work for me. Although now I am on Paxil which worked briefly, then we added Wellbutrin to the Paxil and this combo seems pretty good. I may add the Wellbutrin to Prozac my next time around.
Why is your depression considered atypical?
Posted by Jim on March 7, 1999, at 14:54:50
In reply to Re: Atypical depression..., posted by MA on March 7, 1999, at 11:34:46
Hi--
Several people have asked what atypical depression
is:This is a frequently used term in psychiatry,
although there is some debate about it. As I
understand it, it refers to cases of depression
that present certain "atypical" features, such as:-- overeating (instead of no appetite)
-- oversleeping (instead of sleep trouble)
-- mood reactivity (can be temporarily cheered up)
-- worse in evening (instead of worse in morning)It's not required to have all these features to
be labelled considered "atypical", but more
than one makes it increasingly likely.For more (and better) information, see the
Harvard Health Letter article at this webpage:http://www.mentalhealth.com/mag1/p5h-dpat.html
-- Jim
Posted by Wayne R. on March 7, 1999, at 16:44:32
In reply to Re: Atypical depression..., posted by MA on March 7, 1999, at 11:34:46
> Wayne, is there any information on why this works? I mentioned this to my doctor and he hadn't heard of Naltrexone used to augment SSRI's.
>
I have attached one of the items that got me to insist on trying Naltrexone. I recently got a letter from Dr Dante noting that he has used it successfully with several hundred patients at this point. He stated that WHY it works is still not known...From: Dr. Lee Dante
Subject: Augmentation of clomipramine with naltrexoneI began using naltrexone clinically a number of years ago. I had long felt that the opiate system was a major player in depression but needed a way of intervening that didn't run the risk of inducing addiction. (Virtually all partial agonists have caused addiction problems and only naltrexone, the pure antagonist, has shown no addictive potential or significant morbidity after almost two decades of clinical use.) After twenty five years of seeing psychiatric patients I have had many patients referred to me who suffer from intractable depressions.
One woman in her twenties had been under my care for three years. She had been hospitalized three times before I got her. She had an eating disorder, had tried suicide, and had in the past done "delicate slicing". She had unremitting depression only weakly responsive to MAOIs, every TCA at therapeutic doses, ECT, fluoxetine, sertraline, and clomipramine. Trazodone, augmentation with lithium, and thyroid were not helpful. She had no relief from trials of anticonvulsant medications. As often happens with the chronically ill she disappeared for a year. When she returned she began by saying,"Doc, could you give me the Anafranil (clomipramine) again (200 mg)? Nothing will ever cure my depression but at least I could sleep." I agreed but asked her if she would try another augmentation strategy. I explained that the approach was not even remotely standard practice, etc. She answered with a shrug.
Four weeks after I added 25 mg of naltrexone at bedtime she phoned me. "Doc, I was playing badminton with my family and I suddenly realized that I was having fun! I have never felt that before!" If I stopped either medicine she would start to relapse. Two years later she was still depression free and engaged.
I have learned through bitter experience to believe only results. This was no placebo response. Neither one of us really expected her to do so well having been down the augmentation trail together many times. I knew after this experience that the question was not *if* this was worthwhile but rather *in whom*.Although the next handful of patients were similarly desperate cases, I no longer restrict the use of this strategy to the "last chance" scenario. In fact, I've done this now with well over fifty of my patients.
Posted by Jim on March 8, 1999, at 9:43:31
In reply to Atypical depression? already tried MAOIs & Prozac, posted by Anita on March 6, 1999, at 22:07:40
Anita--
There are still many options left to try, although
you are right that Prozac and MAOs would be first-
line strategies in atypical depression.
Have you tried other SSRIs, especially Zoloft and
Luvox? Have you discussed augmentation options
with meds like valproate or gabapentin? Have you
tried the older but often effective meds like
Tofranil (imipramine)? Finally, and perhaps
most of all, I'd also recommend looking into
naltrexone, as discussed by Wayne R., since its
use in refractory depression looks extremely
encouraging!
Best wishes to you,
Jim> Anybody find a med good for atypical depression besides
> Nardil, Parnate, Prozac, moclobemide, Marplan, Effexor, Wellbutrin, or stimulants?
> Not much left, is there :-(
>
Posted by Elizabeth on March 9, 1999, at 23:43:09
In reply to Re: Atypical depression options, posted by Jim on March 8, 1999, at 9:43:31
Jim, you left out two salient features of atypical depression: chronic interpersonal sensitivity (not just while depressed, but as a trait throughout life), and feelings of extreme lethargy (especially feelings of "heaviness").
A tricyclic like imipramine, nortriptyline, or desipramine may be worth trying, but be aware that atypical depression was defined as the result of studies of patients who failed to respond to tricyclics but did respond to MAOIs.
I believe that Anita has already tried anticonvulsants. I think the idea of trying the other new antidepressants is reasonable. Another possibility is the many drugs that are available in Europe (France especially) but not here. (I don't mean moclobemide: general clinical experience seems to be that moclobemide is not a substitute for Nardil or Parnate in atypical or refractory depression.) One thing to consider would be the other MAOI, Marplan. I've heard *rumors* that it's now used here again, and it is still used in the U.K. for sure.
And of course, there are always Buprenex and Tramadol. :-)
I haven't heard much good about naltrexone as an antidepressant itself, only for jump-starting ADs that have stopped working. Specifically, the people I know (doctors and patients) who use it (for self-injurious behavior and alcoholism mostly) say that it causes "dysphoria."
-elizabeth
Posted by Jim on March 10, 1999, at 8:51:10
In reply to Re: Atypical depression options, posted by Elizabeth on March 9, 1999, at 23:43:09
Elizabeth wrote:
> Jim, you left out two salient features of atypical depression: chronic interpersonal sensitivity (not just while depressed, but as a trait throughout life), and feelings of extreme lethargy (especially feelings of "heaviness").
>You're quite right, Elizabeth--though I suppose I was lumping the chronic sensitivity in as part of the general notion of "mood reactivity"... As I'm sure you know already, another frequently encountered term is "rejection sensitive", the flip-side of which is obviously feeling markedly better under positive conditions.
As for your naltrexone comments (which basically answer my question in the other thread about buprenorphine!), you're right that it's mostly been used adjunctively to jumpstart SSRIs or the like. I'm not convinced it causes dyphoria across the board however--several recent reports on alcoholism and various "impulse disorders" seem to suggest that it can help with depressive symptoms in certain patients even when used alone, but the jury's still out on this one.
--Jim
Posted by Jim on March 10, 1999, at 9:43:01
In reply to Re: Atypical depression options, posted by Jim on March 10, 1999, at 8:51:10
Real sorry about that fit of repetitive posting there, guys -- My computer seemed jammed but was actually sending the message with every mouse click! Perhaps Dr. Bob will come along and clean this mess of mine up!
Apologies,
Jim
Posted by pej on March 10, 1999, at 10:31:33
In reply to Re: HELP! My computer has OCD !!! -- Sorry, posted by Jim on March 10, 1999, at 9:43:01
> Real sorry about that fit of repetitive posting there, guys -- My computer seemed jammed but was actually sending the message with every mouse click! Perhaps Dr. Bob will come along and clean this mess of mine up!
> Apologies,
> JimHey Jim,
I needed a good laugh today...thanks. Phil
Posted by Wayne R. on March 10, 1999, at 12:54:14
In reply to Re: Atypical depression options, posted by Elizabeth on March 9, 1999, at 23:43:09
> I haven't heard much good about naltrexone as an antidepressant itself, only for jump-starting ADs that have stopped working. Specifically, the people I know (doctors and patients) who use it (for self-injurious behavior and alcoholism mostly) say that it causes "dysphoria."
>
Dr Dante's observations of Naltrexone that I have posted have been exclusively as an augmentation for the SSRI family of ADs. As to "dysphoria", my experience with Naltrexone augmenting Prozac has been one of an overall feeling of "wellbeing" (not euphoria) and optimism never before attained. Wayne...
Posted by Elizabeth on March 10, 1999, at 21:58:50
In reply to Re: Atypical depression options, posted by Jim on March 10, 1999, at 8:51:10
> As for your naltrexone comments (which basically answer my question in the other thread about buprenorphine!), you're right that it's mostly been used adjunctively to jumpstart SSRIs or the like. I'm not convinced it causes dyphoria across the board however--several recent reports on alcoholism and various "impulse disorders" seem to suggest that it can help with depressive symptoms in certain patients even when used alone, but the jury's still out on this one.
It's also what I heard from a psychopharm researcher who has quite a bit of experience using opioids (both the mixed agonist/antagonists and Revia) for non-substance-related psych disorders. Certainly it's not an absolute - some people won't feel crappy on it - but I get the impression that (1) a lot do, and (2) people who've studied it get the same impressino.
I sort of agree with you about interpersonal sensitivity (I think it tends to be broader than just "rejecton sensitivity BTW) being the flip side of "reactive mood." Howeer, the way they define reactive mood, it only refers to the ability to be influenced positively by one's environment. (As an aside, I think that most people, including those with so-called typical or melancholic depression, retain the ability to feel *worse* due to things in the environment while depressed.)
-elizabeth
Posted by Elizabeh on March 10, 1999, at 22:01:48
In reply to Re: Atypical depression options, posted by Wayne R. on March 10, 1999, at 12:54:14
> Dr Dante's observations of Naltrexone that I have posted have been exclusively as an augmentation for the SSRI family of ADs. As to "dysphoria", my experience with Naltrexone augmenting Prozac has been one of an overall feeling of "wellbeing" (not euphoria) and optimism never before attained. Wayne...
So we her, Wayne. :-)
As I said, I was referring to the use of naltrexone *by itself*. It's been used successfully as an adjunct for "poop-out" for some time.
BTW Wayne, do you have atypical depression?
Posted by Wayne R. on March 11, 1999, at 11:47:57
In reply to Re: Atypical depression options, posted by Elizabeh on March 10, 1999, at 22:01:48
> So we hear, Wayne. :-)
>
Sorry... I guess I've gotten a bit over excited about having relief after fighting depression for 38 years. ;-)> BTW Wayne, do you have atypical depression?
>
I have never been told that. When my Dr of 25 years transfered me to another he described it as "intransigent" depression. Wayne
Posted by Elizabeth on March 11, 1999, at 16:42:11
In reply to Re: Atypical depression options, posted by Wayne R. on March 11, 1999, at 11:47:57
> > BTW Wayne, do you have atypical depression?
> >
> I have never been told that. When my Dr of 25 years transfered me to another he described it as "intransigent" depression. WayneI posted the symptoms - did they sound like the symptoms you have?
(I'm sorry if I came across as harsh when I teased you about your enthusiasm about ReVia. I am feeling much the same about buprenorphine so I do get where you are coming from. :-)
-elizabeth
Posted by phyl on March 11, 1999, at 17:57:22
In reply to Re: Atypical depression options, posted by Elizabeth on March 9, 1999, at 23:43:09
>New here. Can anyone please define: **chronic interpersonal sensitivity (not just while depressed, but as a trait throughout life)**? Thank you. --Phyl.
Posted by Wayne R. on March 11, 1999, at 18:08:19
In reply to Re: Atypical depression options, posted by Elizabeth on March 11, 1999, at 16:42:11
> I posted the symptoms - did they sound like the symptoms you have?
I reviewed your postings, Jims definition and reviewed the Harvard letter - I would conclude that I have had "typical" depression. I should have stayed out of this thread... Wayne
Posted by Anita on March 12, 1999, at 16:44:40
In reply to Re: Atypical depression options, posted by phyl on March 11, 1999, at 17:57:22
And I thought I'd get no feedback! :-)
Well, after seeing 2 psychopharms so far (I've lost the one I've been seeing
for over 5 years) I guess I'll try adding pindolol and/or naltrexone to my current
Parnate & lamictal regimen. Those didn't help when I tried them with Nardil, but who
knows... If no luck, then I guess I'll try Prozac again (had some positive effect eons ago)
or Ultram. I know meds aren't a cure for me, but _something's_ got to get me off of my d*mn
couch!Oh, yes I've tried Zoloft & Luvox. No antipsychotics yet, but I'm afraid of the weight gain.
anita
Posted by Elizabeth on March 13, 1999, at 10:08:39
In reply to Re: Atypical depression options, posted by Anita on March 12, 1999, at 16:44:40
> And I thought I'd get no feedback! :-)
> Well, after seeing 2 psychopharms so far (I've lost the one I've been seeing
> for over 5 years) I guess I'll try adding pindolol and/or naltrexone to my current
> Parnate & lamictal regimen. Those didn't help when I tried them with Nardil, but who
> knows... If no luck, then I guess I'll try Prozac again (had some positive effect eons ago)
> or Ultram. I know meds aren't a cure for me, but _something's_ got to get me off of my d*mn
> couch!Hey there. I think Ultram might be a pretty good idea. Be sure to observe a wash-out period after stopping Parnate, though!
You seem to have a lot of the same med reactions as I have (but minus the weird metabolic quirks I seeem to have). What exactly is the trouble with Parnate for you?
BTW, where do you see your psychopharm? (Email if you want, I'm very curious.)
-elizabeth
Posted by anita on March 18, 1999, at 20:48:02
In reply to Re: Atypical depression options, posted by Elizabeth on March 13, 1999, at 10:08:39
> You seem to have a lot of the same med reactions as I have (but minus the weird metabolic quirks I seeem to have). What exactly is the trouble with Parnate for you?
>
Basically, Parnate doesn't seem to be doing much good. Also, it makes me extremely tired about 2 hours after each dose (due to the short-acting
amphetamine-like metabolite thingy, I think -- I have the same problem with all stimulants, like Ritalin).> BTW, where do you see your psychopharm? (Email if you want, I'm very curious.)
>
I can't afford any of the really good ones here in NYC, so I have to go thru my insurance (Oxford). I had the hardest time just finding a psychiatrist, any psychiatrist,
who would take my insurance (it has a terrible rep in the mental health field). The first one I went to didn't even know what Lamictal was!anita
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