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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 25 to 49 of 49. Go back in thread:
Posted by Scott L. Schofield on November 8, 1999, at 19:01:13
In reply to Re: atypical depression -how typical?, posted by Annie on November 8, 1999, at 9:44:01
> > > Some researchers are grouping the unipolar depressions with bipolar illness--because the "atypical" version is akin to the depressive states of those with bipolar. > I hope these researchers are put in their place as quickly as possible. There is no question that the epidemiology of unipolar versus bipolar depression is manifestly very different. If the response rates to mood-stablizers turns out to be different between the two, their conceptualization would be extremely counterproductive. My "current" psychiatrist is one of the proponents of the theory that there is no such thing as atypical depression. If a person exhibits the atypical subset of symptoms, like me, they are really bipolar whether or not they have ever experienced a manic or hypomanic episode.
... researching my depression online is manic, assertiveness is manic...
...You know, I just don't care anymore. Let him call it whatever he wants. I'm dying a little bit more every day and soon there won't be enough left to matter. When I am totally gone it won't matter what my dx was.
Annie <
Dear Annie,Although your doctor may be accurate in his appraisal of your illness, I think his characterization of your conducting research as being manic is unfair. Because I have seen at least two recent posts regarding the concept that all presentations of atypical depression are actually bipolar, I decided to do a little research of my own. The attitude I expressed in my previous post may have been unfounded.
I was more than just a little surprised at how few studies have been conducted in this area. There is quite a bit more uncertainty now as to the existence of a true atypical unipolar depression than there was ten years ago. I found a few studies in which sequential patients meeting the DSM IV diagnostic criteria for atypical depression were evaluated for bipolar disorder. At least two studies demonstrated that roughly 40% of those meeting the definition of atypical depression were actually bipolar II.
I would like to see a study conducted in which both the 40% bipolar group and the 60% non-bipolar group are first treated with Depakote alone.
Either way, it might not be a bad idea to act under the premise that you are bipolar. It may lead to a successful trial using other mood-stablizers in addition to antidepressants.
Please care for a little while longer.
- Scott
P.S. Today has been a very upsetting one for me. The story is too long to get into here, but I didn't care a whole hell of a lot either. I hope I'm strong enough to take my own advice.
Posted by Judy on November 8, 1999, at 18:25:10
In reply to Re: atypical depression -how typical?, posted by Annie on November 8, 1999, at 9:44:01
> When I am totally gone it won't matter what my dx was.
Annie ~ I'm *sure* that's not true. Have you considered getting a second opinion? ~ Judy
Posted by Noa on November 8, 1999, at 18:39:00
In reply to Re: atypical depression -how typical?, posted by Scott L. Schofield on November 8, 1999, at 18:25:26
I think it is important to keep some perspective on the whole diagnosis thing. Diagnosis is just a way to organize one's thinking about a presentation of symptoms. Our understanding of all of these illness is still so rudimentary. Whether "atypical" depression is a stand alone category or is somehow akin to the depressions in the bipolar "family" is still up for grabs, and may never be answered, as it is also possible that different people's "atypical" presentations are of different types of underlying illness. Response to medication, I don't believe, is a good enough reason to confirm an absolute diagnosis because so many different problems are responding well to the same medications, and even people with similar presentations respond differently to the same medications.
Annie, it sounds like you feel your doctor is a reductionist in his thinking--everything is chalked up to hypomania, etc. That makes you feel he is dismissing your self advocacy efforts. I agree about the second opinion. Perhaps you would feel better with another doc. Or, bring it up with this doc--tell him how it makes you feel.
My pdoc, though far from perfect (I have issues with him today that I won't go into now) never presents his opinions as unequivocal. He shares his thinking with me and that the issues about atypical vs. soft bipolar signs is not currently resolvable. Again, despite some weaknesses he has, he has been supportive of my getting info online and elsewhere.
Hang in there Annie. I am struggling too, and sometimes feel the effort is futile, but we need to support each other and give each other encouragement to keep trying.
Posted by Elizabeth on November 9, 1999, at 7:11:09
In reply to Re: atypical depression -how typical?, posted by Annie on November 8, 1999, at 9:44:01
Annie, you sound so sad...I wish there was something I could do to help. I hope that you can pull together the energy to get a second opinion -- it seems pretty obvious that you know something isn't going right with the guy you're seeing now.
I think that docs who diagnose anyone with mood-reactive or atypical depression as bipolar II (and I seem to keep hearing of instances of this) are probably doing more harm than good. Atypical depression has been well documented, and the proper treatment for it is antidepressants (strong evidence for MAOIs, moderate support for SSRIs), not mood stabilizers. Until there is specific evidence that many patients diagnosed as atypical depressive respond to mood stabilizers (as opposed to meeting the [fuzzy] criteria for bipolar II), this should be a treatment reserved for those who do not improve or who worsen on antidepressants.
I don't recall off the top of my head what antidepressants you've tried (if you even mentioned it), but for what it's worth, MAOIs are supposed to be great for irritability. Another thing that sometimes works for people with atypical presentations is stimulants -- amphetamine, Ritalin, etc.
Posted by Elizabeth on November 9, 1999, at 7:39:34
In reply to Re: atypical depression vs typical -- Eliz?, posted by dj on November 8, 1999, at 2:10:19
Hi dj. This is from DSM-IV (paraphrased):
Atypical depression is characterized by "reactive mood" (i.e., can sometimes "cheer up" in response to pleasant experiences) and 2 or more of the following:
- increase in appetite (often with significant weight gain) (may manifest as cravings for sweets)
- hypersomnia
- "leaden paralysis:" feelings of heaviness, especially in arms and legs
- trait rejection sensitivity (not exclusively during depression, but may be worse when depressed)Atypical depression may be associated with irritability or mood swings (the reactive mood works both ways); substance abuse; personality disorders (e.g., borderline, histrionic, avoidant) or anxiety disorders (e.g., panic disorder, social phobia). Atypical depression occurs 2-3 times as often in women as in men. Onset is often in adolescence or early adulthood. Course tends to be chronic, or episodic with only partial recovery between episodes. Seasonal affective disorder usually presents as atypical.
Melancholia, in contrast, requires that an individual's mood be "nonreactive" (i.e., inability to experience pleasure from previously enjoyable activities; does not cheer up even when something good happens) along with 3 or more of the following:
- depressed mood is experienced as being different from normal moods such as grief, loneliness, sadness, etc.
- depression is generally worst in the morning
- early morning awakening
- psychomotor retardation or agitation (i.e., appears slowed-down or sped-up)
- loss of appetite/significant weight loss
- excessive or inappropriate feelings of guilt or self-reproachMelancholic features predict greater severity of depression, nonresponse to placebo, and response to ECT or antidepressants. Certain laboratory findings are more common in patients with melancholic depression than in those with nonmelancholic depression. Melancholic depression is equally common among men and women and more common in older people than in younger people.
A third cateogory that is sometimes used is "simple mood-reactive depression." This is just mood-reactive depression without atypical features. I think it's probably the most common kind, and also the least understood.
Posted by Scott L. Schofield on November 9, 1999, at 10:21:55
In reply to Re: atypical depression: Annie, posted by Elizabeth on November 9, 1999, at 7:11:09
> I think that docs who diagnose anyone with mood-reactive or atypical depression as bipolar II (and I seem to keep hearing of instances of this) are probably doing more harm than good. Atypical depression has been well documented, and the proper treatment for it is antidepressants (strong evidence for MAOIs, moderate support for SSRIs), not mood stabilizers. <
--------------------------------------------------
I'm not a big proponent of using drugs that don't work.Unfortunately, medicine has not yet reached the point where choosing a drug that will work can be determined by some sort of objective test. I know I can't. I know my doctor can't. And I also know that Robert Post can't. Doctors can, however, make an educated guess based upon some of the empirical evidence gleaned from statistics.
From what little I know, Elizabeth's suggestion to try an MAO-inhibitor seems like a good one. The ones most commonly used in the U.S. are Parnate and Nardil. Another MAO-I, Marplan, was recently reintroduced. The old rule-of-thumb was to consider Parnate as a first choice for bipolar depression and Nardil for atypical unipolar depression, particularly if there also exists some social-phobia, panic-attacks, or obsessive-compulsive characteristics. Again, there are no hard rules to adhere to because there are many instances where the reverse is true.
One thing worth mentioning is that low-dose lithium in combination with an antidepressant has been used with some success at treating unipolar depressives. The range of dosages used was between 300 - 600 mg/day. 450 seemed to be the sweet-spot.
There's a bunch more strategies to try.* Hopefully, both you and I will find one that works. Keep researching. Our doctors can use all the help they can get.
* I tend to be more optimistic when it comes to other people's plights than I do for my own. Does anyone else experience this?
- Scott
Posted by Refractory on November 9, 1999, at 18:47:14
In reply to Re: atypical depression -how typical?, posted by Annie on November 8, 1999, at 9:44:01
Annie, your story is ridiculous. You have a bad doctor. Find a new one...fast. You need to be on antidepressants. Your current doctor's ability to practice psychiatric medicine needs to be looked at by the appropriate people...your state medical board. After you find a new doc and get on antidepressants I strongly encourage you to report this current doc with your state medical board. You have clear severe depressive symptoms...this is a medical emergency the way you describe it. It needs to be treated that way, aggressively with antidepressant medication. My heart goes out to you, you are one of the unlucky ones who unfortunately landed an incompetent psychiatrist.
Posted by Noa on November 9, 1999, at 20:10:07
In reply to Re: atypical depression: Annie, posted by Scott L. Schofield on November 9, 1999, at 10:21:55
> * I tend to be more optimistic when it comes to other people's plights than I do for my own. Does anyone else experience this?
>
> - ScottOf Course!!!
Posted by Annie on November 10, 1999, at 11:18:54
In reply to Re: atypical depression -how typical?, posted by Judy on November 8, 1999, at 18:25:10
Thank you Judy, Scott, Noa, Elizabeth and
"Refractory" for your thoughtful advice and caring support. I normally don't post when my depression is in control because, well, the depression does the talking. I have been on many different drug trials including Prozac, Zoloft, Effexor, Wellbutrin, Serzone, Desipramine, Nardil, Parnate and Marplan and now, Neurontin. I have augmented with Synthroid, Cytomel, Pindolol, Dilantin, Klonopin, Depakote, Doxepin, Lithium, Lamictal, Zyprexa. I have participated in studies for rTms, P Substance, and Transdermal Selegiline. There may be others that I've forgotten. Except in instances when the side effects were life threatening, the trials were of adequate duration and the dosages were as high as tolerable, frequently well beyond the suggested maximum because my liver metabolizes 'too' well. What you read in my post was the frustration that many of you must feel when one after another a trial fails. In two weeks, if the depression has not lessened, my psychiatrist has said he will lower the Neurontin dosage (from 3200 mg) and add Parnate. I had a spontaneous hypertensive crisis during the first few days of my last trial of Parnate, so the dosage will increased very slowly. I wish I could tell you I was hopeful, but the depression doesn't allow that. I just want something to work well enough for me to last until Transdermal Selegiline is available. It is the only drug (30 mg) that has substantially helped me, although at that dosage, it didn't touch the Anhedonia. Oral selegiline is a posibility for a future trial with a different psychiatrist but I've been told the dosage would have to be so high, it might not be tolerable. So this is where I am right now. I sincerely appreciated your kind words and in true atypical fashion, it made me feel much better.
Annie
Posted by Elizabeth on November 10, 1999, at 15:45:14
In reply to Re: atypical depression: Annie, posted by Scott L. Schofield on November 9, 1999, at 10:21:55
> I'm not a big proponent of using drugs that don't work.
What a nice, noncontroversial statement. ("I support the good things in life. I oppose the bad things.")
> The old rule-of-thumb was to consider Parnate as a first choice for bipolar depression and Nardil for atypical unipolar depression, particularly if there also exists some social-phobia, panic-attacks, or obsessive-compulsive characteristics.
Really? I'd never heard this. What's the rationale? There is better evidence for Nardil when it comes to social phobia (I think MAOIs are falling out of favor for OCD), and Parnate may be better avoided in panic disorder (because of its stimulant-like properties), but why the unipolar vs. bipolar dichotomy?
Parnate seems to be better tolerated, from what I can tell -- Nardil tends to cause quite a bit of weight gain. Patients with diabetes mellitus should not take Nardil.
> One thing worth mentioning is that low-dose lithium in combination with an antidepressant has been used with some success at treating unipolar depressives. The range of dosages used was between 300 - 600 mg/day. 450 seemed to be the sweet-spot.
Really you need to check blood levels -- should be somewhere between 0.5 and 0.8 mmol/L. As an example, I'm a fairly small person with healthy kidneys taking 300 mg twice a day, and my most recent level was 0.7.
But yeah, lithium augmentation (of low-dose Parnate) did a really nice job for me when my mood had improved somewhat but my interest in life and ability to enjoy things were still absent.
Posted by Adam on November 10, 1999, at 20:44:13
In reply to Re: atypical depression: Annie, posted by Elizabeth on November 10, 1999, at 15:45:14
>(I think MAOIs are falling out of favor for OCD)
Is this because of lack of efficacy, or simply because of
the relative safety of the SSRIs?I've been diagnosed with (in this order)
-Depression (*really*)
-Psychosis (my absolute favorite)
-OCD (bingo!)
-Melancholia (nope)
-Dysthymia (I wish)
-Deep, deep depression (uh, yeah...)
-Major Depression (I'll say)For which I have taken (not 100% sure of the order...)
-Nothing
-Desipramine (lasted all of a week-sick as a dog)
-Imipramine (no different)
-Nothing (did OK, drank too much, probably, but OK)
-Clomipramine (Lasted all of two weeks-getting hit with a bat might
feel better)
-Zoloft (lackluser, put on 30lbs. in six months, bad sex)
-Effexor (OK on mood, still fat, tired, thumbs down on sex)
-Effexor+Wellbutrin (hey, my first augmentation-didn't really help, though)
-Wellbutrin alone (Sex! Yay! Depression! Boo!)
-Serzone (We're talking downward spiral here, depression reaching nearly
unbearable dimensions, obsessions taking over, in the breakdown lane,
litarally and figuratively)
-Serzone+clozapine (no benefit, got funny looks from the pharmacist, made doctors in
hospital frown in consternation)
-(Hospital) ECT (Worked great, for a month or so-I forget...)
-(Hospital) Lorazipam (Mmmmmm)
-Celexa (Sex is natural, sex is good, not everybody does it, especially on this drug)
-Remeron (somewhat improved mood, no sexual dysfunction, amazing dreams, ever OD on benedryl?)
-Selegiline (finally, finally, finally, finally, finally, finally, finally, finally, finally...)(Out of fairness, clozapine has been shown in isolated cases to help with OCD, but not
my OCD. It also has been shown to exacerbate it...)I certainly have been, at times, noncompliant. I just couldn't see taking a drug that
didn't make me much happier while causing intolerable side effect(s).Where has diagnosis gotten me in all this? With the exception of six months of intensive
behavioral therapy for OCD (helped a great deal) and the suggestion I try an MAOI, noplace.I don't know what I am, typical, atypical, who knows. I'm curious, but at this point,
it doesn't matter. I tried a bunch of drugs, found something that works tolerably well,
and do therapy. End of story. I'd love to know what mutation I've got, what part of my
brain is smaller, what chemical compound there is a dearth/surplus of. But I probably
never will, and besides, no one yet knows what to do with such information. DSM-IV. Well,
it's a start.
Posted by Noa on November 11, 1999, at 4:35:54
In reply to Re: atypical depression: Annie, posted by Adam on November 10, 1999, at 20:44:13
GREAT POST.
BTW, LOL re the following:
> -(Hospital) ECT (Worked great, for a month or so-I forget...)
Posted by Noa on November 11, 1999, at 4:39:40
In reply to Thanks from Annie, posted by Annie on November 10, 1999, at 11:18:54
I sincerely appreciated your kind words and in true atypical fashion, it made me feel much better.
> AnnieWell put. It may be especially frustrating to have this form of depression, but you reminded me of one of the "good" things (can there be anything good?)-- if we can find it, at least we have this mood-responsivity to social support.
Posted by antz on November 11, 1999, at 11:22:19
In reply to Re: Thanks from Annie, posted by Noa on November 11, 1999, at 4:39:40
Your post made me laugh so hard that I just had to respond back and let you know. I think its great you can keep such a wonderful sense of humor dealing with such a difficult situation.
Hope you keep posting. I and probably many others could use such a good laugh.
Thanks again.
Antz
Posted by dj on November 11, 1999, at 17:15:11
In reply to definitions (for dj), posted by Elizabeth on November 9, 1999, at 7:39:34
Eliazabeth, Thanks for that. It clarifies things somewhat. I surmise than that melancholic depression is considered typical &/or "simple mood-reactive depression."
In the first line of the following do you have any idea what lab. findings are referred to?
>Certain laboratory findings are more common in patients with melancholic depression than in those with nonmelancholic depression. Melancholic depression is equally common among men and women and more common in older people than in younger people.
>
> A third cateogory that is sometimes used is "simple mood-reactive depression. This is just mood-reactive depression without atypical features. I think it's probably the most common kind, and also the least understood.
Posted by Elizabeth on November 12, 1999, at 1:21:56
In reply to Re: def.s (for dj) -- slight clarification, svp, posted by dj on November 11, 1999, at 17:15:11
> Eliazabeth, Thanks for that. It clarifies things somewhat. I surmise than that melancholic depression is considered typical &/or "simple mood-reactive depression."
I think melancholia is actually not too common. Simple mood-reactive depression is usually "typical" neurovegetative symptoms (insomnia, loss of appetite, marked psychomotor changes, etc.) with mood reactivity. But it's generally a wastebasket term for any depression that doesn't clearly fall into one of the other two categories.
> In the first line of the following do you have any idea what lab. findings are referred to?
It kind of depends which definition of melancholia you're using. Some of the laboratory findings are polysomnographic changes (decreased REM latency and prolonged first REM period), hypercortisolism and nonsuppression of cortisol levels in the dexamethasone suppression test, low TSH, a couple other weird test results. None of them is diagnostic by itself, though.
Posted by Scott L. Schofield - sorry on November 14, 1999, at 11:42:08
In reply to Re: atypical depression: Annie, posted by Elizabeth on November 10, 1999, at 15:45:14
> > I'm not a big proponent of using drugs that don't work.
> What a nice, noncontroversial statement. ("I support the good things in life. I oppose the bad things.")Calm down.
Sarcasm.
As far as the rest is concerned, just because *you* have never heard of something does not exclude its possible existence.
> > The old rule-of-thumb was to consider Parnate as a first choice for bipolar depression and Nardil for atypical unipolar depression, particularly if there also exists some social-phobia, panic-attacks, or obsessive-compulsive characteristics.
> Really? I'd never heard this. What's the rationale?
Sometimes the mere fact that something works is enough of a rational.
> There is better evidence for Nardil when it comes to social phobia (I think MAOIs are falling out of favor for OCD), and Parnate may be better avoided in panic disorder (because of its stimulant-like properties), but why the unipolar vs. bipolar dichotomy?
No comment.
> > One thing worth mentioning is that low-dose lithium in combination with an antidepressant has been used with some success at treating unipolar depressives. The range of dosages used was between 300 - 600 mg/day. 450 seemed to be the sweet-spot.
> Really you need to check blood levels -- should be somewhere between 0.5 and 0.8 mmol/L. As an example, I'm a fairly small person with healthy kidneys taking 300 mg twice a day, and my most recent level was 0.7.What does low-dose mean?
Let us not start a flame-war. It might not serve any constructive purpose.
- Scott
Posted by Dr. Bob on November 14, 1999, at 13:41:10
In reply to Re: atypical depression - Last try., posted by Scott L. Schofield - sorry on November 14, 1999, at 11:42:08
> Let us not start a flame-war. It might not serve any constructive purpose.
As I've said before, if someone isn't sure a message they're thinking about posting is civil (anticipating flames is one indication), then it would probably be better if they didn't just go ahead and post it anyway.
Bob
Posted by Elizabeth on November 14, 1999, at 14:23:22
In reply to Re: atypical depression - Last try., posted by Scott L. Schofield - sorry on November 14, 1999, at 11:42:08
> > > I'm not a big proponent of using drugs that don't work.
>
> > What a nice, noncontroversial statement. ("I support the good things in life. I oppose the bad things.")
>
> Calm down.
>
> Sarcasm.Calm down. Humor.
> As far as the rest is concerned, just because *you* have never heard of something does not exclude its possible existence.
Don't be so defensive. I never denied its possible existence; I was curious where you had heard of it and what the evidence was. Your only response when I asked for a reason was "no comment." Is this really a "fact," or just something you heard somewhere?
> Let us not start a flame-war. It might not serve any constructive purpose.
I flamed no one. You're being rather snide. I don't feel I've done anything to deserve this treatment. Do you feel a need to attack anyone who doesn't blindly accept every claim you make as "fact?"
Posted by Scott L. Schofield on November 14, 1999, at 19:56:05
In reply to Re: atypical depression - Last try., posted by Elizabeth on November 14, 1999, at 14:23:22
Please forgive my misperception.
Sometimes I just like to hear myself talk.
- Scott
Posted by Scott L. Schofield on November 14, 1999, at 20:15:55
In reply to Re: atypical depression: Annie, posted by Adam on November 10, 1999, at 20:44:13
> -Selegiline (finally, finally, finally, finally, finally, finally, finally, finally, finally...)I'm confused. Has selegiline been helpful?
I hope so.
> I certainly have been, at times, noncompliant. I just couldn't see taking a drug that didn't make me much happier while causing intolerable side effect(s).Ditto.
> Where has diagnosis gotten me in all this? With the exception of six months of intensive behavioral therapy for OCD (helped a great deal) and the suggestion I try an MAOI, noplace.What about Zoloft + Wellbutrin. I've seen some encouraging posts regarding this combination.
Perhaps one of Dr. Bob's tipsters has a practice near you.
- Scott
Posted by Adam on November 14, 1999, at 23:46:28
In reply to Re: atypical depression: Adam, posted by Scott L. Schofield on November 14, 1999, at 20:15:55
>
> I'm confused. Has selegiline been helpful?
> I hope so.
>
Yes, it has, as far as improving my mood. It hasn't been a very good anxiolytic. Unfortunately,
I cannot augment selegiline at the present as I am being administered selegiline through a clinical trial,
and the trial protocol doesn't allow the use of other psychoactive medications.
> What about Zoloft + Wellbutrin. I've seen some encouraging posts regarding this combination.
>
The reasons one of my old pdocs prescribed Wellbutrin as an augmentation to Effexor was to help with
depression and also counteract sexual side effects. It did neither. I found Effexor to be, if anything,
a better antidepressent than Zoloft (though I use "better" rather charitably). Though I haven't tried
Zoloft+Wellbutrin, and thus can't say for certain that it wouldn't work, I think it's safe to assume,
given the failure of Zoloft alone or Effexor+Wellbutrin to help me in a way that made the side effects
worth enduring, that this would not be a viable approach.I have a feeling that, barring some unforseen advances in psychopharmacology, that an MAOI will be my
treatment for good. Knowing what I know now, this isn't so bad, when you think about it.
Posted by Elizabeth on November 15, 1999, at 1:03:53
In reply to Re: atypical depression - Last try., posted by Scott L. Schofield on November 14, 1999, at 19:56:05
> Please forgive my misperception.
Forgiven.
[feeble attempt to keep discussion on-topic]
You know, I hear SSRIs are supposed to help with over-sensitivity.
Posted by Scott L. Schofield on November 15, 1999, at 8:25:40
In reply to Re: atypical depression - Last try., posted by Elizabeth on November 15, 1999, at 1:03:53
> > Please forgive my misperception.
>
> Forgiven.
>
> [feeble attempt to keep discussion on-topic]
> You know, I hear SSRIs are supposed to help with over-sensitivity.That is, of course, unless someone has an over-sensitivity to SSRIs.
- Scott
Posted by Is everyone here a qualified doctor? on November 30, 1999, at 12:55:18
In reply to Re: Lofepramine and tricyclics, posted by Elizabeth on November 3, 1999, at 12:05:09
I can't relate to a lot of the terminology used here but my 3x70mg of Lofepramine per day hasn't helped me sleep any better. It has, however, helped me get a better perspective on life and calmed me down a little. Also it makes me rather dreamy on the way to work in the morning, but makes urinating really difficult and slow, explodes my pupils to an amazing size all day long and makes me a bit shaky in the early evening. Is this normal?
This is the end of the thread.
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