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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 jzp on June 30, 2000, at 4:18:24
Last time I was in the hospital/being treated I was
diagnosed as having Bipolar II, and was in a depressed
mode. That was in November of 1998. I was given
Depakote and Wellbutrin, and then Depakote and Zoloft,
but my mood and energy level did not improve. I left
school and lost my health insurance, so I went off all
medication in November of 1999. It didn't make any
difference; I was depressed on the medicine and off it.Now, I'm still depressed, but am in the process of
resuming treatment for it. From everything that I have
read, I fit all the qualifications of atypical depression:
extreme rejection sensitivity, weight gain, lack of energy
hypersomnia... It isn't so much that I just constantly
feel sad and empty, it's more that any little thing is
enough to make me feel terrible. Good things can
often make me feel better (very) temporarily, but it
invariably falls apart. Everything is overwhelming. I
feel like I'm just one big exposed nerve-- everything
affects me, everything hurts.I'm sorry it's taken me this long to get to the pertinent
question: What kind of treatments have been helpful
for those of you who also suffer from atypical
depression?Thanks for any help that you can offer.
-jzp
Posted by Andre Allard on June 30, 2000, at 5:27:34
In reply to atypical depression treatment?, posted by jzp on June 30, 2000, at 4:18:24
Maoi's, or manoanine oxidase inhibitors, have been known for their effectiveness in atypical depression. Nasty side effects and diet restrictions though. Good luck!
Posted by noa on June 30, 2000, at 14:36:11
In reply to Re: atypical depression treatment?, posted by Andre Allard on June 30, 2000, at 5:27:34
Question: have you had your thyroid functions tested?
If so, what were the results? If you only got the results in terms of "within normal limits", find out what the actual numbers were. Many docs rely too heavily on the usual statistical cut-offs, thus overlooking many cases of hypothyroidism.
If not, it is a good idea. Subclinical hypothyroidism is frequently not diagnosed but it can cause a lot of devastating symptoms.
Some of the symptoms of refractory atypical depression are the same as hypothyroidism.For more info, see
www.thyroid-info.com
Good books: The Thyroid Solution by Dr. Ridha Arem, and Living Well with Hypothyroidism by Mary Shomon.
Treating my hypothyroidism has made a HUGE difference in my response to antidepressants. I had such a rough few years, with this past year the worst, but since aggressive treatment with thyroid meds, under the care of a great endocrinologist, I am finally feeling better.
Posted by JohnL on July 1, 2000, at 2:53:58
In reply to atypical depression treatment?, posted by jzp on June 30, 2000, at 4:18:24
Adrafinil.
Posted by SLS on July 1, 2000, at 10:18:09
In reply to atypical depression treatment?, posted by jzp on June 30, 2000, at 4:18:24
> Last time I was in the hospital/being treated I was
> diagnosed as having Bipolar II, and was in a depressed
> mode. That was in November of 1998. I was given
> Depakote and Wellbutrin, and then Depakote and Zoloft,
> but my mood and energy level did not improve. I left
> school and lost my health insurance, so I went off all
> medication in November of 1999. It didn't make any
> difference; I was depressed on the medicine and off it.> Now, I'm still depressed, but am in the process of
> resuming treatment for it. From everything that I have
> read, I fit all the qualifications of atypical depression:
> extreme rejection sensitivity, weight gain, lack of energy
> hypersomnia... It isn't so much that I just constantly
> feel sad and empty, it's more that any little thing is
> enough to make me feel terrible. Good things can
> often make me feel better (very) temporarily, but it
> invariably falls apart. Everything is overwhelming. I
> feel like I'm just one big exposed nerve-- everything
> affects me, everything hurts.> I'm sorry it's taken me this long to get to the pertinent
> question: What kind of treatments have been helpful
> for those of you who also suffer from atypical
> depression?
>
> Thanks for any help that you can offer.
>
> -jzp
Hi there.Do you know why you were diagnosed as being bipolar? The distinction between bipolar and unipolar is important as it determines the emphasis placed upon using mood stabilizers such as Depakote.
Have you ever been, or suspect that you may have been, manic or hypomanic? If so, how would you describe these manic states? How old were you when you first became ill? Any family history?
Atypical depression and bipolar depression look very similar.
You may indeed suffer from atypical unipolar depression. From your description, and in the absence of mania, this is probably the case. A thyroid examination is certainly something worth putting on your list, although I don't think thyroid abnormalities are as often associated with bipolar disorder as they are with unipolar disorders.
Noa - Is this true? Are thyroid abnormalities more common in atypical depression as opposed to melancholic (typical endogenous) depression? How much do thyroid tests cost?
I don't think either Provigil (modafinil) or adrafinil used alone is going to do it. Of course, I would not want to mistakingly persuade someone from choosing the right treatment for themselves, but I don't think these drugs belong at the top of your list. You may want to try adding one of these drugs to the antidepressants you are already taking at some point in the future. Adrafinil is not sold in the U.S., however, the two drugs may not be completely interchangeable. JohnL has responded better to adrafinil (added to the other antidepressants he is already taking). Others have had success with Provigil.
You have only mentioned two antidepressants. Did either of them help at all? Were they combined? What else have you tried? Have any drugs been partially effective?
It is becoming increasingly apparent that combinations of antidepressants are often required to acquire an adequate response.
MAO inhibitors must not be avoided if you have failed to respond to many different drugs. Nardil has been the drug traditionally chosen first for atypical depression. Years ago, it was thought that rejection-sensitivity was a symptom that Nardil was particularly well suited to treat. It is certainly effective in cases where social anxiety is present. Parnate is the MAOI usually thought of to treat bipolar depression and depressions in which having extremely low energy is a prominent feature. These associations do not represent rules, but rather trends. Either drug can work for either set of symptoms. Nardil is associated with greater weight gain than is Parnate. The other MAOI worth mentioning is Marplan.
Trial and error sucks. Sorry.
I recommend that you document which drugs you have tried and how you have responded to them. I would also recommend that you discuss your thoughts with your doctor. Thirdly, I recommend that you hang-out here for awhile to receive more replies so as to see what drugs other "real" people have had success with and how closely their symptoms match yours.
Mucho good luck.
- Scott
Posted by KarenB on July 1, 2000, at 11:01:33
In reply to Re: atypical depression treatment? - jzp and noa, posted by SLS on July 1, 2000, at 10:18:09
jzp,
Another possibility to consider is the presence of ADD as the cause or even co-morbid along with your depression.
I was diagnosed bipolar as well but the symptoms of ADD, innattentive type (without hyeractivity but rather HYPOactivity) are what better fits my symptoms. You can check it out at www.chadd.org and follow the links to take online tests, etc. if it sounds all too familiar.
I am struggling too, right now, searching for something that works. I hope we both find our answer soon.
My next stop may be an MAOI, like Nardil or Parnate, although the diet restrictions are especially unattractive to me.
Karen
Posted by Noa on July 1, 2000, at 14:00:16
In reply to Re: atypical depression treatment? - jzp and noa, posted by SLS on July 1, 2000, at 10:18:09
Scott, I really don't know if it is more common in one type of depression or the other, but I do know that some of the symptoms of hypothyroid overlap with those of atypical depresseion:
fatique
sluggishness
sleepiness
weight gain
lack of motivation
feeling of heaviness in the limbsSo, especially with women, who are more prone to hypothyroid (though not exculsively a women's problem), I believe that with atypical depresion, hypothyroidism should be looked into.
I would guess that quite often, both an endocrine approach and a psychopharm approach might be needed, but for many people with difficult to treat chronic depression, who also have subclinical hypothyroid, treating the hypothyroid aggressively is key to getting a good response to the antidepressants.
Posted by SLS on July 1, 2000, at 14:57:28
In reply to Re: atypical depression treatment? - jzp and noa, posted by Noa on July 1, 2000, at 14:00:16
> Scott, I really don't know if it is more common in one type of depression or the other, but I do know that some of the symptoms of hypothyroid overlap with those of atypical depresseion:
> fatique
> sluggishness
> sleepiness
> weight gain
> lack of motivation
> feeling of heaviness in the limbs> So, especially with women, who are more prone to hypothyroid (though not exculsively a women's problem), I believe that with atypical depresion, hypothyroidism should be looked into.
> I would guess that quite often, both an endocrine approach and a psychopharm approach might be needed, but for many people with difficult to treat chronic depression, who also have subclinical hypothyroid, treating the hypothyroid aggressively is key to getting a good response to the antidepressants.
Noa - thanks for helping out here.I forgot to mention that thyroid hormone is also used to augment antidepressants in the absence of abnormally low levels in the body. Blood levels of 150% of normal are often needed to produce a response. I found something today that indicated that this strategy is also effective for treating bipolar depression. In the studies cited, T4 was used.
- Scott
Posted by jzp on July 1, 2000, at 15:48:35
In reply to Re: atypical depression treatment? - jzp and noa, posted by SLS on July 1, 2000, at 14:57:28
Wow, thanks for all your responses.
Scott-- I have had hypomania in the past. Up until
this most recent episode, the ups and downs have
had a fairly seasonal pattern. I would crash in
November, perk up in April, and then in late June/
early July I would have about two weeks of hypomania.
Nothing major like the depressed part, but it was
definitely there. I grew up in Minnesota, where
the seasonal thing was a lot more pronounced (starting
when I was about 17, I'm 24 now). When I still lived
up there I experimented with light therapy, but couldn't
ever quite come up with the right amount-- always too
much (became hypomanic) or too little (no effect.)
When I moved to Arizona during college, the two years
I was there were really good-- just a little trouble with
the hypomania in the summer, but the depression was
almost totally under control.I live in southern California now, so you wouldn't
think that the seasonal thing would be causing major
problems. Still, I crashed in November of '98, and
haven't managed to get back up, despite a summer
and a half passing since then.I've been on Paxil, Zoloft, and Wellbutrin, as well
as the Depakote. I feel like there is one more
antidepressant in there, too, but my mind is drawing
a blank. My doctors have tended toward the "wait-and-see"
approach, even when it was clear that it wasn't
doing much good. I have an appointment with a new
doc this coming Friday, so hopefully we will be
able to work something out.thanks,
Jannette
Posted by jzp on July 1, 2000, at 15:59:55
In reply to Re: atypical depression treatment? - jzp and noa, posted by Noa on July 1, 2000, at 14:00:16
I thought that I posted a reply to the your thyroid
question yesterday, but it didn't show up.One of my previous doctors (I have moved around a lot)
told me that I did in fact have mild hypothyroid,
and had me on Synthroid and Cytomel. I felt good
while I was taking it, but other doctors have since
told me that my thyroid is fine.I had it checked a couple weeks ago, and the TSH
(the only thing she would check) was 5. From my reading
I know that that is the high end of the standard "normal"
range, and that some doctors would argue that it actually
shouldn't be considered normal.My hunch is that it is somehow out of whack, and that
that is why I have failed to have my usual summertime
"ups" this year and last. (see my other post)
The only difference between now and 4 months ago, is
that I am sleeping only 10-11 hours a night instead
of 12-14 hours a night like I was this winter. And of
course the fact that now I am with-it enough to think
that this depression might be something worth trying
to fight. It's almost like there is something (maybe
the hypothyroid) quashing my normal seasonal pattern.
I don't know. All speculation, of course.I'm seeing a new doctor next Friday, so I'm going
to bring him the thyroid test results and see what
his reaction is.Thanks so much for all your input. I feel like I've
just been blathering on here.-jannette
Posted by noa on July 3, 2000, at 8:49:19
In reply to Re: atypical depression treatment? - jzp and noa, posted by jzp on July 1, 2000, at 15:59:55
Yes, as far as I know, a TSH of 5, with normal levels of T4 (ie, not hyper levels of thyroid hormone) is indicative of subclinical hypothyroid, which could be the culprit in your not feeling well.
Since you were helped by the thyroid hormones, it is hard for me to understand the docs taking you off of it. I hope your new doc is more reasonable.
Check out www.thyroid-info.com, which has loads of info and links to more info. You can even look up good endocrinologists in your area on the topdocs page.
Posted by noa on July 3, 2000, at 8:53:09
In reply to Re: atypical depression treatment? - jzp and noa, posted by jzp on July 1, 2000, at 15:59:55
The endo I see has recommended the strategy of suppressing my TSH (to 0 if needed) by raising the T4 dose (I am also on T3) gradually, as long as there is noticeable benefit from it. Once I don't notice any more improvement, then I stop increasing. I feel so much better with my TSH suppressed (last check it was .3)
Many docs are fearful of increasing the risk of osteoporosis, but the link between taking thyroid hormones and osteoporosis is questionable, according to Mary Shomon's site (www.thyroid-info.com).
Posted by Angela5 on July 6, 2000, at 22:27:19
In reply to Re: atypical depression treatment? - PS » jzp, posted by noa on July 3, 2000, at 8:53:09
This thread reminds me of a question that I have. I read that even with "normal" levels of TSH, T3, and T4, a low value of free T4 can indicate hypothyroid. Does anyone know what value is a clinical low, what is a subclinical low, etc?
Thanks.
Posted by noa on July 7, 2000, at 8:49:45
In reply to Re: atypical depression treatment? - free T4, posted by Angela5 on July 6, 2000, at 22:27:19
Check out the following web page, which gives normal ranges for lab test values--it is a page from Mary Shomon's (author of Living Well with Hypothyroid) web site.
http://thyroid.about.com/health/thyroid/library/weekly/bltest-values.htmAnd, btw, a lot of TSH tests are considered "normal" if below 5.5 or 6, but there was an article in one of the big medical journals by a British doc who says anything 2 or higher is indicative of hypothyroid.
Good luck.
Posted by jzp on July 7, 2000, at 17:36:34
In reply to Re: atypical depression treatment? - free T4, posted by noa on July 7, 2000, at 8:49:45
Met my new pdoc today. I think it went really well.
In addition to the standard anti-depressant/mood-
stabilizer combo, he has ordered a full thyroid panel,
and indicated that he would be willing to prescribe
thyroid supplement if these tests showed that I was
borderline hypothyroid (which I think they will).Thanks for all your input (especially Noa).
-Jannette
Posted by michael on July 13, 2000, at 16:07:10
In reply to Re: atypical depression treatment? - PS » jzp, posted by noa on July 3, 2000, at 8:53:09
Noa -
Just wondering if you might share your T3 dosage...? My pdoc has just prescribed cytomel 50mcg/day - in place of the adrafinil I had been trying - in an attempt to augment 500mg wellbutrin.
Coincidentally, I also recently had some lab tests done in relation to adrafinil, and she also had a TSH test done (this was after the cytomel was prescribed). Mine was .6, which if I understand correctly, wouldn't indicate hypothyroid. (unfortunately, only the TSH was done)
Just wondering, since I have dysthymia-like symptoms (my official diagnosis) which sound similar to hypothyroid symptoms.
I'm feeling better than I had previously (it's been a couple of weeks now), but not as good as with the adrafinil. Thinking about trying 75mcg, it see if it makes any difference...
Thanks,
michael
> The endo I see has recommended the strategy of suppressing my TSH (to 0 if needed) by raising the T4 dose (I am also on T3) gradually, as long as there is noticeable benefit from it. Once I don't notice any more improvement, then I stop increasing. I feel so much better with my TSH suppressed (last check it was .3)
>
> Many docs are fearful of increasing the risk of osteoporosis, but the link between taking thyroid hormones and osteoporosis is questionable, according to Mary Shomon's site (www.thyroid-info.com).
Posted by noa on July 14, 2000, at 6:59:13
In reply to Re: atypical depression treatment? - PS » noa, posted by michael on July 13, 2000, at 16:07:10
Michael, are you sure your TSH was .6, as in 0.6? That is definitely low, meaning NOT hypothyroid. With a TSH that low, you would think the doc would also get free t3 and free t4 tests, just to be sure you aren't hyperthyroid, and also to get a baseline before beginning treatment.
My cytomel dose is 12.5 mcg 2x day. It had been 25 mcg once a day, but the endocrinologist suggested I split it, because it has a short half life. Also, when first starting on cytomel, my pdoc started small, 12.5 mcg per day.
I guess you will judge the cytomel by how you feel after a few weeks. Also, I would retest TSH, free T3, free T4 again in 6-8 weeks.
Maybe you might want to check out the thyroid/depression folder at
http://www.egroups.com/links/psycho-babble-tips
There is a link to Mary Shomon's site, a page that gives info on specific tests and normal value ranges.
Good luck.
Posted by Dr. Bob on July 14, 2000, at 14:12:44
In reply to Re: atypical depression treatment? - PS, posted by noa on July 14, 2000, at 6:59:13
> Maybe you might want to check out the thyroid/depression folder at
>
> http://www.egroups.com/links/psycho-babble-tipsIt's great to see these in action already! Each folder does have its own URL, too. They're kind of unwieldy, for example:
http://www.egroups.com/links/psycho-babble-tips/Noa_s_thyroid_links_000963272558
But that does make it possible to go to them directly. Or to bookmark them...
Bob
Posted by Hi Di on June 11, 2007, at 0:05:52
In reply to Re: psycho-babble-tips in action, posted by Dr. Bob on July 14, 2000, at 14:12:44
> > Maybe you might want to check out the thyroid/depression folder at
> >
> > http://www.egroups.com/links/psycho-babble-tips
>
> It's great to see these in action already! Each folder does have its own URL, too. They're kind of unwieldy, for example:
>
> http://www.egroups.com/links/psycho-babble-tips/Noa_s_thyroid_links_000963272558
>
> But that does make it possible to go to them directly. Or to bookmark them...
>
> BobI have done extensive research on thyroid, as I have never had my hypothyroidism under control. every blood test they change med dosage. I did try a web site www.wilsonsthyroidsyndrome.com which, after the treatment, I felt so much relief. since moving, I cannot find a dr. who knows about this method in my area.
This is the end of the thread.
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