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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 8 of 8. This is the beginning of the thread.
Posted by ItsJustMe on January 5, 2001, at 4:11:05
Hi - I'm just wondering if any ADs have been shown to work better than others for chronic depression.
Thx!
Posted by stjames on January 5, 2001, at 19:54:41
In reply to which AD for chronic depression?, posted by ItsJustMe on January 5, 2001, at 4:11:05
The TCA's, Effexor or Remeron. The combo of Effexor and Remeron is considered a "big gun".
Many other polydrug combos also work for chronic depression. SSRI's are not as effective for significant and/or chronic depression as the older
TCA's. Psycothearpy is also indicated.James
Posted by JohnL on January 6, 2001, at 5:26:52
In reply to Re: which AD for chronic depression?, posted by stjames on January 5, 2001, at 19:54:41
> The TCA's, Effexor or Remeron. The combo of Effexor and Remeron is considered a "big gun".
> Many other polydrug combos also work for chronic depression. SSRI's are not as effective for significant and/or chronic depression as the older
> TCA's. Psycothearpy is also indicated.
>
> JamesJames is absolutely correct. Effexor, Effexor+Remeron, Remeron, Nortriptyline, or Desipramine would be top choices in the antidepressant category as I see it.
Of course though, that would assume that the chronic depression has its roots in chemsitries involving low neurotransmitter levels or disregulation of receptors. This only covers about half of the possible causes. Others might be dopamine/NE failure (neuros are fine, but receptors are not functioning properly), chemical instable, or electrical instable, or GABA deficient, dopamine hypofunction, or NE hypofunction.
Just because someone has chronic depression doesn't mean an antidepressant is the correct choice. Chronic depression looks a whole lot like the negative type symptoms of schizophrenia, except without the psychosis. That is, lack of pleasure, lack of interest in normal activities, lack of motivation, social withdrawal, etc. Antidepressants can make those symptoms even worse through a flattening or numbing effect. Often times a chronic depression needs an uplifting, not a flattening.
Outside of the antidepressant category top choices, as I see it, would be Ritalin, Adderall, Modafinil, Adrafinil, Zyprexa, Amisulpride. If the chronic depression has a significant anxiety component with it, then Klonopin or Xanax might be better choices to start with. Any drugs mentioned here will often speed the response time of an antidepressant as well, so you might consider starting two drugs at the same time. There are all kinds of studies proving this, such as early psychostimulant augmentation of Zoloft for fast response, early augmentation with Zyprexa..., early augmentation with Xanax..., and more.
I have seen it in literature a lot, and from my own experience I believe it, that chronic depression is much more difficult to cure than a straight-forward bout of depression. Chronic depression often requires multiple drugs, higher doses, and longer time for response. It's easy to think that chronic is mild, but in actuality it's more serious. Attack it aggressively. My lifelong chronic depression was not helped by antidepressants or mood stabilizers. Instead, a psychostimulant (Adrafanil) combined with an antipsychotic (Amisulpride) has been the most effective of the dozens of things I've tried.
John
Posted by Kaarina on January 7, 2001, at 21:07:53
In reply to Re: which AD for chronic depression?, posted by JohnL on January 6, 2001, at 5:26:52
"Chronic depression looks a whole lot like the negative type symptoms of schizophrenia, except without the psychosis."
Have you ever found any information on the internet which links the two?
Posted by JohnL on January 8, 2001, at 4:50:53
In reply to Re: chronic depression? John, posted by Kaarina on January 7, 2001, at 21:07:53
> "Chronic depression looks a whole lot like the negative type symptoms of schizophrenia, except without the psychosis."
>
> Have you ever found any information on the internet which links the two?Hi Kaarina,
I don't recall seeing anything that directly links the two. They are almost always considered to be totally different beasts, though I don't understand why. They are so similar and so easily mistaken. There are different kinds of depression. One kind is where the patient is functional, that is, they go to work everyday and stuff, but they are in a constant sad state with no pleasure in normal hobbies or activities, no motivation, no interest. The blahs. But not suicidal, and no crying fits, and no anxiety. This kind of depression is usually not serotonin related, but is instead usually dopamine or norepinephrine related. And it looks almost identical to the negative symptoms of schizophrenia, which is best treated with drugs that affect the dopamine and/or norepinephrine chemistries.There is a book by Hagop Akiskal called "Dysthymia, The Spectrum of Chronic Depression". He makes the case that all the psychiatric disorders have considerable overlap. So it is quite possible to confuse one diagnosis with another, and in fact many of us may actually have remnants of this and remnants of that without falling clearly into any one category. There are some schizophrenics who do not have pshychosis or hallucinations. They instead are socially withdrawn and have no pleasure in life. For all practical purposes of diagnosis and treatment, it looks identical to what many doctors might mistakenly call depression.
I've always felt that putting a label on someone's symptoms by making a diagnosis is not very helpful though. For example if someone is diagnosed as depressed, then they are prescribed antidepressants. If those don't work, then was the diagnosis accurate? What if they instead get better on a stimulant or an antipsychotic? Does that mean they had ADD or schizophrenia instead? It just gets too muddled. Doctors use well-constructed guidelines to make a diagnosis. But in the end, in all reality, that diagnosis has little to do with which medication actually worked.
John
Posted by Kaarina on January 9, 2001, at 18:37:05
In reply to Re: chronic depression? Kaarina, posted by JohnL on January 8, 2001, at 4:50:53
"They are almost always considered to be totally different beasts, though I don't understand why. They are so similar and so easily mistaken."
I have over the past year done amateur searches of the net and haven't been able to find much on the subject besides the diagnostic codes, etc. I do agree with most of what you wrote.
If you do ever come across something could you post it on the board for me.
Thanks again!
Posted by Andre Allard on January 10, 2001, at 13:14:16
In reply to which AD for chronic depression?, posted by ItsJustMe on January 5, 2001, at 4:11:05
Just like stjames wrote. SSRIs tend not to be efficient in severe and chronic cases of depression.
Before I began my second trial of effexor I researched the drug extensivly. What I found over and over again was that effexor was equal to and more often better than others at decreases depression scores.
What this means is that although an SSRI might improve your symptoms by 50%, which is considered a response, effexor has be shown to improve symptoms beyond 50%.
From what I researched I also came to a conclusion that of all the ADs, effexor tends to give a maximum response and lowers depression scores the greatest.
Posted by phillybob on January 10, 2001, at 13:40:42
In reply to Re: chronic depression? John, posted by Kaarina on January 7, 2001, at 21:07:53
I'm gonna cut and paste from research of the day:
*************************************************
Edward S. Hume, M.D., J.D.
Bipolar Disorder, the hidden epidemic.
1999/10/14At the 1998 meeting of the APA in Toronto, I put a question to a distinguished panel of clinicians gathered to present various methods of treating refractory depression. I asked, “When do you consider that you might be dealing with bipolar disorder and treat the patient with a mood stabilizer?”
They had no answer. None of them did.
I have an answer: you consider the diagnosis before you treat in the first place. Many patients who have depression have unrecognized bipolar disorder. Many people with bipolar disorder respond only partially or not at to antidepressants. They need mood stabilizers to get well.
I grill every patient I see thoroughly for possible hypomanic and sub-hypomanic episodes. Even little ones, brief ones, mild ones will cause me to apply a diagnosis of bipolar disorder and treat the patient with a mood stabilizer. I get great results. In new-to-treatment cases of depression I have found where the depression was part of a bipolar disorder, patients do beautifully on a mood stabilizer.
When you have a patient who has been referred to you because he/she has failed to respond to anti-depressants, think hard about bipolar disorder.
When you have a patient who has been referred to you from an alcohol rehab or methadone treatment program, think hard about bipolar disorder.
Pry carefully into the course of illness. Does the patient have “dysthymia”, never stably depressed? That is a pattern for anticonvulsant-responsive bipolar disorder. Dig for those micro-manic episodes.
We have wonderful treatment options for bipolar disorder.
I distinguish between the classic bipolar disorder, manic depressive illness, and the other forms of bipolar disorder. I still treat manic depressive illness with lithium. But the other forms of bipolar disorder I treat with anticonvulsants.
Your choices for a complete treatment with an anticonvulsant:
Divalproex sodium (Depakote in the US)
Topiramate (Topamax in the US)
Lamotrigine (Lamictal in the US)
Valproic acid (Depakene in the US; Epilim in some other countries) (In New Zealand—where divalproex was not available to ordinary patients—my patients often experienced full remission of symptoms with 200mg TID.)
When a patient responds to a mood stabilizer, the patient may not need an antidepressant. A hypnotic might be the only other medication needed.
To sum up, I believe that bipolar disorder should be a not be a diagnosis of exclusion. We should look hard for it. If we get the diagnosis right the first time, our patients will not suffer while their illness continues without effective treatment. If we get the diagnosis right the first time, our patients will be happy sooner. That’s where it’s at for us, isn’t it?
[Note for prescribing physicians—Using lamotrigine requires starting low and going slow. I have found that starting with the pediatric dosing form of 5mg BID and moving up every two weeks can be a practical way to dodge the rash (in my experience psychiatric patients seem to have this side effect more often than neurologic patients seem to). If the rash occurs at 5mg or 10mg BID, patients have simply continued taking lamotrigine at that low dose. Unlike the experience of patients taking adult doses, these patients have had their rashes fade over the course of a month, not to recur. IF YOU ARE A PATIENT reading this, do NOT do ANYTHING without consulting closely with the doctor who prescribed your medication. This page has been published as a communication to doctors, and is not intended to be advice to patients. I do not treat patients over the Internet nor give advice to patients over the Internet. If you are a patient and want some advice aimed at you, look at Dr. Ivan Goldberg’s wonderful website.]
E-mail: ehume@pshrink.com
To Dr. Hume's home page
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Dr. Bob is Robert Hsiung, MD,
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