Psycho-Babble Medication Thread 79075

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Re: Dysthymia/Chronic Depression - Med Time-Scales SalArmy4me

Posted by sweetmarie on September 19, 2001, at 16:24:07

In reply to Re: Dysthymia/Chronic Depression - Med Time-Scales sweetmarie, posted by SalArmy4me on September 19, 2001, at 13:54:14

Sal,

I have to disagree here - the most often quoted `time-scale` that I have come across in 11 years (and countless medication changes) is 8 - 12 weeks before the medication *starts* to work. This is from medical proffessionals - and I`ve been on the case, believe me.

Anna.

 

Re: Med Time-Scales - to Anna and SalArmy4me

Posted by Jane D on September 19, 2001, at 16:59:44

In reply to Re: Dysthymia/Chronic Depression - Med Time-Scales sweetmarie, posted by SalArmy4me on September 19, 2001, at 13:54:14

> There is no evidence to support the assertion that a medicine should take more than 6 weeks to work--if it is going to work at all. The only drug that might take months is Lithium--for smoothing out cycles.

Sal - My understanding is that anyone with a history like Anna's would have been screened out from most med studies. As are the suicidal. As are people with more than one diagnosis. It makes me wonder just how much we can infer from these studies. What do you think? - Jane

 

Re: Dysthymia/Chronic Depression - Med Time-Scales

Posted by JohnL on September 19, 2001, at 18:07:18

In reply to Dysthymia/Chronic Depression - Med Time-Scales , posted by sweetmarie on September 19, 2001, at 11:44:07


Just thought I would jump in with my two cents worth.

I am of the opinion that the closer a drug is to targetinig whatever the true underlying brain chemical problem is, the quicker and more dramatic it will work. I've just witnessed it too many times to discount it. And, the farther away a drug is from targeting the real problem, the longer it takes to work, if ever, through a cascade of chain reactions that occur over time. With that in mind, then it would just seem that whatever meds have already been tried, well, look elsewhere. Like in the antipsychotic category (Zyprexa, Risperdal), and/or the stimulant category(Ritalin, Adderall). I've seen a lot of life-long sufferers experience dramatic improvement in anywhere from one day to one week, when they finally stumbled onto the right meds through systematic trial and error.

I continue to favor Zyprexa + Prozac as a powerful double depression buster.
John

 

I think you might benefit from ketoconazole

Posted by Cruz on September 19, 2001, at 18:40:13

In reply to Dysthymia/Chronic Depression - Med Time-Scales , posted by sweetmarie on September 19, 2001, at 11:44:07

Your struggle resonates with alot of similarities to mine. After numerous trials, Ive finally found that ketoconazole to be effective. I am takeing 200mg once every two weeks. I responded immediately after the first dose. I think it might be an option for you. Keep well, look after yourself.

> This is a question about Dysthymia plus severe depressive episodes (`Double Depression`), the role of medications and the role of therapy.
>
> I suffer from `Double` depression, which is complicated by the fact that I`m treatment resistant. I have suffered Dysthymia ever since I was a child (I can remember being depressed at the age of 6, and I had a major episode at the age of 11 - 12). I have had a series of severe episodes since then, and was diagnosed with depression when I was 23 - although I knew that I had been depressed for a long time before that. My parents always `made light` of my depression, and had always put it down to moodiness and laziness. A very severe episode at age 23 made me eventually go to the GP, when I was prescribed with Dothiepin.
>
> This `worked` 100% first time (after being on it for a day), 2nd time it took about 8 months for me to feel a benefit. The only other medication that has worked for me was Seroxat (Paroxetine), which worked in the end - but it was about a year before I was having more good days than bad days. Since then, I have been on various meds and haven`t had any success.
>
> I was recently in hospital for 4 months, where I was started on Mirtazapine, Venlafaxine and Lamotragine. By the end of the 4 months, I was functioning and even having SOME good times (but not many). However, before admission, I was just existing - I couldn`t do anything but the very basic things, and wanted to be dead 98% of the time. So, I did come some way, and was prepared to keep working at my progress after discharge. After discharge just about everything that could go wrong - went wrong (after-care not being available, being alone again, plus this recent disaster). Basically, the momentum that I had built up came to a grinding halt.
>
> My question is about what my consultant (who is a leading professor in the field of TR depression) told me regarding recovery. He told me that recovery was likely to take about a year - maybe more. He said that this was generally the case with chronic (treatment resistant) cases like mine - this current episode has been going on for about 6 years. He explained that with such deep-rooted depression, meds would take longer, plus I had to deal with all the accumulated negative thought patterns that had developed as a result. I am due to have Cognitive Behavioural Therapy to help me with my automatic negative thoughts - it`s well recognised as a good treatment for treatment depression (or so I`ve heard).
>
> In the meantime (over the past years), my life has `narrowed` to just me and my family. I haven`t worked for 3 and a half years, and haven`t seen most of my friends for years. My self-confidence is minimal, and leaving the flat is a major thing for me.
>
> The stuff that my consultant told me makes sense to me logically - especially given that I have a `depressed personality` to begin with. My own consultant agrees with his interpretation, and has always emphasised my need for regular `social` contact, and also exercise - neither of which I have taken seriously in the past. My sister (who is a psychiatric nurse) also subscribes to this opinion - based on experience of working with chronic cases of depression.
>
> Has anyone got any feedback on this - i.e. whether or not this makes sense?
>
> Any info would be good.
>
> Thanks,
>
> Anna.

 

Re: I think you might benefit from ketoconazole

Posted by Neal on September 19, 2001, at 23:38:52

In reply to I think you might benefit from ketoconazole, posted by Cruz on September 19, 2001, at 18:40:13

Cruz,
I know you posted on an earlier thread, but what class of drug is ketoconazole?

-Neal

 

Re: Med Time-Scales - to Anna and Jane D

Posted by sweetmarie on September 20, 2001, at 3:43:45

In reply to Re: Med Time-Scales - to Anna and SalArmy4me, posted by Jane D on September 19, 2001, at 16:59:44

> > There is no evidence to support the assertion that a medicine should take more than 6 weeks to work--if it is going to work at all. The only drug that might take months is Lithium--for smoothing out cycles.
>
> Sal - My understanding is that anyone with a history like Anna's would have been screened out from most med studies. As are the suicidal. As are people with more than one diagnosis. It makes me wonder just how much we can infer from these studies. What do you think? - Jane

Jane,

I know that your question was directed at Sal, but it`s also my understanding that such research is *normally* carried out on people who are experiencing their second or third depressive episode. Cases like mine which are complicated by Dysthymia (plus other `life` issues, which I won`t go into) and a complex `negative` way of thinking, must surely necessitate an amount of therapy as well as meds. If the brain chemistry is altered, but other `issues` are not tackled, then surely `wellness` cannot be inevitable.

A good friend of mine who is Bipolar, who I met during one of my hospital visits now feels pretty much `well` after 14 years of illness. She tells me that it wasn`t until about 6 months after her last discharge that she began having more good days than bad. She now feels in a position to have counselling, but those months after discharge she had to cope with a lot of stuff, not least her son being put into care.

Re. the professor treating me - he told me that with some sufferers become well in a dramatic way `overnight`, whereas others see a gradual improvement over months. He has been treating chronic `resistant` sufferers for over 10 years, and must therefore be basing this assertion on experience.

I`ve never previouly subscribed to the medication is only effective with some kind of therapy idea, but it really does make sense to me now. Mandi (above mentioned friend) has always told me that it`s 50% meds and 50% effort. I was always sceptical, but I`ve seen the way that she`s turned her life around, and I`m convinced.

Then there`s the time that I was taking Seroxat - I think I started it in the August of 1994, and by about March 1995, I was seeing a lot more `good` days than `bad`. By the July, I was having only the occasional bad day, so much so that I stopped taking it (stupid in retrospect), and by September I had totally crashed. This suggests to me that the medication WAS working effectively, and I would not have experienced such good results if I had discontinued it after 3 months or so (which I had previously done before). Others that I have spoken to have had similar experiences.

This is just conjecture, but it seems to me to be possible that with continued use of different medications of different types over a long period, the brain`s chemicals will be out of kilter to an extent. So there`s that to sort out. This is not based on anything I`ve read or been told, just kind of makes sense to me.

Anna.


 

Re: Dysthymia/Chronic Depression - Med Time-Scales

Posted by sweetmarie on September 20, 2001, at 4:05:54

In reply to Re: Dysthymia/Chronic Depression - Med Time-Scales , posted by JohnL on September 19, 2001, at 18:07:18

> I am of the opinion that the closer a drug is to targetinig whatever the true underlying brain chemical problem is, the quicker and more dramatic it will work. I've just witnessed it too many times to discount it. And, the farther away a drug is from targeting the real problem, the longer it takes to work, if ever, through a cascade of chain reactions that occur over time. With that in mind, then it would just seem that whatever meds have already been tried, well, look elsewhere. Like in the antipsychotic category (Zyprexa, Risperdal), and/or the stimulant category(Ritalin, Adderall). I've seen a lot of life-long sufferers experience dramatic improvement in anywhere from one day to one week, when they finally stumbled onto the right meds through systematic trial and error.
>
> I continue to favor Zyprexa + Prozac as a powerful double depression buster.

John,

I take your point, but my experience of meds that have worked is that they have taken a long time to work - as I`ve already mentioned with Dothiepin and Seroxat (although the Dothiepin was `instant` the first time I was on it - literally the day after).

My depression is so severe that changing medications is a nightmare - I invarably become suicidal. And the fact that I `crashed` so badly when I stopped taking the Seroxat shows me that it WAS working, and working effectively. However, as I`ve said, it took from August 94 to about March 95, before I was having more good than bad days. With my record of resistance (up to that point I had been on 9 different meds/combos), I have to say that I`m glad that I waited that long.

I know of other people with cases of chronic resistant depression who have had a similar experience. And we all have different `workings` (metabolic rates etc.), so wouldn`t it be the case that where some respond to meds early (within the first few days, or the first week), some will take `over` the official time-scale?

As I have mentioned in my post to Jane, the professor treating me told me that people with chronic (`resistant`) depression either recover dramatically or gradually over many months. And, by implication, any gradation between. He has been working with chronic cases for over ten years, so must be basing this on previous results.

I was talking with a bloke who, like me, suffered for many years with severe depression. And, like me, he stopped meds after 2 or 3 months if he wasn`t seeing results. He was started on his last combination and encouraged to give it more time that he had previously. He said that after 8 months he was really well, and glad that he`d stuck it out.

At the moment my main objective is not to be suicidal, and be able to function relatively effectively. If this med combination does that, THEN I can start thinking about `finishing the job`. Does this make sense?

I`ve tried so many different meds and combinations of meds (plus I`ve had 20 ECT sessions), that I would hate to miss out on one that could work through my impatience.

Anna.

 

Re: I think you might benefit from ketoconazole Cruz

Posted by v on September 22, 2001, at 7:22:01

In reply to I think you might benefit from ketoconazole, posted by Cruz on September 19, 2001, at 18:40:13

i'm sorry if this has been asked before but what is ketoconazole and why or how 1 dose every 2 weeks?

thnaks,
v

> Your struggle resonates with alot of similarities to mine. After numerous trials, Ive finally found that ketoconazole to be effective. I am takeing 200mg once every two weeks. I responded immediately after the first dose. I think it might be an option for you. Keep well, look after yourself.
>

 

Ketoconazole(Nizoral), anti-fungul med.

Posted by Cruz on September 22, 2001, at 11:20:12

In reply to Re: I think you might benefit from ketoconazole Cruz, posted by v on September 22, 2001, at 7:22:01

One of probably many effects of Nizoral is that it lowers cortisol, which is usually elevated in people with depression. I believe there is an adjustment of my circadian rythmn with Nizoral treatment. I try to keep my sleeping hours consistant, to avoid altering my circadian rythmn after treating myself with Nizoral. So far I have been able to limit my use to 200 mg every 2 weeks.

> i'm sorry if this has been asked before but what is ketoconazole and why or how 1 dose every 2 weeks?
>
> thnaks,
> v
>
> > Your struggle resonates with alot of similarities to mine. After numerous trials, Ive finally found that ketoconazole to be effective. I am takeing 200mg once every two weeks. I responded immediately after the first dose. I think it might be an option for you. Keep well, look after yourself.
> >

 

Re: I think you might benefit from ketoconazole Neal

Posted by Elizabeth on September 24, 2001, at 12:24:38

In reply to Re: I think you might benefit from ketoconazole, posted by Neal on September 19, 2001, at 23:38:52

> what class of drug is ketoconazole?

It's an antiglucocorticoid. It's used topically in the treatment of fungal infections.

The dexamethasone suppression test is a pretty good predictor of who will respond to ketoconazole.

-elizabeth

 

Re: I think you might benefit from ketoconazole Elizabeth

Posted by SLS on September 24, 2001, at 22:39:19

In reply to Re: I think you might benefit from ketoconazole Neal, posted by Elizabeth on September 24, 2001, at 12:24:38

> > what class of drug is ketoconazole?
>
> It's an antiglucocorticoid. It's used topically in the treatment of fungal infections.
>
> The dexamethasone suppression test is a pretty good predictor of who will respond to ketoconazole.
>
> -elizabeth


Hi Elizabeth.

How would you characterize the quality of the antidepressant response produced by ketoconazole? What would you guess to be the percentage of people would respond to it. I'm a non-suppressor to the DST.

Muchas gracias.


- Scott

 

Re: ketoconazole SLS

Posted by Elizabeth on September 25, 2001, at 0:40:01

In reply to Re: I think you might benefit from ketoconazole Elizabeth, posted by SLS on September 24, 2001, at 22:39:19

> Hi Elizabeth.

Hi there.

> How would you characterize the quality of the antidepressant response produced by ketoconazole?

This I don't know. I never tried it, although I keep meaning to bring it up to my pdoc.

> What would you guess to be the percentage of people would respond to it. I'm a non-suppressor to the DST.

If you look in the literature, you may find mixed results. I think this is misleading. If you look only at the subset of depressed patients who are DST nonsupressors, antiglucocorticoids are pretty effective. (I have no idea how ketoconazole compares to other antiglucocorticoids.) Based on the existing data, it's hard to come up with a number, but I would expect nearly all DST nonsuppressors to show at least a partial response (certainly in this subset of patients I'd expect a higher response rate than is seen in depressed patients in general to typical AD therapy). This is just a guess, of course, so take it with a big grain of salt.

-e

 

Re: ketoconazole-Elizabeth

Posted by Cecilia on September 27, 2001, at 1:17:21

In reply to Re: ketoconazole SLS, posted by Elizabeth on September 25, 2001, at 0:40:01

> > Hi Elizabeth.
>
> Hi there.
>
> > How would you characterize the quality of the antidepressant response produced by ketoconazole?
>
> This I don't know. I never tried it, although I keep meaning to bring it up to my pdoc.
>
> > What would you guess to be the percentage of people would respond to it. I'm a non-suppressor to the DST.
>
> If you look in the literature, you may find mixed results. I think this is misleading. If you look only at the subset of depressed patients who are DST nonsupressors, antiglucocorticoids are pretty effective. (I have no idea how ketoconazole compares to other antiglucocorticoids.) Based on the existing data, it's hard to come up with a number, but I would expect nearly all DST nonsuppressors to show at least a partial response (certainly in this subset of patients I'd expect a higher response rate than is seen in depressed patients in general to typical AD therapy). This is just a guess, of course, so take it with a big grain of salt.
>
> -e


What percent of depressed people are DST non-suppressors?

 

Re: ketoconazole/dexamethasone suppression test Cecilia

Posted by Elizabeth on October 1, 2001, at 14:57:07

In reply to Re: ketoconazole-Elizabeth, posted by Cecilia on September 27, 2001, at 1:17:21

> What percent of depressed people are DST non-suppressors?

A good question! I don't know. Does anybody? I would guess it's less than half. But that's just a guess.

-elizabeth

 

Re: ketoconazole/dexamethasone suppression test

Posted by SLS on October 1, 2001, at 16:47:51

In reply to Re: ketoconazole/dexamethasone suppression test Cecilia, posted by Elizabeth on October 1, 2001, at 14:57:07

> > What percent of depressed people are DST non-suppressors?
>
> A good question! I don't know. Does anybody? I would guess it's less than half. But that's just a guess.
>
> -elizabeth


I was under the impression that it was more than half. That is a good question.

- Scott

 

DST in major depression SLS

Posted by Elizabeth on October 1, 2001, at 19:42:46

In reply to Re: ketoconazole/dexamethasone suppression test, posted by SLS on October 1, 2001, at 16:47:51

> I was under the impression that it was more than half. That is a good question.

It depends how narrowly you define major depression, that's my guess. (bearing in mind that even given the same diagnostic criteria, different clinicians may come to wildly different diagnoses of the same patient)

But this ought to be a pretty easy thing to find out....

Okay, the first report found that 40-50% of patients with "endogenous depression" (what we would call "major depression with melancholia" or something similar). Later studies seem to have confirmed this. The rate is similarly pretty high (higher, actually) in people with psychotic depression. But these results probably don't have much bearing on the general rate of DST-nonsuppression in people who are today considered to have major depression. In nonmelancholic depression the rate is more like 10-20%. In general, DST nonsuppression seems to correlate with severity (inpatients are more likely than outpatients to be nonsuppressors) and the presence of melancholic or psychotic features.

Lately there's been some interest in whether people respond differently to dexamethasone before and after successful treatment or remission. It appears that the DST response switches (i.e., that dexamethasone is able to suppress the HPA axis again) when remission is achieved.

That's a general overview. The DST has been studied in other disorders too, with variable and interesting results. Because of the recent surge in diagnosis of bipolar disorders (especially bipolar II), I'd prefer not to discuss the rate in bipolar depression, as the results of clinical trials that used more restrictive samples might be misleading.

-elizabeth

 

Re: DST in major depression-SLS and ELizabeth

Posted by Cecilia on October 2, 2001, at 3:38:38

In reply to DST in major depression SLS, posted by Elizabeth on October 1, 2001, at 19:42:46

> > I was under the impression that it was more than half. That is a good question.
>
> It depends how narrowly you define major depression, that's my guess. (bearing in mind that even given the same diagnostic criteria, different clinicians may come to wildly different diagnoses of the same patient)
>
> But this ought to be a pretty easy thing to find out....
>
> Okay, the first report found that 40-50% of patients with "endogenous depression" (what we would call "major depression with melancholia" or something similar). Later studies seem to have confirmed this. The rate is similarly pretty high (higher, actually) in people with psychotic depression. But these results probably don't have much bearing on the general rate of DST-nonsuppression in people who are today considered to have major depression. In nonmelancholic depression the rate is more like 10-20%. In general, DST nonsuppression seems to correlate with severity (inpatients are more likely than outpatients to be nonsuppressors) and the presence of melancholic or psychotic features.
>
> Lately there's been some interest in whether people respond differently to dexamethasone before and after successful treatment or remission. It appears that the DST response switches (i.e., that dexamethasone is able to suppress the HPA axis again) when remission is achieved.
>
> That's a general overview. The DST has been studied in other disorders too, with variable and interesting results. Because of the recent surge in diagnosis of bipolar disorders (especially bipolar II), I'd prefer not to discuss the rate in bipolar depression, as the results of clinical trials that used more restrictive samples might be misleading.
>
> -elizabeth

It sounds from what you`re saying that people with atypical depression are not too likely to respond to ketoconazole, is that correct? Also Cruz says he takes it only once every 2 weeks, wouldn`t it be long gone from your system before 2 weeks? My pdoc has never suggested a DST suppression test, (of course, I`m in a HMO), what is the main purpose of this test? I`ll ask my pdoc about this at my next appointment, but it`d be nice to have some more info, I dont have the impression that this is something most doctors would go for.

 

Re: DST in major depression Elizabeth

Posted by SLS on October 2, 2001, at 8:59:22

In reply to DST in major depression SLS, posted by Elizabeth on October 1, 2001, at 19:42:46

Hi Elizabeth.

Thanks. That helps clarify things.

> Because of the recent surge in diagnosis of bipolar disorders (especially bipolar II), I'd prefer not to discuss the rate in bipolar depression, as the results of clinical trials that used more restrictive samples might be misleading.

I'm a little confused. Do you feel the more restrictive criteria used in the bipolar studies of DST were invalid? How old are the studies? I guess I should do a search on Medline.

My case profile is a little weird. I guess you know that by now. I forgot which doctor (witch-doctor) made the comment to me, but he said my condition was more similar to bipolar I than bipolar II. I think his main criterion was the severity of my manic episodes, even though they were all induced by exposures to medication.

Parnate + desipramine = hypomania - > psychotic dysphoric mania
Nardil = protracted hypomania, mixed type
Nardil discontinuation = severe psychotic mania, dysphoric.

Some diagnostic schemes proposed for DSM V include this presentation as bipolar III. I think another diagnostic subtype once proposed for bipolar disorder was one for which chronic depression is the only symptom. For some reason, the word "symptom" just doesn't cut it for me. I guess I'm somewhere in between these two. Add a smidgen of ultra rapid-cyclicity, and you've got a neat little package. Between ages 20 - 22, I displayed a remarkably regular 11-day cycle: 8 days of severe depression followed by 3 days of normothymia followed by 8 days of severe depression... etc. I was able to keep a social calendar around it. Unfortunately, Fieve's lithium did away with all of that.


- Scott

 

mood disorders, ketoconazole, etc - Scott, Cecilia

Posted by Elizabeth on October 2, 2001, at 10:58:06

In reply to Re: DST in major depression Elizabeth, posted by SLS on October 2, 2001, at 8:59:22

Hi everyone.

Cecilia:
> It sounds from what you`re saying that people with atypical depression are not too likely to respond to ketoconazole, is that correct?

Yes, that would seem to follow from what we know about it so far. People with atypical depression do seem to have some sort of HPA axis dysregulation, but it's different from the problems seen in "typical" depression (which, as we've seen, isn't so typical after all :-) ).

> Also Cruz says he takes it only once every 2 weeks, wouldn`t it be long gone from your system before 2 weeks?

I'm not sure what to make of this, but there certainly are some medications which can be taken in this way, for reasons other than
Some researchers have used dexamethasone, given for just a few days a month (or something like that), to achieve the same effect as you'd get from taking ketoconazole. I'm not sure what is achieved by Cruz's strategy, though; I would need to know the details of ketoconazole's pharmacodynamics and pharmacokinetics, which I don't.

> My pdoc has never suggested a DST suppression test, (of course, I`m in a HMO), what is the main purpose of this test?

It tests whether your cortisol level goes down following a single dose of the corticosteroid dexamethasone. If it doesn't, there's something odd going on. Alcoholism, anorexia nervosa, Cushing's syndrome, and some other things can also cause abnormal DST response (i.e., nonsupression).

Scott:
> I'm a little confused. Do you feel the more restrictive criteria used in the bipolar studies of DST were invalid? How old are the studies? I guess I should do a search on Medline.

On the contrary. I think that in clinical trials, researchers adhere more firmly to diagnostic criteria than do clinicians in naturalistic settings. Although the DSM criteria aren't perfect by a long shot, they're the best we've got. So I think that findings about bipolar disorder may not apply to "soft" bipolar disorders which seem to have become extremely common in the last few years.

> My case profile is a little weird. I guess you know that by now.

If our case profiles weren't a little weird, we might not be here. :-}

> I forgot which doctor (witch-doctor) made the comment to me, but he said my condition was more similar to bipolar I than bipolar II. I think his main criterion was the severity of my manic episodes, even though they were all induced by exposures to medication.

That's interesting. Multiple full-blown manias, even if they only occur when you're on ADs, are a lot more suggestive of BP than are the "mixed hypomania" and things like that (these quasi-hypomanias seem to be pretty common reactions to ADs and, IMO, shouldn't be used to justify a dx of bipolar disorder).

> Parnate + desipramine = hypomania - > psychotic dysphoric mania

I never tried desipramine with MAOIs, although it would be a logical next step. I think I'm going to try something different, though: psychostimulants (which I didn't tolerate in combination with MAOIs).

> Nardil = protracted hypomania, mixed type

When Nardil pooped out on me, my depression didn't exactly return in its original state: instead of being strictly depressed, I got really irritable and excitable (in a bad way -- kind of reminded me of adolescence, only much more so). The possibility of mixed mania was brought up, but it was never confirmed and trials of Neurontin, Lamictal, and Depakote didn't help any.

> Nardil discontinuation = severe psychotic mania, dysphoric.

MAOI withdrawal symptoms, whatever you want to call them, *suck*. My experience was an exacerbation of the poop-out syndrome described above. After several *months* of this -- ouch -- I returned to my former depressed state.

> Some diagnostic schemes proposed for DSM V include this presentation as bipolar III.

That's what the doctors I talked to in Boston called it.

> I think another diagnostic subtype once proposed for bipolar disorder was one for which chronic depression is the only symptom.

I must be missing something: in what sense is that "bipolar?"

> Between ages 20 - 22, I displayed a remarkably regular 11-day cycle: 8 days of severe depression followed by 3 days of normothymia followed by 8 days of severe depression... etc. I was able to keep a social calendar around it. Unfortunately, Fieve's lithium did away with all of that.

Unfortunately?

 

Re: mood disorders, ketoconazole, etc - Scott, Cecilia Elizabeth

Posted by SLS on October 2, 2001, at 13:48:30

In reply to mood disorders, ketoconazole, etc - Scott, Cecilia, posted by Elizabeth on October 2, 2001, at 10:58:06

> Hi everyone.

Hi back.

I had thought to mention it to you a few weeks ago, but I figured I'd wait to see how things turned out for you with desipramine. It seems to me that the next logical step would be to add Nardil right now. Since you reported that DMI produced some vague improvements, and Nardil had once been helpful to you, the strategy of combining them probably makes sense. I wouldn't choose Parnate for you given your history of hypertensive reactions to it. For me, one benefit of adding desipramine to Nardil has been that it helps to ward off carbohydrate cravings and definitely minimizes weight-gain compared to those time when I took Nardil by itself. Also, I think the traditional approach when combining these two medications is to establish the tricyclic first and add the MAOI afterward. I've done it both ways without any problems. You are currently in the position to initiate the combination in the order most doctors would feel more comfortable with.

> > Nardil discontinuation = severe psychotic mania, dysphoric.
>
> MAOI withdrawal symptoms, whatever you want to call them, *suck*. My experience was an exacerbation of the poop-out syndrome described above. After several *months* of this -- ouch -- I returned to my former depressed state.

I would not call this so much a withdrawal symptom as a rebound reaction. One time, mania actually developed latently a week or two after my having gone through the withdrawal-type stuff.

> > Some diagnostic schemes proposed for DSM V include this presentation as bipolar III.
>
> That's what the doctors I talked to in Boston called it.
>
> > I think another diagnostic subtype once proposed for bipolar disorder was one for which chronic depression is the only symptom.
>
> I must be missing something: in what sense is that "bipolar?"

I think the idea is that in these instances, depression is the only expression of a bipolar etiology, although I don't know how it would be differentiated clinically. I'm sure that at some point, it will be. It does make sense to ascertain whether a sufferer of chronic or recurrent depression is bipolar or unipolar. The treatment approaches for the two are substantially different with regard to the place that mood-stabilizing drugs occupy in a treatment regime. I think that statistical outcomes for properly identified "unipolar" bipolars would be higher. My case might make a good example. I am pretty sure that my diagnosis of bipolar is accurate. My sister has a softer case of bipolar that has manifested as moderate depression and Nardil-induced hypomania. My mother has what would probably qualify as a bipolar temperament. I was unipolar up until the point I became bipolar ;-). I became bipolar once my manic reaction to antidepressants emerged. Of course, I was always bipolar. Perhaps an earlier intervention with valproate or carbamazepine in combination with lithium would have helped prevent my current refractoriness to medical treatment.

Actually, I probably have Prozac to blame for all of this, but that's another story.

> > Between ages 20 - 22, I displayed a remarkably regular 11-day cycle: 8 days of severe depression followed by 3 days of normothymia followed by 8 days of severe depression... etc. I was able to keep a social calendar around it. Unfortunately, Fieve's lithium did away with all of that.
>
> Unfortunately?

Yes. 3 days of living out of every 11 is better than 0 days out of 365. Lithium seemed to abolish my cycle within a few weeks of beginning treatment.

I was having a conversation with a friend of mine this morning when the topic came up of how one experiences time. For me, 9 years ago seems more like 9 months ago. I think being so vegetative and without the varied activities that most people experience daily has caused time to slip away for me and somehow become compressed. By contrast, a single day in an improved state can contain more life in it than a full year of my depressed state. This also applies to personal growth and self-actualization. 5 years ago, Dr. Apter pulled me off of Nardil + desipramine in favor of Lamictal monotherapy. During my second and third weeks of Lamictal treatment, I experienced a wonderfully clean and robust antidepressant response. Unfortunately, it faded and was not recoverable with as much as 500mg/day. In retrospect, I think it was a combination of a rebound improvement from the discontinuation of the antidepressants superimposed upon the mild therapeutic effects that Lamictal provides me. During this time, there were not enough hours in a day to do everything I felt like doing. Every moment became an actualization of my potential mental and physical experience. It's great to have the desire and confidence to walk into any night club alone and walk out with a new friend. I was like a kid in a candy store. It was a hell of a lot of fun. Thank God I was blessed with a Carpe Diem disposition. I seem not to waste a moment in lament, even after two decades of pain, failure, and mental oppression. I hope this hasn't been beat out of me since then. I doubt it has.

Thanks for listening.


- Scott

 

Re: mood disorders, ketoconazole, etc - Scott, Cec Elizabeth

Posted by Zo on October 2, 2001, at 15:14:41

In reply to mood disorders, ketoconazole, etc - Scott, Cecilia, posted by Elizabeth on October 2, 2001, at 10:58:06

> People with atypical depression do seem to have some >sort of HPA axis dysregulation, but it's different from >the problems seen in "typical" depression (which, as >we've seen, isn't so typical after all :-) ).

This is said to be true with CFS as well. Hmm.

> Also Cruz says he takes it only once every 2 weeks, >wouldn`t it be long gone from your system before 2 >weeks?

Nizoral is strange stuff. The Rx for it's onlabel use is commonly for 1 tab. . .and is said to to go on working for days, if not a week.

> My case profile is a little weird. I guess you know that >by now.

Did Cece say that?! It is not! Besides, it all depends on what the docs you've been exposed to think.

> When Nardil pooped out on me, my depression didn't >exactly return in its original state: instead of being >strictly depressed, I got really irritable and excitable (in a >bad way -- kind of reminded me of adolescence, only >much more so). The possibility of mixed mania was >brought up

Hm. Sounds way familiar. . like ten days ago, in my Mixed States.

> MAOI withdrawal symptoms, whatever you want to call >them, *suck*. My experience was an exacerbation of the >poop-out syndrome described above. After several >*months* of this -- ouch -- I returned to my former >depressed state.

*And* there is a *major* poop-out after any kind of mania. I see it like taking cocaine: it feels so good, so right, because all your chemicals are being released at once. . which means there ain't *nothing* left when it's done. A ghastly state to which even depression is perferable.

> >Some diagnostic schemes proposed for DSM V include > >this presentation as bipolar III.
>
> That's what the doctors I talked to in Boston called it.

Really? Can anybody say more?

Thanks,
Zo

 

Re: mood disorders, ketoconazole, etc - Scott, Cec SLS

Posted by Zo on October 2, 2001, at 15:26:55

In reply to Re: mood disorders, ketoconazole, etc - Scott, Cecilia Elizabeth, posted by SLS on October 2, 2001, at 13:48:30

> For me, 9 years ago seems more like 9 months ago. I think >being so vegetative and without the varied activities that >most people experience daily has caused time to slip >away for me and somehow become compressed. By >contrast, a single day in an improved state can contain >more life in it than a full year of my depressed state.

Yes!

> This also applies to personal growth and >self-actualization.

Oh yes!

> During this time, there were not enough hours in a day >to do everything I felt like doing. Every moment became >an actualization of my potential mental and physical >experience.

Ahem. I too have had many such golden times. Every symptom of my Chronic Fatigue is *gone*, I think I'm cured, I have posture , I am free of pain, a busy, happy little bee. . .and, god damn it, they've all been one form of mania or another.

And since my Bipolar has gotten spectacularly worse, I am now on a forced search for a Feel Good that isn't mania. Of course, as my pdoc said, they are only the tiniest degree apart.

Zo

 

Re: mood disorders, ketoconazole, etc - Scott, Cec

Posted by SLS on October 3, 2001, at 11:07:12

In reply to Re: mood disorders, ketoconazole, etc - Scott, Cec SLS, posted by Zo on October 2, 2001, at 15:26:55

> > For me, 9 years ago seems more like 9 months ago. I think >being so vegetative and without the varied activities that >most people experience daily has caused time to slip >away for me and somehow become compressed. By >contrast, a single day in an improved state can contain >more life in it than a full year of my depressed state.
>
> Yes!
>
> > This also applies to personal growth and >self-actualization.
>
> Oh yes!
>
> > During this time, there were not enough hours in a day >to do everything I felt like doing. Every moment became >an actualization of my potential mental and physical >experience.
>
> Ahem. I too have had many such golden times. Every symptom of my Chronic Fatigue is *gone*, I think I'm cured, I have posture , I am free of pain, a busy, happy little bee. . .and, god damn it, they've all been one form of mania or another.
>
> And since my Bipolar has gotten spectacularly worse, I am now on a forced search for a Feel Good that isn't mania. Of course, as my pdoc said, they are only the tiniest degree apart.
>
> Zo

Dear Zo,

Thanks for your response. It is in some way comforting to know that I have "comrades" in this frustrating and painful struggle. I'm sure other people posting on Psycho-Babble profit in this way as well.

I wanted to make one remark about the *hypomania* that is part of a true bipolar II. It very rarely becomes severe and is sometimes very manageable. I'm probably not up to date with this stuff, but by definition, severe mania does not occur with bipolar II. If such a mania occurs without being precipitated by medication, I think the illness must necessarily be reevaluated and diagnosed as bipolar I.

The point is this. Many people lead productive lives in a chronic state of hypomania. I think some doctors find that for some individuals, allowing it to continue is preferable to the results of the medical treatments tried. Perhaps the hypomania is resistant to mood stabilizing drugs or that these drugs produce unacceptable side effects or produce depression. Maybe this is an option for you.

Trying to read between the lines, it sounds to me like your hypomania is somehow impairing your judgment and functioning sufficiently to be treated. Do you feel this is true? Even if your episodes of hypomania are manageable and don't impact negatively upon your life, should they consistently be a prelude to or facilitating a depressive episode, it is important that it be treated and your cycling minimized.

What do you think? How would you describe your mania? How often do you get depressed, and how severe are these episodes? Does depression always follow mania? Do you ever experience periods of normalcy?

Please don't answer my questions if you feel they are too personal.

It is quite possible that antidepressants only make things worse, and that treatment with mood-stabilizers alone is indicated.


- Scott

 

Re: mood disorders SLS

Posted by Zo on October 3, 2001, at 16:11:23

In reply to Re: mood disorders, ketoconazole, etc - Scott, Cec, posted by SLS on October 3, 2001, at 11:07:12

> I wanted to make one remark about the *hypomania* that is part of a true bipolar II. It very rarely becomes severe and is sometimes very manageable.

True .But if you rapid cycl, like I now know is true of me, the ups and downs make a mishmosh of your days and confuses the hell out of your meds.

>I'm probably not up to date with this stuff, but by >definition, severe mania does not occur with bipolar II. If >such a mania occurs without being precipitated by >medication, I think the illness must necessarily be

I'll bring this up with pdoc. My impression is it's not that distinct, at the lower levels of Mania and the higher levels of Hypomania. This last go round I became "possessed". . . but never gradulated to Baking Cookies For San Francisco, as an old doc put it, and never have.. Now that, to me, *is* intuitively and experientially, utterly distinct.

But one thing I don't know is how long people stay high. If this is not daily cycling, my next level hypomania doesn't last more than 2 or 3 weeks. . .it crashes itself.

> The point is this. Many people lead productive lives in a >chronic state of hypomania.

Hm. I would guess they cycle alright, but their lows are not horrible. It's impossible for the chemistry to go and to *stay* on go, we can only churn out so much per period.

> I think some doctors find that for some individuals, >allowing it to continue is preferable to the results of the >medical treatments tried.

Actually we played with that, which is how my illness got worse. He let me poke at a mild high, when I could. . .and in the long run, I am sorry I did. What goes up must come down. To be able to live in that state. . .I feel like a junkie for that state. It wasn't til 2 weeks ago. . after all these years. . . that the clear and easy plans for how I'm going to suicide came to me, as is often the case with Agitated Mania, in devilish ease.

Now I have to live with that. I wish I'd never let a single hypomania run. Lucky are those creatives who can do it.

> Perhaps the hypomania is resistant to mood stabilizing >drugs or that these drugs produce unacceptable side >effects or produce depression. Maybe this is an option >for you.

I just pushed up to 3 lamictal, a bit ahead of time, and am waking up in *much* better shape.

> Trying to read between the lines, it sounds to me like your hypomania is somehow impairing your judgment and functioning sufficiently to be treated. Do you feel this is true? Even if your episodes of hypomania are manageable and don't impact negatively upon your life, should they consistently be a prelude to or facilitating a depressive episode, it is important that it be treated and your cycling minimized.
>

Sounds like we're in agreement. We talked about gettting rid of Effexor once I get a bit stronger. If I have enough days that feel this reliable, like the ice is thick and I don't have to *think* about whether it will support me, I'd like to get off the AD. For cycling's sake.

> Does depression always follow mania?
Damn it, yes. See above.

>Do you ever experience periods of normalcy?
I don't think I am on very familiar terms with normalcy. You mean, with no meds at all?

> Please don't answer my questions if you feel they are too personal.

Not at all, ask anything you like.

> It is quite possible that antidepressants only make things worse, and that treatment with mood-stabilizers alone is indicated.
>
> - Scott

Absolutely, and thanks for your interest.

Zo

 

stuff SLS

Posted by Elizabeth on October 6, 2001, at 11:03:28

In reply to Re: mood disorders, ketoconazole, etc - Scott, Cecilia Elizabeth, posted by SLS on October 2, 2001, at 13:48:30

> It seems to me that the next logical step would be to add Nardil right now.

Interesting idea, but the other times I've taken Nardil, it's pooped out (or something) with devastating results (in addition to causing unbelievably rapid weight gain). I mentioned this in my last post. I'm not willing to risk that again. If I were going to add a MAOI, it would be Parnate. But that's not the direction I'm planning on going, either. As far as I can tell, desipramine and Parnate are interchangeable for me. Neither one helps with the anergia. Buprenorphine helps, but I'm hoping that I can find something with fewer side effects that will work as well.

> I wouldn't choose Parnate for you given your history of hypertensive reactions to it.

Actually I solved this problem, after which I was able to take it at 60 mg/day for more than a year without any problems. I might have been able to go up to 80 (taken in 4 divided doses).

> For me, one benefit of adding desipramine to Nardil has been that it helps to ward off carbohydrate cravings and definitely minimizes weight-gain compared to those time when I took Nardil by itself.

> Also, I think the traditional approach when combining these two medications is to establish the tricyclic first and add the MAOI afterward.

That's right, although the two times I've tried such a combination (Parnate + amoxapine, Marplan + nortriptyline), I did it in the reverse order with no ontoward consequences (although I couldn't tolerate either of those TCAs past about 75 mg).

> I think the idea is that in these instances, depression is the only expression of a bipolar etiology, although I don't know how it would be differentiated clinically.

Maybe the cycling in this sort of situation could be slowed by mood stabilisers, as you suggest.

> I was unipolar up until the point I became bipolar ;-).

:-)

> I became bipolar once my manic reaction to antidepressants emerged.

Well, I've had mania on ADs too, and what might have been a dysphoric mania on Nardil (although mood stabilizers didn't help), but I don't think I'm considered bipolar. I've never been dx'ed as bipolar, although I have tried several mood stabilisers (Depakote, Lamictal, Neurontin, lithium, and now Trileptal).

> > > Unfortunately, Fieve's lithium did away with all of that.
> >
> > Unfortunately?
>
> Yes. 3 days of living out of every 11 is better than 0 days out of 365. Lithium seemed to abolish my cycle within a few weeks of beginning treatment.

And left you stable at what level? (BTW, 0/11 = 0/365 = 0. :-})

> I think being so vegetative and without the varied activities that most people experience daily has caused time to slip away for me and somehow become compressed.

I understand. I also understand how vast one day can seem when you're feeling well -- you described it better than I ever could.

> During my second and third weeks of Lamictal treatment, I experienced a wonderfully clean and robust antidepressant response. Unfortunately, it faded and was not recoverable with as much as 500mg/day.

I went up to 500 mg also, but I never got anything out of it.

-elizabeth


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