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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 9 of 9. This is the beginning of the thread.
Posted by jay on April 29, 2002, at 17:37:43
Hey folks:
Well, after a lengthy trial of Effexor, Welbutrin, and Zyprexa all at various doses, and even seperately, I am taking a return shot at Nortriptyline.(It has been almost three years!) (Note: I seem to only get benefit from the brand name of this drug, Aventyl or Pamelor)
This medication was *the* only medication I can recall that seemed like a 'powerhouse' of greatness compared to all the newer drugs. I know my depression is very much so organic based, and that is I suffered from severe developmental disabilities when I was young. I almost ended up in a 'special' school for developmentally handicap kids because of this. I have worked now as an adult with many developmentally handicap adults, and the medications that seem to help their symptoms are many of the older meds.
In honesty, the best med I have found to take with Nortriptyline (actually, even PRN) has been some of the stronger benzos. I also really feel that many of my anxious sysptoms come from the developmental handicap experience, and it took a MAJOR blow to my self esteem as a youngster, and that has snowbaled into areas of major difficulty regrading work; relationships; finances; all things that can make-or-break our lives.
Anybody else with similar symptoms, especially related to childhood disorders? If the Nortip/benzo combo works, may I be best in just working with that?
I may have symptoms of 'ADD', BUT, I honestly think they are more related to my developmental problems, and ADD is Dx'ed too broadly too often. Plus, I have had horrid dysphoric reactions to the stimulants. So, I won't go the stimulant route. Also, after augmenting with so many meds, much of it honestly not only is a shot in the dark, and I think often is an excuse for doctors not to simply prescribe a med that looks after many, many symptoms, which are benzos.
Anyhow...any comments appreciated! Thanx..
Jay
Posted by Ritch on April 29, 2002, at 23:44:21
In reply to Nortriptyline Augmentation..Questions, posted by jay on April 29, 2002, at 17:37:43
> Hey folks:
>
> Well, after a lengthy trial of Effexor, Welbutrin, and Zyprexa all at various doses, and even seperately, I am taking a return shot at Nortriptyline.(It has been almost three years!) (Note: I seem to only get benefit from the brand name of this drug, Aventyl or Pamelor)
>
> This medication was *the* only medication I can recall that seemed like a 'powerhouse' of greatness compared to all the newer drugs. I know my depression is very much so organic based, and that is I suffered from severe developmental disabilities when I was young. I almost ended up in a 'special' school for developmentally handicap kids because of this. I have worked now as an adult with many developmentally handicap adults, and the medications that seem to help their symptoms are many of the older meds.
>
> In honesty, the best med I have found to take with Nortriptyline (actually, even PRN) has been some of the stronger benzos. I also really feel that many of my anxious sysptoms come from the developmental handicap experience, and it took a MAJOR blow to my self esteem as a youngster, and that has snowbaled into areas of major difficulty regrading work; relationships; finances; all things that can make-or-break our lives.
>
> Anybody else with similar symptoms, especially related to childhood disorders? If the Nortip/benzo combo works, may I be best in just working with that?
>
> I may have symptoms of 'ADD', BUT, I honestly think they are more related to my developmental problems, and ADD is Dx'ed too broadly too often. Plus, I have had horrid dysphoric reactions to the stimulants. So, I won't go the stimulant route. Also, after augmenting with so many meds, much of it honestly not only is a shot in the dark, and I think often is an excuse for doctors not to simply prescribe a med that looks after many, many symptoms, which are benzos.
>
> Anyhow...any comments appreciated! Thanx..
>
> JayHi Jay,
Notriptyline+benzo combo working very effectively suggests ADD+anxiety dx. Nortrip. is the only TCA I can take in the daytime and still function reasonably. I added it to Wellbutrin a few times because of WB agitation and it settled it down! A Nortripytline+Zoloft combo works really well too for ADD+anxiety (if you can tolerate the Zoloft).
Mitch
Posted by jay on April 30, 2002, at 14:43:28
In reply to Re: Nortriptyline Augmentation..Questions » jay, posted by Ritch on April 29, 2002, at 23:44:21
> > Hey folks:
> >
> > Well, after a lengthy trial of Effexor, Welbutrin, and Zyprexa all at various doses, and even seperately, I am taking a return shot at Nortriptyline.(It has been almost three years!) (Note: I seem to only get benefit from the brand name of this drug, Aventyl or Pamelor)
> >
> > This medication was *the* only medication I can recall that seemed like a 'powerhouse' of greatness compared to all the newer drugs. I know my depression is very much so organic based, and that is I suffered from severe developmental disabilities when I was young. I almost ended up in a 'special' school for developmentally handicap kids because of this. I have worked now as an adult with many developmentally handicap adults, and the medications that seem to help their symptoms are many of the older meds.
> >
> > In honesty, the best med I have found to take with Nortriptyline (actually, even PRN) has been some of the stronger benzos. I also really feel that many of my anxious sysptoms come from the developmental handicap experience, and it took a MAJOR blow to my self esteem as a youngster, and that has snowbaled into areas of major difficulty regrading work; relationships; finances; all things that can make-or-break our lives.
> >
> > Anybody else with similar symptoms, especially related to childhood disorders? If the Nortip/benzo combo works, may I be best in just working with that?
> >
> > I may have symptoms of 'ADD', BUT, I honestly think they are more related to my developmental problems, and ADD is Dx'ed too broadly too often. Plus, I have had horrid dysphoric reactions to the stimulants. So, I won't go the stimulant route. Also, after augmenting with so many meds, much of it honestly not only is a shot in the dark, and I think often is an excuse for doctors not to simply prescribe a med that looks after many, many symptoms, which are benzos.
> >
> > Anyhow...any comments appreciated! Thanx..
> >
> > Jay
>
> Hi Jay,
>
> Notriptyline+benzo combo working very effectively suggests ADD+anxiety dx. Nortrip. is the only TCA I can take in the daytime and still function reasonably. I added it to Wellbutrin a few times because of WB agitation and it settled it down! A Nortripytline+Zoloft combo works really well too for ADD+anxiety (if you can tolerate the Zoloft).
>
> MitchHi Mitch:
Hnmm..interesting, as I was at one point on Zoloft + nortriptyline, with excellent results. I really think this is a highly underused med. So far Nortriptyline + benzo seems good, and it was this combo that has only ever pulled me from the depths of depression, helping me lose weight, and feel much more "complete", and didn't numb me like the newer meds. (Esp Effexor). I actually found my first and best romantic relationship on nortriptyline, and actually lived very well on that med. I think I am going to stay with it, period, as I have found no med that equals it.
It also seems to be a major reliever of social phobia, minus the 'speedy' effect of SSRI's.Anyhow...thanks for your comments. :-)
Jay
Posted by Ritch on April 30, 2002, at 23:05:49
In reply to Re: Nortriptyline Augmentation..Questions » Ritch, posted by jay on April 30, 2002, at 14:43:28
Posted by Dave1 on May 1, 2002, at 23:52:12
In reply to Nortriptyline Augmentation..Questions, posted by jay on April 29, 2002, at 17:37:43
> Hey folks:
>
> Well, after a lengthy trial of Effexor, Welbutrin, and Zyprexa all at various doses, and even seperately, I am taking a return shot at Nortriptyline.(It has been almost three years!) (Note: I seem to only get benefit from the brand name of this drug, Aventyl or Pamelor)
>
> This medication was *the* only medication I can recall that seemed like a 'powerhouse' of greatness compared to all the newer drugs. I know my depression is very much so organic based, and that is I suffered from severe developmental disabilities when I was young. I almost ended up in a 'special' school for developmentally handicap kids because of this. I have worked now as an adult with many developmentally handicap adults, and the medications that seem to help their symptoms are many of the older meds.
>
> In honesty, the best med I have found to take with Nortriptyline (actually, even PRN) has been some of the stronger benzos. I also really feel that many of my anxious sysptoms come from the developmental handicap experience, and it took a MAJOR blow to my self esteem as a youngster, and that has snowbaled into areas of major difficulty regrading work; relationships; finances; all things that can make-or-break our lives.
>
> Anybody else with similar symptoms, especially related to childhood disorders? If the Nortip/benzo combo works, may I be best in just working with that?
>
> I may have symptoms of 'ADD', BUT, I honestly think they are more related to my developmental problems, and ADD is Dx'ed too broadly too often. Plus, I have had horrid dysphoric reactions to the stimulants. So, I won't go the stimulant route. Also, after augmenting with so many meds, much of it honestly not only is a shot in the dark, and I think often is an excuse for doctors not to simply prescribe a med that looks after many, many symptoms, which are benzos.
>
> Anyhow...any comments appreciated! Thanx..
>
> JayHow about adding lithium. I did that with anafranil and had some success. I was already taking a good dose of ativan so I was already augmenting with a benzo.
Note: I had some problems getting a doctor to prescribe the 'old' tricyclics. It was pretty annoying.
See you,
Dave
Posted by JohnX2 on May 2, 2002, at 22:41:44
In reply to Re: Nortriptyline Augmentation..Questions » jay, posted by Ritch on April 29, 2002, at 23:44:21
>
> Hi Jay,
>
> Notriptyline+benzo combo working very effectively suggests ADD+anxiety dx. Nortrip. is the only TCA I can take in the daytime and still function reasonably. I added it to Wellbutrin a few times because of WB agitation and it settled it down! A Nortripytline+Zoloft combo works really well too for ADD+anxiety (if you can tolerate the Zoloft).
>
> MitchHi Mitch,
I've been toying with the idea of adding in low dose
Nortriptyline to me Lamictal+Serzone+Klonopin.I bumped the Serzone dose to upper limits and dropped
topamax on a hunch that this would stabilize me and
still be anti-depressant. The Serzone generally doesn't
induce hypomania and helps with myofacial pain.Unfortunately I am still feeling a bit of atypical
depression symptoms.I always wake up in the morning feeling like crap.
Do you think a Nortriptyline add on would help with
A) pscyhomotor agitation (ADD or hypomania...?)
B) atypical depression symptoms
C) myofacial painI have found that anti-cholinergic medicines also
help with my pain.-John
Posted by Ritch on May 3, 2002, at 0:13:01
In reply to Re: Nortriptyline Augmentation..Questions » Ritch, posted by JohnX2 on May 2, 2002, at 22:41:44
> Hi Mitch,
>
> I've been toying with the idea of adding in low dose
> Nortriptyline to me Lamictal+Serzone+Klonopin.
>
> I bumped the Serzone dose to upper limits and dropped
> topamax on a hunch that this would stabilize me and
> still be anti-depressant. The Serzone generally doesn't
> induce hypomania and helps with myofacial pain.
>
> Unfortunately I am still feeling a bit of atypical
> depression symptoms.
>
> I always wake up in the morning feeling like crap.
>
> Do you think a Nortriptyline add on would help with
> A) pscyhomotor agitation (ADD or hypomania...?)
> B) atypical depression symptoms
> C) myofacial pain
>
> I have found that anti-cholinergic medicines also
> help with my pain.
>
> -John
Hi John,Well, the good part about adding on nortriptyline (just an opinion), *might* be further reduction of the myofacial pain (or at least not aggravate it). Also, I found it to be generally helpful for inattentive/limbic ADD-type symptoms. You mentioned that anticholinergics seem to help. Also in some of your previous posts you mentioned chlortrimeton? helping as well. You are going to get an NE reuptake blockade+anticholinergic+antihistaminic action with the nortrip. with a mild sedative feeling (that's what I noticed anyhow).
Ok, here's the possible *bad* stuff that might happen. It might trigger dysphoria (TCA's in bipolars), I got it with doxepin and desipramine, but not with amitriptyline or nortriptyline.
Another possible minus: TCA's generally aren't looked at as meds helpful for "atypical depression". If you had it combined with Serzone+Lamictal that could likely be a very different story.
And yet another *possible* minus: TCA's are going to play around with liver enzymes and Serzone is already doing that. Plasma levels of Serzone and TCA will be changed (possibly a bunch) from the add-on. So, that will make how you subsequently feel difficult to attribute to what meds.
The psychomotor agitation thing? All you can do is try it and see what happens.
Wow, feeling like crap when you get up every day...It makes me wonder whether it is meds? What is the *timing* of your doses? If you take a truckload of one med at bedtime-but little or none during the day-that might be a possible culprit. You might try to spread out *everything* evenly throughout the day, and then see how you are feeling *all* day long.
hope this helps,
Mitch
Posted by JohnX2 on May 3, 2002, at 2:58:42
In reply to Re: Nortriptyline Augmentation..Questions » JohnX2, posted by Ritch on May 3, 2002, at 0:13:01
> > Hi Mitch,
> >
> > I've been toying with the idea of adding in low dose
> > Nortriptyline to me Lamictal+Serzone+Klonopin.
> >
> > I bumped the Serzone dose to upper limits and dropped
> > topamax on a hunch that this would stabilize me and
> > still be anti-depressant. The Serzone generally doesn't
> > induce hypomania and helps with myofacial pain.
> >
> > Unfortunately I am still feeling a bit of atypical
> > depression symptoms.
> >
> > I always wake up in the morning feeling like crap.
> >
> > Do you think a Nortriptyline add on would help with
> > A) pscyhomotor agitation (ADD or hypomania...?)
> > B) atypical depression symptoms
> > C) myofacial pain
> >
> > I have found that anti-cholinergic medicines also
> > help with my pain.
> >
> > -John
>
>
> Hi John,
>
> Well, the good part about adding on nortriptyline (just an opinion), *might* be further reduction of the myofacial pain (or at least not aggravate it). Also, I found it to be generally helpful for inattentive/limbic ADD-type symptoms. You mentioned that anticholinergics seem to help. Also in some of your previous posts you mentioned chlortrimeton? helping as well. You are going to get an NE reuptake blockade+anticholinergic+antihistaminic action with the nortrip. with a mild sedative feeling (that's what I noticed anyhow).
>
> Ok, here's the possible *bad* stuff that might happen. It might trigger dysphoria (TCA's in bipolars), I got it with doxepin and desipramine, but not with amitriptyline or nortriptyline.
>
> Another possible minus: TCA's generally aren't looked at as meds helpful for "atypical depression". If you had it combined with Serzone+Lamictal that could likely be a very different story.
>
> And yet another *possible* minus: TCA's are going to play around with liver enzymes and Serzone is already doing that. Plasma levels of Serzone and TCA will be changed (possibly a bunch) from the add-on. So, that will make how you subsequently feel difficult to attribute to what meds.
>
> The psychomotor agitation thing? All you can do is try it and see what happens.
>
> Wow, feeling like crap when you get up every day...It makes me wonder whether it is meds? What is the *timing* of your doses? If you take a truckload of one med at bedtime-but little or none during the day-that might be a possible culprit. You might try to spread out *everything* evenly throughout the day, and then see how you are feeling *all* day long.
>
> hope this helps,
>
> MitchHi Mitch,
Thanks for the long well thought out reply.
As far as feeling like crap in the morning, this has
always been a problem with me. I usually need caffeine
or substantial excersize to get out of it. I think it
is an indicator of atypical depression (worse in morning,
better later in day)?I've noticed that increasing my lamictal dose a bit
and the higher dose Serzone is substantially alleviating
the psychomotor agitation. However I still have some
myofacial pain (which may be alleviated by lowering lamictal).
And I get "SSRI" apathy syndrome..I feel very numb
emotionally. I can ride this out and maybe it will wear
off?Well, sounds like nortrip add-on might be a tough sell.
Unless I swapped out Serzone for nortrip. I would need
to have good evidence that nortrip would erase the
myofacial pain.Adderall helped my myofacial pain. It seems medicines that
can increase dopamine in an area of the brain called the
prefrontal cortex alleviate my myofacial pain (the dopamine
counteracts acetylcholine that induces muscle contraction).
The dopamine release is gated by serotonin 5-ht2 receptors.
Blocking those receptors increases dopamine.
The prefrontal cortex extends into the frontal cortex.
Its thought that the "negative psychosis" (emotional blunting)
seen in schizophrenia is caused by a hypodopaminergic state
in these brain areas. Serzone blocks that 5-ht2a receptor
and decreases serotonin firing..I believe this helps release
more dopamine. Zoloft,fyi, makes things *really* bad.I'm still balking on lithium for some reason. But I feel
I need some sort of add-on and Serzone is a tough med
to work with drug-interaction wise.Oh, I'll see how this goes over the next few days and
then crater to lithium (which may change the whole face
of the ballgame, I bet).Thanks,
John
Posted by Ritch on May 3, 2002, at 11:01:44
In reply to Re: Nortriptyline Augmentation..Questions » Ritch, posted by JohnX2 on May 3, 2002, at 2:58:42
> Hi Mitch,
>
> Thanks for the long well thought out reply.
>
> As far as feeling like crap in the morning, this has
> always been a problem with me. I usually need caffeine
> or substantial excersize to get out of it. I think it
> is an indicator of atypical depression (worse in morning,
> better later in day)?
John, is your sleep interrupted or light? I find the feeling like crap in the morning thing generally is a result of crummy sleep the night before.
>
> I've noticed that increasing my lamictal dose a bit
> and the higher dose Serzone is substantially alleviating
> the psychomotor agitation. However I still have some
> myofacial pain (which may be alleviated by lowering lamictal).
> And I get "SSRI" apathy syndrome..I feel very numb
> emotionally. I can ride this out and maybe it will wear
> off?
It sounds like you have found the "sweet spot" of 150mg for Lamictal, IMO. I have found that "SSRI Apathy" is a desired state when you *need* to take that kind of medication. I have doubts about that sort of thing "wearing away", unlike some of the physical side effects, but now it seems that even the physical sfx are more persistent than once thought (while taking the medicine).>
> Well, sounds like nortrip add-on might be a tough sell.
> Unless I swapped out Serzone for nortrip. I would need
> to have good evidence that nortrip would erase the
> myofacial pain.
It wouldn't hurt to ask. If he says: "No, we will have to drop the Serzone if you want to try nortriptyline" or "I don't want you on any tricyclics", then you can just tell him to forget the idea. If he agrees to it, you just need to give the NT a couple of weeks, if it is making things worse (in any way) then just ditch the stuff and resume your pre-trial combination.
>
> Adderall helped my myofacial pain. It seems medicines that
> can increase dopamine in an area of the brain called the
> prefrontal cortex alleviate my myofacial pain (the dopamine
> counteracts acetylcholine that induces muscle contraction).
> The dopamine release is gated by serotonin 5-ht2 receptors.
> Blocking those receptors increases dopamine.
> The prefrontal cortex extends into the frontal cortex.
> Its thought that the "negative psychosis" (emotional blunting)
> seen in schizophrenia is caused by a hypodopaminergic state
> in these brain areas. Serzone blocks that 5-ht2a receptor
> and decreases serotonin firing..I believe this helps release
> more dopamine. Zoloft,fyi, makes things *really* bad.
Yes, that is probably why the Serzone settles down agitation. If I take regular SSRI's (of any kind) I start puttering and pacing around all over (even though I don't *feel* anxious). I tried Serzone before and I noticed how different that it was-I could sit still and watch an entire TV program (30 minutes) in one sitting (which *is* a big accomplishment-hypomania or not). Zoloft does "get into your motor circuits" in a big way. I get restless legs even in my sleep, and lots of jaw clenching. It sounds like jaw clenching is something you probably want to avoid. You might ask him about a 10mg nortriptyline add-on and see what happens. I *think* that Serzone will inhibit CYP2D6 (which is what will metabolize NT), which should raise NT levels (Sunnelly, MedLib?) Interesting what you say about Adderall. I get left hand tremor when I am taking Depakote (which I am taking 250mg at bedtime now). When I went through my dexedrine trial a few weeks back I noticed the hand tremor went away! That is a little spooky (Parkinsons'-wise).
>
> I'm still balking on lithium for some reason. But I feel
> I need some sort of add-on and Serzone is a tough med
> to work with drug-interaction wise.
>
> Oh, I'll see how this goes over the next few days and
> then crater to lithium (which may change the whole face
> of the ballgame, I bet).
>
> Thanks,
> John
The lithium might be a better add-on than NT if you can tolerate it. I personally, *like* taking about 450mg of lithium a day, it is just my GI tract doesn't like it.good luck,
Mitch
This is the end of the thread.
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