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Dr. Bob is Robert Hsiung, MD,
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Posted by moxy1000 on September 23, 2002, at 18:11:42
In reply to Txment Refract. Maj.Unipolar Depressive Seeks Same, posted by Alice Anne on September 23, 2002, at 15:44:55
I think one reason a lot of drug companies don't market/test drugs for "atypical" patients (i.e. treatment refractory, unipolar, manic, etc.) is because your average, run of the mill type depression is where the money is at. (And pardon my terminology - I say "average" meaning patients that meet the criteria for major depression and nothing else. Nothing about a depressive episode or any mental illness is "average.") Anyway, atypical patients are called "atypical" for a reason - they are in some way different from the standard depressed patient. They may be depressed, yes, but then they may also bring some other illnesses to the table along with the depression that makes them especially hard to treat. Being bi-polar, or manic, or refractory makes treatment much more difficult, as many already know.
I think the reason drug companies are not knocking themselves out to find cures for these different illness combinations is because the population suffering them is too small (in relative terms) for the manufacturers to make a profit on. Depression is suffered by millions and millions of people each year, and yes, there are many who suffer from some variation of depression along with another illness. But if you were going to invent a drug, would you try to invent one that could benefit millions or a medicine that would help a much smaller segment of the population? Just from a financial standpoint, it makes more sense for the drug companies profit margins to try to market drugs that will help as many people as possible.
This is just my theory. I think it makes sense to some extent that atypical patients are excluded from certain studies - Number one, SSRI's are not marketed or promoted for bipolar individuals or manic depressives. This is probably over simplifying things a bit, but if a drug has never claimed to work for those particular illnesses, why should the drug be tested in individuals suffering from those illnesses? Maybe they are tested in those specific patient populations, the drug doesn't work, and it's just never published...who knows. My assumption is always this: SSRI's generally work for the same types of illnesses - if two have been proven to work for G.A.D., I can usually safely assume that all will work for that condition. I think it's interesting to note that NOT ONE ssri has ever claimed to be beneficial for manic or bipolar patients. I think the expectation by many of us is simply to high for a single agent to live up to. Maybe in a few years something will become available that is a "cure all," but as many of us know, that day has not yet arrived.
Perhaps we should just expect SSRI's to be effective for the illnesses they are indicated for. I guess I'm suggesting that we take the indications of SSRI's at face value. If a certain agent (or similar agent) is not indicated for what ails you, it probably isn't going to work. I realize "off label" prescribing goes on all the time, but I wouldn't point a finger at a drug that never claimed it would be able to help me in the first place.
Posted by Geezer on September 23, 2002, at 18:23:07
In reply to Txment Refract. Maj.Unipolar Depressive Seeks Same, posted by Alice Anne on September 23, 2002, at 15:44:55
Lost all faith in SSRIs.
Posted by Geezer on September 23, 2002, at 19:01:52
In reply to Txment Refract. Maj.Unipolar Depressive Seeks Same, posted by Alice Anne on September 23, 2002, at 15:44:55
Alice Anne,
Please pardon my abrupt response re: SSRIs. I don't mean to bad-mouth any drug, most of them help most people. I think those of us who are refractory accept drug cocktails as a way of life. We seem to be going down the same road...I would be interested to here any experiences you would wish to share.
Geezer
Posted by Geezer on September 23, 2002, at 19:56:54
In reply to atypicals, posted by moxy1000 on September 23, 2002, at 18:11:42
Moxy,
All good points. Drug companies must apply a risk to benefit ratio and if they end up on the wrong side of the profit line they won't be around long.
I think what we are referring to as "atypical depression" is actually the atypical features specifer that might be applied to the major depressive episode in either Unipolar or Bipolar disorder. I have read somewhere that it is very common in Bipolar II (I think-don't have the reference). Atypical Features Specifer appears on page 203 of my DSM-IV-TR/American Psychiatric Association.
The factor of treatment resistance accounts for our smaller numbers - correct too many TRDs would bias the results just as too many normals would - hence my desire for MEDICAL testing. I agree - by definition TRDs have to be treated "off label".
I wouldn't want to point a finger at drug but I would like a less painful trial and error (mostly error) process to arrive at a proper DX and eventually appropriate treatment. Maybe the orthan drug program would be a good plan.
Good cheer
Posted by Alice Anne on September 23, 2002, at 20:28:04
In reply to Re: Txment Refract. Maj.Unipolar Depressive Seeks Same » Alice Anne, posted by Geezer on September 23, 2002, at 19:01:52
I understand your response-- Almost 10 yrs ago a much more naive version of myself walked out of my psychiatrist's office with some Paxil samples, thinking I was finally going to get out of hell. Ten years later I'm still engaged in chemical warfare trying to find something that helps. Have you found relief in any of the other meds? MAO's, trycyclics, anti-psychotics, etc. etc.?
Posted by alaskagirl on September 23, 2002, at 21:34:15
In reply to Anyone switched to Lexapro? « ggrrl, posted by Dr. Bob on June 11, 2002, at 7:52:48
Pharmrep, can Lexapro be used to treat anxiety?
I was on Celexa 2 years ago for depression/anxiety
and it worked within 5 days. However, it later
caused me to develop colitis. I've tried numerous
drugs since then, but nothing has worked as well
as Celexa.I started Lexapro 9 days ago at 5mg
for 5 days (for anxiety, no depression this time),
and have bumped the dosage to 10mg for the last 4
days. My stomach has tolerated the Lexapro well,
however, it's not helping at all with the anxiety.If Lexapro does help with anxiety, does it take
longer than the typical 1-2 weeks Lexapro treats
depression?Also, I'm suffering from insomnia and am wondering
if this is a temporary side effect that will go
away, or if it will last with continued use?Thank you for your help!
Posted by pharmrep on September 24, 2002, at 0:21:49
In reply to Question for Pharmrep regarding Lexapro Anxiety, posted by alaskagirl on September 23, 2002, at 21:34:15
> Pharmrep, can Lexapro be used to treat anxiety?...........Yes
> I was on Celexa 2 years ago for depression/anxiety
> and it worked within 5 days. However, it later
> caused me to develop colitis. I've tried numerous
> drugs since then, but nothing has worked as well
> as Celexa.
>
> I started Lexapro 9 days ago at 5mg
> for 5 days (for anxiety, no depression this time),
> and have bumped the dosage to 10mg for the last 4
> days. My stomach has tolerated the Lexapro well,
> however, it's not helping at all with the anxiety.
>
> If Lexapro does help with anxiety, does it take
> longer than the typical 1-2 weeks Lexapro treats
> depression? ...............at 10mg it worked at 1-2wks for most people
>
> Also, I'm suffering from insomnia and am wondering
> if this is a temporary side effect that will go....... insomnia was found in 9%, but should subside with time
> away, or if it will last with continued use?...........if you dont already, take it in the morning...not at night
>
> Thank you for your help!
Posted by Geezer on September 24, 2002, at 10:07:31
In reply to Re: Txment Refract. Maj.Unipolar Depressive Seeks Same, posted by Alice Anne on September 23, 2002, at 20:28:04
Hi,
I was DXed in 1963 but never treated until 1973. Had plenty of self medicating drug abuse in the past (can't honestly blame anyone but myself for the possible neuro. brain damage). Clean and dry since 1985. Admitted to various psyc. wards 10 times between 1973 and 2002.
Think I have taken nearly all the TCAs - had some improvement with Ludiomil for several years but nothing close to remission. Took all the MAOIs (including one from Europe on a test basis) but this goes back to the 70s, can't remember benefit, only side effects. I had almost complete remission from Prozac for the years 97/98, then poop out and have not had any response from serotonin ADs since that time. I have no start up symptoms and can cold turkey from high doses with no withdrawal. Had only one experience with an AP-Remeron = sever anxiety/panic attack at first dose increase - resolved with 1mg Klonopin. Wellbutrin at 400mg does nothing. Will have another try at Parnate. After that its ECT or the "big dirt nap".
Sorry to be so negative, promise to be more uplifting as we go......but always honest.
Good cheer
Posted by Alice Anne on September 24, 2002, at 12:25:36
In reply to Re: Txment Refract. Maj.Unipolar Depressive Seeks Same » Alice Anne, posted by Geezer on September 24, 2002, at 10:07:31
Thank you for your honesty. God, I wish there were some kind of brain scan they could put us through that could once and for all identify exactly which chemicals were out of balance and adjust them accordingly. I think we're getting closer, but not nearly close enough. Hopefully these problems will be obsolete in 10 years. Wish they were now.
Posted by Geezer on September 24, 2002, at 13:13:03
In reply to Re: Txment Refract. Maj.Unipolar Depressive Seeks Same, posted by Alice Anne on September 24, 2002, at 12:25:36
Agreed!! You have just reinforced my "biomedical testing for biomedical brain disorder rant". I know about the progress in testing methods (can't come soon enough) but I am concerned about the obstacles standing in the way of new drug development.
Have you ever had experience with a Neurologist? I just have a "hankering" to see a real medical doctor.
Posted by Alice Anne on September 24, 2002, at 13:36:43
In reply to Re: Txment Refract. Maj.Unipolar Depressive Seeks Same » Alice Anne, posted by Geezer on September 24, 2002, at 13:13:03
Hmmm. No, I have not had experience with a neurologist. Had an MRI a couple of years ago to rule out some other cdxs-- nothing showed, thank God. I wonder what, if anything, you could learn-- what do you think? I know there is some institute (Amen?) where they make claims about being able to see into your brain (the guy wrote "Change Your Brain Change Your Life"), but my doctor thinks it's, well...suspect. He explained it to me scientifically, but I can't remember how. So I'm still waiting for the big Brain Wave of the future. You're right-- testing methods can't come soon enough, and the obstacles are many for drug testing, especially in the US. I'm off with my addled self for the day--- take care.
Posted by xiola on September 24, 2002, at 20:03:57
In reply to Re: LEXAPRO/lobotomy...HAHAHA!!!!, posted by URCONFUSED on September 21, 2002, at 16:39:34
i've been on 150mg of wellbutrin 2x a day and my doctor just added 10mg of lexapro, as well. she did this after i told her i was having anxiety. does this sound like too much to any of you? i haven't started on the lexapro yet.
Posted by Geezer on September 24, 2002, at 21:31:06
In reply to Lexapro Wellbutrin, posted by xiola on September 24, 2002, at 20:03:57
The dosage for each drug is within normal range and I don't believe there is any negative interaction between the two. As to how well they manage your symptoms....it is a trial and error process. I don't mean to sound insensitive....we all go through the same process because there is no medical test to predict response.
Very best wishes
Posted by pharmrep on September 24, 2002, at 23:47:05
In reply to Lexapro Wellbutrin, posted by xiola on September 24, 2002, at 20:03:57
> i've been on 150mg of wellbutrin 2x a day and my doctor just added 10mg of lexapro, as well. she did this after i told her i was having anxiety. does this sound like too much to any of you? i haven't started on the lexapro yet.
** Lexapro being the single isomer of celexa should be a good combo..."cel-well" has been used a lot and Lex-well is already getting used some now...the wellbutrin is to help with some of the sexual side effects often associated with ssri's. 10mg of Lexapro is the starting dose, and about 80%+ patients will not need to titrate up. Good luck, and keep us posted.
PS anxiety might feel better in 1 week or so, so let us know how youre doing.
Posted by CarolinaGirl on September 25, 2002, at 15:21:26
In reply to Anyone switched to Lexapro? « ggrrl, posted by Dr. Bob on June 11, 2002, at 7:52:48
I have switched computers to try and send this
message, forgive the previous empty ones. I am on 5 mgs of lexapro. This is the end of the second week for me. My Pdoc started me at this dose because in the past I have had side effects
from other SSRI's. Creepy crawly, not quite fitting into my skin......The budgies (my mama's
term from a long time ago)feelings. This is kind of a last chance for me I guess.
I have GAD and insomnia. I guess I don't really know what normal feel like.After the second day on lexapro....no more ambien. That is a plus. One less pill to take! I feel less anxious except when I smoke.
That seems to negate the effect of the lexapro.
ANyway, so far so good. I will check back in in a week or so to share my thoughts on this medicine.
Posted by sebastian on September 26, 2002, at 13:48:02
In reply to Re: why/see bottom, posted by hawkeye on September 22, 2002, at 7:05:02
I was staring to notice bad side-effects from my Zypexa 10mgs, told my doc, and he reduced it to 5mgs, after awhile I started to enjoy this so much I told him I could handle anouther decrese, we argued over 2.5 or 0mgs. Somehow we came to 0mgs. Well within a week my mind was racing so fast that I couldn't eat, sleep. Called my doc, instantly he put me 2.5mgs . Went in to see him later got put on 5mgs, now I wonder should I be on 7.5mgs. I tryed to call him and ask but he never returned the call. Anyways it was fun to loose the side-effects for awhile.
Posted by dr. dave on September 27, 2002, at 6:13:23
In reply to Re: Dosage/see bottom » hawkeye, posted by pharmrep on September 21, 2002, at 23:59:42
Again, the claim has been made that Lexapro has fewer side-effects than Celexa. This has been extensively discussed on this thread and the relevant data have been posted.
http://www.dr-bob.org/babble/20020821/msgs/118023.html
They clearly fail to demonstrate any significant difference. Despite repeated calls for any other research data which might back up the claim, none have appeared. So it is puzzling that this claim is again presented as fact.
The repeated statement of unsubstantiated claims leads to confusion. For instance, it has been said that r-citalopram cannot be inert because it is blamed for side-effects from Celexa. While it is true that this is claimed, there is no evidence to show that it is true. Removing r-citalopram does not cause a significant decrease in side-effects. But if the claim is made often enough, people begin to take it as fact and make deductions which stray further and further from what the research actually shows.
If there is now evidence that Lexapro has significantly fewer side-effects than Celexa, It would be very useful to see it.
> ** great question. 10mg of Lex is at least as efficacious as 40mg of cx...but with less s/e, less drug to drug interactions, and less discontinuation due to adverse events, and will work as fast as 1-2 weeks for most people. It is linear, however...5mg will not work as fast, and is not the recommended starting dose. In general, for most drugs many doctors reduce dosages to avoid side effects, but since Lexapro at 10mg is "comparable to placebo" it shouldnt be needed. In the Dr's I've seen...I would say 95%+ are starting w/ 10mg...only a few have gone to 20mg (only 2 weeks out now) and maybe a few Dr's are just "set in there ways" and are starting with 5mg (for a week or so...then up to 10mg) So far...I have only heard good responses from them, but most of their patients havent been back for their "monthly" visit...I'll hear more in about 2 weeks or so.
> PS...the starting dose for celexa was 20mg (62% of patients stayed there)...40mg was at about 30% (for a total of 92% of all Celexa prescriptions...the last 8% were at 60mg or higher.) I think Lexapro at 10mg will be effective for 80%+ of patients...then 15mg+ will make up the last 20%
Posted by Mr. SadPuppyDog on September 27, 2002, at 12:39:01
In reply to Re: Txment Refract. Maj.Unipolar Depressive Seeks Same » Alice Anne, posted by Geezer on September 24, 2002, at 13:13:03
Geezer, I agree with what you are saying. However I must also say Im VERY skeptical anything like you are talking about will ever occur on a large scale in psychiatry. To have the sort of thing you are talking about occur on a large scale and take over, we really need to formally integrate psychiatry into Neurology and just let Neurologists treat the serious forms of mental illness. Severe mental illness needs to be 100% "medicalised" and people with severe forms of this stuff just need to be given to Neurology to fix. Psychiatry does a poor job of it and Im skeptical psychiatry will ever achieve high tech status in medicine.
Mr. Sad PuppyDog
Posted by IsoM on September 27, 2002, at 13:02:22
In reply to Lexapro side-effects - where's the evidence? » pharmrep, posted by dr. dave on September 27, 2002, at 6:13:23
It's nice to see you post again, Dr. Dave. I like to hear from all sides.
It would be so simple to test to see if r-citalopram causes side effects. In healthy voluteers who have no problem with depression, if they were to take only the inert isomer, it could be judged if it causes side effects.
Another thing that could be tried, is to see if r-citalopram has any agonist or antagonist properties to any receptors in vitro. I realize that there's quite a few recepetors that would need testing this way & that the expensive wouldn't be justified by any possible profit, so it's unlikely to happen.
I think the main problem that people have in knowing whether there's fewer side effects with just Lexapro, as opposed to Celexa, is understanding why side effects occur. Few people understand that an effective medication doesn't just bind to the receptors needed to improve mood but to these same receptors but on different neurons throughout our body, not just the ones in our brain.
Dr. Dave, I have a full write-up by Aimee L McRae on Lundbeck's escitalopram from "Current Opinions In Investigational Drugs". Is she associated with Lundbeck at all, or impartial in your opinion?
Posted by Anyuser on September 27, 2002, at 13:31:14
In reply to Re: Lexapro side-effects - where's the evidence? » dr. dave, posted by IsoM on September 27, 2002, at 13:02:22
Posted by IsoM on September 27, 2002, at 13:50:05
In reply to What does Aimee say? (nm) » IsoM, posted by Anyuser on September 27, 2002, at 13:31:14
There's quite a bit written & copyright laws would prevent me from posting it, but is there any particular thing you're wondering about? If you tell me, I'll check for that in the article.
Much of what's said has already been stated. I noticed that in the diff studies, none involved more than a few hundred patients at a time. I think we'll really need to wait till thousands of patients' reports start coming in to make a better assessment of Lexapro vs ordinary Celexa.
Posted by Anyuser on September 27, 2002, at 14:25:22
In reply to Re: What does Aimee say? » Anyuser, posted by IsoM on September 27, 2002, at 13:50:05
Wouldn't want to break any copyright laws on the internet.
What are her conclusions re efficacy and s/e?
Posted by Geezer on September 27, 2002, at 16:07:14
In reply to Re: merge psychiatry into Neurology is only hope, posted by Mr. SadPuppyDog on September 27, 2002, at 12:39:01
Hi Mr. Sad Puppydog - thanks for the response. It seems you are very aware of the current problems facing people with sever TRD. Historically, I wish the Neurologists had won the battle with the Psychiatrists at the time the "asylums" were still active. There is huge resistance to "medical" treatment (and research) in psychiatry..... note the increased importance of treatment by social scientists (psychologists), the importance of holistic treatments (add seeds & twigs to your diet to improve mental health) - the recent Surgeon Generals report would suggest any bed-wetting do-gooder that cared to should have a go at us. HOWEVER, current drugs do help 70% of the people who take them - at least to some degree for some period of time (that credit goes to the drug companies) - its just us 30%ers left to face ECT or nothing.
It is difficult to manage the logistics of proper care. The psychologist part is easy - they can go the way Freud did - treat the neurotics but stay away from biochemical mood disorders. I would agree the rest of us belong with Neurologists but I can't find one willing to treat.
On the brighter side do a search on Dr. Fuller Torrey. You will find huge attacks against him from the press but he is in the forefront of biomedical research for Bipolar Disorder (Director of The Stanely Foundation - PRIVATE FUNDING; he is a psychopharmacologist).
Good cheer
Posted by IsoM on September 27, 2002, at 16:08:33
In reply to Re: What does Aimee say? » IsoM, posted by Anyuser on September 27, 2002, at 14:25:22
One thing stated that's diff from pharmrep's statements is that 20 mg escitalopram (Lexapro) [not 10 mg] is equivalent to 40 mg citalopram (Celexa).
|| from "A single-dose crossover pharmakinetic study comparing racemic citalopram (40 mg) with the S-enantiomer (escitalopram, 20 mg) in healthy male volunteers."
Drews P New Clinical Drug Evaluation Meeting - Phoenix, AZ 2001 May 28-31 ||She lists a few different studies that compare Lexapro's faster onset of action than imipramine, fluoxetine, & venlafaxine but none that compared it to Celexa even though she mentioned that Lexapro was faster than Celexa. That's one reason I wondered about her affiliation. She states Lexapro is faster than Celexa but the studies don't state that - just the other 3 ADs. The idea that it’s faster is inferred from a study predicted from a rat model only.
It also states that escitalopram is 30-fold more potent than the R-isomer (Celexa).
|| Escitalopram oxalate. Anti-depressant 5-HT reuptake inhibitor.
Sorbera LA, Revel L, Martin L, Castaner J
Drugs Future 2001 26 2 112-120 ||To be honest, I found nothing in the article that states that Lexapro is more effective than Celexa in an equivalent dose. (1:2 equivalency rate)
It didn’t compare side effects but only said that with escitalopram, nausea was the most common side effect (15%), somnolence (7%), ejaculation disorder (9%), & anxiety (no percentage given). As the percentage of s/e with Celexa seem to vary somewhat depending on what study or journal one looks at, this may be true for Lexapro too.
Posted by moxy1000 on September 27, 2002, at 16:52:41
In reply to re efficacy and s/e » Anyuser, posted by IsoM on September 27, 2002, at 16:08:33
Dr. Dave,
I have a question regarding the design of most studies done by drug companies to evaluate the efficacy of anti-depressants. Most study designs evaluate moderate-severe patients (as determined by widely used rating scales), diagnosed with major depression. However, the study designs don't include patients with mild depression or patients with comorbidities.
My question is why do you think these types of patients are excluded from most clinical trials?
I've heard conflicting theories. The first is that many believe if an anti-depressant works for moderate or severe depressed patients, it would be logical to assume that it would work for the milder, easier to treat patients as well. Conversely, I've heard that drug companies are "scared" to evaluate mild depression, because they are fearful that placebo would work as well as the active agent, if not better.
I tend to agree with the first statement, because even if placebo worked better then an active agent, the depression could not have been that debilitating to begin with. It would seem that for many patients, several things other then "placebo-affect" would have a positive impact on depression. Simply the desire to want to feel better, and the constant attention given to patients by clinicians involved in studies, would seem like it would help in improving depressive symptoms.
Anyway, just a question that's been rattling around in my brain for awhile, and I thought I'd get your take on it.
Thanks!
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