Psycho-Babble Medication Thread 136050

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Cortisol testing

Posted by Dinah on January 15, 2003, at 21:12:22

I would like to convince my gp to do cortisol testing, but I'm not altogether sure of the benefits. Is there anything they can do if they find elevated levels, or is it just oh yes you are stressed?

 

Re: Cortisol testing Dinah

Posted by bozeman on January 15, 2003, at 22:27:06

In reply to Cortisol testing, posted by Dinah on January 15, 2003, at 21:12:22

I believe so . . . . my gp (who is actually very cool for a gp, more with it than most psych-types I've known) told me there was . . . one of the problems of depression, forget things! Will look for it and re-post when I find my notes from that session (pathetic, having to take notes from dr. visits, huh? but it's the only way I remember what to take, when. )

> I would like to convince my gp to do cortisol testing, but I'm not altogether sure of the benefits. Is there anything they can do if they find elevated levels, or is it just oh yes you are stressed?

 

Re: Cortisol testing bozeman

Posted by Pfinstegg on January 16, 2003, at 0:26:12

In reply to Re: Cortisol testing Dinah, posted by bozeman on January 15, 2003, at 22:27:06

There are some things one can do about cortisol abnormalities, although not as many as one would like. There are two things to discover about cortisol; first, do you have non-suppression on the Dexamethasone Suppression Test? This involves taking one mg. of Dexamethasone in the evening and then having an 8 AM serum cortisol drawn. Normally, your reading should be 5. Not suppressing at all is associated with about half of the cases of both major depression and bipolar disorder. Another test, the 24-hour urinary cortisol, is associated with very severe depressive disorders- the kind which may have psychotic features- it's not as common as the DST non-suppression.

Having DST non-suppression means that cortisol and other hormones have gone into over-drive, and have decreased the number of receptor cells in the hippocampus. So you are losing the feedback mechanism which tells your hypothalamus to shut off its production of CRH- you have HPA axis dysregulation- too much cortisol too much of the time. People who have this show smaller left dorsolateral prefrontal cortexes, and smaller left hippocampuses on MRI; if you have a SPECT scan to study blood flow, it will be lower than it should be in these areas.

So far, the most effective treatments for HPA axis dysregulation, and the resulting brain changes I mentioned above are either ECT or TMS. However, successful drug treatment, with all the different classes of ADs and mood stabilizers, can also reverse these changes. So far, I have not been able to find much research showing that this happens, but there are isolated reports in the literature of this occurring. It probably happens quite a bit with successful drug treatment, but isn't documented.

Other things which one can consider are taking adequate fish oil and B vitamins in fairly high doses, so as to make sure your brain metabolism is as healthy and efficient as possible. Phosphadatylserine is thought to lower cortisol, and can be helpful in going to sleep easily, if taken at bedtime. Going out on a limb here, I take tianeptine, not because it is a good anti-depressant, but because research in a number of centers, on tree shrews, shows that stressed baby animals do not develop shrunken prefrontal lobes or hippocampuses, or a decrease in the number of receptors, if they are given tianeptine during the time they are stressed. It is thought to put a barrier between your brain and the excessive cortisol. I don't know of any similiar studies in human beings, but, knowing it's a safe drug, I decided to do an experiment on myself!

In a few years, we will have CRH antagonists which will probably prevent the axis dysregulation from occuring. Mefipristone is now being fast-tracked in studies as an AD which can rapidly return cortisol metabolism to normal.

Don't forget, thyroid abnormalities usually occur simultaneously with the cortisol abnormalities. Even if your TSH, etc. is normal, you can obtain an antidepressant effect by making sure that the TSH is at the lowest range by taking supplemental T3 and T4 in low doses.

Pfinstegg

 

Re: Thank you Bozeman and Pfinstegg (nm)

Posted by Dinah on January 16, 2003, at 3:27:52

In reply to Re: Cortisol testing bozeman, posted by Pfinstegg on January 16, 2003, at 0:26:12

 

Re: Cortisol testing

Posted by Bill L on January 16, 2003, at 8:39:35

In reply to Cortisol testing, posted by Dinah on January 15, 2003, at 21:12:22

I asked an endocrinologist at Johns Hopkins Hospital the same question a few years a go. He said that the cortisol level is often elevated due to anxiety and depression but that there is no reason to have it tested. I didn't go into detail with him but my understanding is that knowing how high your cortisol level is does not affect your treatment.

I guess it would be simple if you could simply see how high your cortisol is. Then take a drug to lower it and then you feel better. But apparently it doesn't work that way. I guess it's possible that elevated cortisol is an effect of anxiety and not a cause of it. But I'm not sure.

 

Re: Cortisol testing Pfinstegg

Posted by judy1 on January 16, 2003, at 10:10:38

In reply to Re: Cortisol testing bozeman, posted by Pfinstegg on January 16, 2003, at 0:26:12

Thank you for the detailed explanation, I have the very typical presentation of smaller left hyppocampus on MRI along with an abnormal 24 hour urinary cortisol test. You explained it better than my neurologist did- thank you, judy

 

Re: Cortisol testing judy1

Posted by Pfinstegg on January 16, 2003, at 10:38:35

In reply to Re: Cortisol testing Pfinstegg, posted by judy1 on January 16, 2003, at 10:10:38

Thank you, Judy. Can you tell us what you have decided upon as a treatment plan, and/or what has been helpful to you so far?

Pfinstegg

 

Re: Cortisol testing

Posted by glenn on January 16, 2003, at 11:43:54

In reply to Cortisol testing, posted by Dinah on January 15, 2003, at 21:12:22

I am not sure I can agree with some of the above, in particular the idea that high cortisol is only an effect of stress/anxiety.
Recently the emphasis seems to have shifted to the idea that cortisol may well be the cause and not just an effect of depression/ anxiety.
The problem is that endocrinologists in my experience tend to lose interest if you do not have cushings disease or addisons disease and there are not many good medications to treat high cortisol if you have it. Ketoconazole and Metyrapone are pretty awful and one has to rely in the main on finding out what helps in the supplement/ herb area as very few docs seem to know about this.
The breakthrough may be ru 486 which lowers cortisol dramatically and dramatically seems to help some people who have apparent trd.
As it is the abortion drug and very very expensive it has sadly its own set of problems.
I would agree that it is worth having the test, the salivary one seems to have a better reputation than the urinary one and unless the doc is prepared to try you on one of the above, have a look at holy basil (ocimum sanctum) and seriphos ( as opposed to phosphatidyl serine which is more expensive and less effective)
Good luck

Glenn

 

Re: Cortisol testing

Posted by jerrympls on January 16, 2003, at 20:12:20

In reply to Re: Cortisol testing, posted by glenn on January 16, 2003, at 11:43:54

I saw an endocrinologist and he ordered some blood tests and the 24-hour cortisol urine test. I see him next week for results. He basically said that there's not much he can do if my cortisol levels turn out to be high. So - even if I have high levels I'm not sure anything medication-wise will be done. he did mention the possibility of low dose testosterone to see if it would help. Perhaps. We'll see next week I guess.

 

Re: Cortisol testing jerrympls

Posted by Pfinstegg on January 16, 2003, at 21:22:13

In reply to Re: Cortisol testing, posted by jerrympls on January 16, 2003, at 20:12:20

I hope you will let us know what the tests show. Are you having a DST suppression as well as a 24-hour cortisol? I had the impression, also, that my endocrinologist really didn't know what to offer, other than adding T3 to the T4 I was already taking. But knowing what those tests show can help you make good decisions yourself.

If you have a high 24-hour cortisol, you could consider going into one of the studies of mefipristone, which has been reported to eliminate depression, and bring cortisol rapidly back to normal (within 7 days)- there are studies going on at Stanford and NIH. I think that would be much safer than trying something like ketanozodole,which, although it is used by endocrinologists for elevated cortisol in Cushing's Disease, can cause impaired liver function.

If you have DST non-suppression, but normal 24-hour cortisol, the treatment that will probably work the best would be ECT or TMS. (I'm assuming that you have a treatment resistant depression). I should add, though, that you could keep looking for an effective AD (maybe a tricyclic, MAOI inhibitor or atypical antipsychotic)- if you find one that really helps, it will be helping your cortisol as well. There are reports of this occurring on Medline- but there just aren't very many as yet. I think the concept of abnormal cortisol metabolism being central to PTSD, anxiety disorders and depressive disorders is sufficiently new that careful research on the effects of medications on cortisol just hasn't been done yet.

Please let us know what happens.

Pfinstegg

 

Re: Cortisol testing

Posted by NikkiT2 on January 17, 2003, at 10:19:40

In reply to Cortisol testing, posted by Dinah on January 15, 2003, at 21:12:22

I had the 24 hour urine test a few months ago.. and while it didn;t show up anything much, my doctor has reffered me for further investigation for possible Cushings as I have all the other symptoms (even weight loss isn;t reducing my buffolo hump *sighs*)

No one has mentioned the saliva test though..

He talked about a possible benign tumour somewhere causing cortisol problems though...

Nikki

 

Re: Cortisol testing Pfinstegg

Posted by judy1 on January 18, 2003, at 10:57:17

In reply to Re: Cortisol testing judy1, posted by Pfinstegg on January 16, 2003, at 10:38:35

actually we haven't come up with a treatment plan, partially because I think my hormones are just getting to a normal stage - having a baby and finishing nursing a few months ago- and mostly because of my lack of drive. I think my pdoc had mentioned a study that showed mood stabilizers and therapy can actually change the abnormal brain structures, but I'm not sure if I remember that correctly. I'm also supposed to schedule an appt. with my endocrinologist (I have a reproductive endocrinologist I used for IVF- talk about messed up hormones then!) take care, judy

 

and also... Pfinstegg

Posted by judy1 on January 18, 2003, at 11:05:48

In reply to Re: Cortisol testing judy1, posted by Pfinstegg on January 16, 2003, at 10:38:35

I was taking Omegabrite (fish oil) for a while- I plan to restart it. I was reading your post about tianeptine- have you noticed any changes after taking this? I ask because the consensus is my hyppocampal abnormality is probably the result of childhood abuse along with bipolar disorder- you mentioned tianeptine protected baby tree shrews from stress. thanks, judy

 

Re: research on tianeptine judy1

Posted by Pfinstegg on January 19, 2003, at 15:13:44

In reply to and also... Pfinstegg, posted by judy1 on January 18, 2003, at 11:05:48

Hi! Congratulations on the new baby! There is a lot a research out there now showing that childhood neglect/abuse leads to neuro-endocrine over-reactivity, and to smaller than normal left hippocampuses, amygdalas and probably other closely related parts of the brain. As you know, the basic cause is generally considered to be excess cortisol, brought on by the initial hyper-reactivity, which shrinks the neurons, shortens the dendrites and prevents the birth of new neurons, which would normally occur, in the hippocampus anyway, at a rate of several thousand per day. Now that people with severe depression are getting MRI's and cortisol testing- and thyroid and sex-hormone testing as well, it's becoming clearer and clearer that the abnormal neuro-reactivity leads directly to the brain abnormalities- and the depressive disorder.

I think that it is generally thought that a wide range of anti-depressants, when they are successful, partially reverse, or at least stop, this adverse sequence of events. However, the AD's don't work for everyone. Because they didn't for me, I began doing as much research as I could on possible other treatments which might reverse the brain abnormalities which I knew I had: a small left hippocampus, DST non-suppression, high basal levels of cortisol, and slight hypothyroidism.

Well, I'm so thankful to be able to say that I've gotten into a complete remission. To do it, I needed a course of TMS (roughly equivalent to ECT). To try to maintain the remission, I'm doing the following: adding cytomel to the synthroid which I had been taking, taking enough fish oil to get 1 gm. of EPA daily, taking a lot of B-complex, taking a low dose of HRT (Ogen and Provera) twice a week, and taking tianeptine. Plus, of course, exercise and as calm and supportive a life as I can manage. It's hard to say which does what- I feel I need them all!

The article on the prevention of hippocampal shrinkage in stressed baby tree shrews is : "Stress-induced changes in cerebral metabolites, hippocampal volume and cell proliferation are prevented by antidepressant treatment with tianeptine" B. Czeh et al, German Primate Center, Gottingen, Germany

http://www.pnas.org/cgi/doi/10.1073/pnas.211427898

wishing you the very best in your search,

Pfinstegg

 

Re: Cortisol toxic...

Posted by missliz on January 20, 2003, at 0:11:48

In reply to Re: research on tianeptine judy1, posted by Pfinstegg on January 19, 2003, at 15:13:44

I haven't been tested but my docs say it's obvious I'm in cortisol overdrive- Shaking, tachycardia, high anxiety, chest pain, ect. I have the whole nine yards of BP2, GAD, Panic disorder, most of the other anxiety disorders ect. and the whole childhood super trauma abuse thing. So they drugged me up on more benzos, which I was already on anyway, and am starting Trileptal.
The heart thing scares me- I've been really tachy round the clock and am exhausted and miserable. I used to be an athlete 'till this pdoc ruined my career, and exercise is what I need but with my sudden cardiac overload I really can't get that started safely. Dr Shrink put me on nifedipine, doesn't seem like the best choice, Just had a Holter and echo in July after the last time he almost killed me and was normal.
So does this calm down again? Any thoughts? If my heart were closer to normal I could train it into improvement, I've done it before. Sporting goods are great for anxiety management if you aren't resting at 110 bpm. I wake up in the morning tachy and rattling and I have no more slack for this. There are stressfull external things mounting, and I can't cope with all this.
And what is tianeptine?

missliz

 

Re: Cortisol toxic... missliz

Posted by judy1 on January 20, 2003, at 11:54:29

In reply to Re: Cortisol toxic..., posted by missliz on January 20, 2003, at 0:11:48

Hi,
saw you on another board :-)- you and I seem to share a similar history. I had a prolonged period of cardiac dysfunction (even had a cardiac catherization done), but once my panic disorder was under complete control (6mg of klonopin/day + xanax prn) my cardiac symptoms subsided. I guess after all the testing I realized the heart pounding, chest pain, etc. was part of my panic disorder. Now, the cortisol problem (which demonstrated itself by MRI irregularities and was most probably a result of childhood abuse) is something Pfinstegg is really knowledgeable about and posted his own treatment a couple of posts back. I'm addressing my own with omega 3s, therapy and may consider tianeptine. I hope you get your symptoms under control. May I ask how your previous pdoc ruined your career? Was it excessive or the wrong medications? take care- judy

 

Thank you! Pfinstegg

Posted by judy1 on January 20, 2003, at 11:58:35

In reply to Re: research on tianeptine judy1, posted by Pfinstegg on January 19, 2003, at 15:13:44

You posted a lot of great information, I appreciate your sharing of your own treatment. What types of side-effects (if any) did you get from the TMS course? Can you post duration and # of times you had it? It sounds like the key component in your recovery, was it something your pdoc or neurologist suggested? Sorry for all the questions- judy

 

Re: undergoing TMS judy1

Posted by Pfinstegg on January 20, 2003, at 16:07:53

In reply to Thank you! Pfinstegg, posted by judy1 on January 20, 2003, at 11:58:35

The TMS was very easy to take. Each treatment consisted of 400 pulses of electromagnetic current to an exact spot over your left dorsolateral pre-frontal cortex- this takes about 20 minutes a day. This spot is located by the doctor before the first treatment, and marked with indelible ink, so the technician can do the rest of the treatments routinely. I didn't ever had a headache during it, or afterwards, was able to talk and think normally while it was going on, and was able to drive myself to and from the treatment sessions; there were absolutely no memory or cognitive problems. Although I was told that most people adjust quickly to the electromagnetic pulses, and that some people even sleep during treatment, I found it quite painful. This was easily overcome, however, by taking tylenol with codeine one hour before.

You are right- having the TMS was the central factor in overcoming my depression, which had been severe. On the Beck Depression Inventory, which was used to see if I was improving, I went in 10 days from scores of 38-41(severe) to no score at all (remission!) I had 15 treatments over a period of 3 weeks.
Some people, who don't respond so rapidly, have as many as 25 treatments. It's also possible to return for brief maintenance treatment, if you relapse. All the other things I mentioned- the tianeptine, T3, T4, fish oil, B vitamins and intermittent estrogen supplementation, are all there in the hope of preventing a relapse.

I know I have a crazy board name, but I'm a woman- not a man!

If I can give you any further information about TMS, I'd be very glad to do so.

Pfinstegg

 

Re: TMS judy1

Posted by Pfinstegg on January 20, 2003, at 16:21:10

In reply to Thank you! Pfinstegg, posted by judy1 on January 20, 2003, at 11:58:35

I forgot to add that none of my doctors suggested it, or even knew much about it: The idea for it came from various posts right here on Psychobabble. I found a good psychiatrist to do it by telephoning all the places which are conducting research on it: Emory University provided the names of two doctors in private practice whom they considered experienced and competent. I trusted their recommendations because they are known as such an outstanding center for the study of childhood stress and abuse, and are leaders in understanding the neurophysiological basis of depressive illness.

Pfinstegg

 

Re: undergoing TMS Pfinstegg

Posted by judy1 on January 21, 2003, at 15:36:13

In reply to Re: undergoing TMS judy1, posted by Pfinstegg on January 20, 2003, at 16:07:53

I know I have a crazy board name, but I'm a woman- not a man!


Duh, I KNEW that- let's just call it left brain problems :-). Anyway, thank you for all the details, I did go to a neuropsychologist once who had recomended TMS, and felt (correctly it seems) that it wasn't very mainstream. Anyway, I'll post what I will land up doing. Fortunately I'm not as deeply depressed as you were when you underwent it, and may be a bit more conservative with my own treatment. take care, judy

 

Re: TMS Pfinstegg

Posted by SLS on December 8, 2003, at 9:44:42

In reply to Re: TMS judy1, posted by Pfinstegg on January 20, 2003, at 16:21:10

> I forgot to add that none of my doctors suggested it, or even knew much about it: The idea for it came from various posts right here on Psychobabble. I found a good psychiatrist to do it by telephoning all the places which are conducting research on it: Emory University provided the names of two doctors in private practice whom they considered experienced and competent. I trusted their recommendations because they are known as such an outstanding center for the study of childhood stress and abuse, and are leaders in understanding the neurophysiological basis of depressive illness.
>
> Pfinstegg

Hi Pfinstegg.

How have you been?

Are you still going for maintenance TMS treatments?

Stay well.


- Scott

 

Re: TMS SLS

Posted by Pfinstegg on December 9, 2003, at 12:41:37

In reply to Re: TMS Pfinstegg, posted by SLS on December 8, 2003, at 9:44:42

Hi Scott! Yes, I go to Atlanta approximately every four months for six follow-up TMS treatments- given at the rate of two daily, so the visit is only three days. It seems to be extremely effective; my next treatment is at the end of January, but I am so far depression-free, which is a HUGE improvement compared to pre-TMS. How are you doing?

Pfinstegg

 

Re: TMS

Posted by SLS on December 10, 2003, at 7:27:16

In reply to Re: TMS SLS, posted by Pfinstegg on December 9, 2003, at 12:41:37

> Hi Scott! Yes, I go to Atlanta approximately every four months for six follow-up TMS treatments- given at the rate of two daily, so the visit is only three days. It seems to be extremely effective; my next treatment is at the end of January, but I am so far depression-free, which is a HUGE improvement compared to pre-TMS. How are you doing?
>
> Pfinstegg


Yay!!!

I am so happy for you. There must have been a time when you thought you would never get well, so you probably feel like you are doing better than you could ever have dreamed.

I'm not doing so well, but I'm afraid to complain all of the time for fear people will get sick of hearing it. I had a few drugs produce transient antidepressant responses last spring and early summer. I was actually shocked that any of them worked at all. I take that as an encouraging sign. My doctor thinks that the reason for the transience of effect has something to do with gene expression downstream. My brain is too friggin' good at maintaining a dysfunctional homeostasis that it, for some reason, believes is normal.

If I remember correctly (a dubious assumption at best), you never had ECT. Is that accurate?

I failed a course of 15 ECT treatments in 1991. My question is this: Is non-response to ECT a prognosticator of non-response to TMS? I would love to know Dr. Hutto's opinion. I did FAX him, as you suggested, to ask him, but his office simply responded that I should make an appointment to come in. Ouch. Recently, I corresponded with Mark George, MD regarding this issue. He declined to opine, citing a lack of data. Another TMS investigator told me that his "gut feeling" was that failure to respond to other biological treatments probably indicated a reduced chance of responding to TMS. My doctor seems to agree with this. However, that statement can me made regardless of which treatment is chosen subsequent to a series of treatment failures. Argh.

Thanks for responding. Stay well. :-)


Sincerely,
Scott

 

Re: TMS SLS

Posted by Pfinstegg on December 12, 2003, at 0:32:43

In reply to Re: TMS, posted by SLS on December 10, 2003, at 7:27:16

Hi Scott.. I don't think anyone knows whether lack of response to ECT would be a poor prognostic sign for TMS. It sounds "logical", but I don't think there's any evidence to back that assumption up.

When I began looking into TMS, two doctors who did it privately were recommended to me (by the Dept. of Psychiatry at Emory): Dr. Hutto and Dr. Steven Best, who is just west of Chicago. Would it be worth your while to see one of these two and consider a trial to see if TMS is helpful? There does not seem to much risk at all with the TMS; it is known to decrease cortisol levels, increase blood flow to the left frontal cortex, increase BDNF, and normalize levels of serotonin, dopamine and nor-epinephrine- things that all depressed people need! I have not had ECT, and although I assume that it works via these same beneficial actions. I am assuming that there are differences also. The TMS is given over the left frontal cortex, and, being an electromagnetic wave, does not spread widely through the brain- the direct effect is only to a depth of about 3 cm. However, it is thought to set up excitation in nerve pathways which reach into the left hippocampus and basal ganglia. It probably doesn't affect the right hemisphere- a big difference from ECT, which sweeps through the entire brain.

One huge drawback with TMS is that, until it is approved, you do have to pay for it privately. I do hope you find something that works, Scott - you have been searching for such a long time. Thank you so much for your encouragement and support- you have mine in full measure, also.

Pfinstegg

I should add that I began psychoanalytic psychotherapy, twice weekly just after the initial TMS treatment. I think the booster TMS seems to help my brain to stay physiologically healthier, while the therapy is aimed at the root causes (abuse)


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