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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 13 of 13. This is the beginning of the thread.
Posted by Stephan on February 9, 2000, at 12:37:59
A positive response would help me as I embark on a bitter five-week washout period.
Posted by Elizabeth on February 10, 2000, at 9:00:09
In reply to Anybody respond to Nardil after failing Parnate?, posted by Stephan on February 9, 2000, at 12:37:59
> A positive response would help me as I embark on a bitter five-week washout period.
I don't have an answer for you (I've taken both, and both worked pretty well). But you don't need to take 5 weeks between stopping Parnate and starting Nardil. 10 days is what the manufacturer of Parnate recommends.
Posted by Scott L. Schofield on February 10, 2000, at 10:13:16
In reply to Anybody respond to Nardil after failing Parnate?, posted by Stephan on February 9, 2000, at 12:37:59
> A positive response would help me as I embark on a bitter five-week washout period.
Elizabeth's description of a 10-day washout period when swithing from Parnate (tranylcypromine) to Nardil (Parnate) is accurate. However, there are some doctors who feel more comfortable allowing for a full 2 weeks. There are plenty of doctors who are not comfortable with using MAO-inhibitors at all.
The washout period when switching from Nardil to Parnate may be a different story. Without going back to search Medline for the references (too lazy), it seems to take longer for MAO activity to recover after discontinuing Nardil than it does for Parnate. However, I have seen people make this type of switch, and they are still alive enough to keep posting here.
Posted by Stephan on February 11, 2000, at 5:15:16
In reply to Re: Anybody respond to Nardil after failing Parnate?, posted by Scott L. Schofield on February 10, 2000, at 10:13:16
> > A positive response would help me as I embark on a bitter five-week washout period.
>
> Elizabeth's description of a 10-day washout period when swithing from Parnate (tranylcypromine) to Nardil (Parnate) is accurate. However, there are some doctors who feel more comfortable allowing for a full 2 weeks. There are plenty of doctors who are not comfortable with using MAO-inhibitors at all.
>
> The washout period when switching from Nardil to Parnate may be a different story. Without going back to search Medline for the references (too lazy), it seems to take longer for MAO activity to recover after discontinuing Nardil than it does for Parnate. However, I have seen people make this type of switch, and they are still alive enough to keep posting here.
Sorry if my post was a little unclear. I tried the Parnate last spring and have most recently been on a combo of nortriptyline (75mg), and (here's the problem) Prozac (80mg). Prozac: the wonder drug that doesn't do squat.
Posted by JohnL on February 11, 2000, at 7:48:38
In reply to Re: Anybody respond to Nardil after failing Parnate?, posted by Stephan on February 11, 2000, at 5:15:16
I've been on this kick lately of encouraging the urgency in trying a different class of drugs when several antidepressants fail. 75mg Nortrip + 80mg Prozac is pretty hefty. Especially in light of the fact that Nortriptyline blood levels are doubled or tripled when combined with normal doses of Prozac. Not to mention 80mg doses. Your blood levels of Nortriptyline are probably double to triple--and maybe a lot more--than the 75mg dose you're taking. If your current meds and previous MAOI trial didn't do the trick, then to me that suggests an urgency to look elsewhere.
I've come to believe that if three or four antidepressants of various classes fail, then remedy is found quicker by trying other classes of drugs instead. The underlying cause of the depression may have little to do with serotonin or norepinephrine in a particular individual's case, making antidepressants nearly useless. It could be chemical or electrical instability, requiring a mood stabilizer. It could be NE/dopamine failure, requiring a psychostimulant. Antidepressants might work through a long drawnout trickle down effect, if they work at all. It could also be dopamine excess(we usually think in terms of deficiency, but too much can cause depression too), easily countered with a small dose of an antipsychotic. We don't need to be schizophrenic to respond nicely to an antipsychotic.
In any case, to me it makes sense to jump to a different class of drugs--the stimulants, the mood stabilizers, antipsychotics--to test them out. If they too fail, then back up and see what might have been overlooked. Usually by then though you will have discovered some unexpected drugs that helped a lot, and perhaps one alone or a blend of your favorites will keep you well indefinitely. The closer a drug is to correcting the problem directly without a trickle down effect, the shorter time it takes to work and the more robust the response. In your case it just seems justified to put other classes of drugs besides antidepressants at the top of the priority list. If antidepressants are going to work with you, you would probably have had at least some decent response by now, considering the wide spectrum and high doses you have tried. I don't know, that's just how I see it. I think a lot of us who are frustrated with poor response to antidepressants are actually assuming the wrong underlying chemical imbalance.
Posted by Scott L. Schofield on February 11, 2000, at 10:25:57
In reply to Re: Anybody respond to Nardil after failing Parnate?, posted by JohnL on February 11, 2000, at 7:48:38
A few years back, an investigation was performed by some of the fine folks at Mass General / Harvard comparing the efficacy of either adding lithium to 20mg of Prozac or raising the dose of Prozac to 60mg. Raising the Prozac to 60 mg/day brought about remissions in a significant number of those who had not responded to 20 mg/day. 80 mg /day is certainly a hefty dose, but I think it is unlikely to be dangerous if all applicable precautions are kept. I know that a dosage this high has been used before.The issue that JohnL has brought up regarding the interaction between Prozac and nortriptyline is important. The blood-levels of nortriptyline are elevated due to its "losing" to Prozac in the competition for enzyme sites that are responsible for the drugs' metabolic breakdowns. This has at least two negative consequences:
1. High levels of any tricyclic are dangerous because they can be cardiotoxic (harmful to heart function).
2. It is possible to take too much nortriptyline and lose the antidepressant effect. This drug is probably the most carefully studied of the tricyclics regarding dose/blood-levels versus antidepressant response. If blood-levels are too low, there is no response. If blood-levels are too high, there is no response. If blood-levels are kept within the upper and lower boundaries of the range of effectiveness (therapeutic window), an antidepressant effect can be achieved and maintained. 75mg of nortriptyline is about the average effective dose that seems to work for most people. If Prozac doubles or triples the blood-levels of nortriptyline as JohnL suggests, it is extremely likely that your blood-levels are way beyond the upper boundary of the therapeutic window.
Another very important issue concerns the washout period that must be adhered to when switching from Prozac to a MAO-inhibitor. One cannot mix MAOIs with SSRIs. It can cause a fatal reaction known as serotonin-syndrome.
The half-life (the time it takes to get rid of half of the drug present in the body) of Prozac, a SSRI, is about one week. The other SSRIs have half-lives of about one day. Therefore, blood-levels of Prozac remain significant for a much longer period of time. With the other SSRIs, the washout waiting period before beginning a MAOI is usually considered to be two weeks. Because of its much longer half-life, switching from Prozac to a MAOI requires a washout period of more like 5 - 8 weeks.
- Scott
Posted by Stephan on February 11, 2000, at 12:04:24
In reply to Re: Anybody respond to Nardil after failing Parnate?, posted by Scott L. Schofield on February 11, 2000, at 10:25:57
>
> A few years back, an investigation was performed by some of the fine folks at Mass General / Harvard comparing the efficacy of either adding lithium to 20mg of Prozac or raising the dose of Prozac to 60mg. Raising the Prozac to 60 mg/day brought about remissions in a significant number of those who had not responded to 20 mg/day. 80 mg /day is certainly a hefty dose, but I think it is unlikely to be dangerous if all applicable precautions are kept. I know that a dosage this high has been used before.
>
> The issue that JohnL has brought up regarding the interaction between Prozac and nortriptyline is important. The blood-levels of nortriptyline are elevated due to its "losing" to Prozac in the competition for enzyme sites that are responsible for the drugs' metabolic breakdowns. This has at least two negative consequences:
>
> 1. High levels of any tricyclic are dangerous because they can be cardiotoxic (harmful to heart function).
>
> 2. It is possible to take too much nortriptyline and lose the antidepressant effect. This drug is probably the most carefully studied of the tricyclics regarding dose/blood-levels versus antidepressant response. If blood-levels are too low, there is no response. If blood-levels are too high, there is no response. If blood-levels are kept within the upper and lower boundaries of the range of effectiveness (therapeutic window), an antidepressant effect can be achieved and maintained. 75mg of nortriptyline is about the average effective dose that seems to work for most people. If Prozac doubles or triples the blood-levels of nortriptyline as JohnL suggests, it is extremely likely that your blood-levels are way beyond the upper boundary of the therapeutic window.
>
> Another very important issue concerns the washout period that must be adhered to when switching from Prozac to a MAO-inhibitor. One cannot mix MAOIs with SSRIs. It can cause a fatal reaction known as serotonin-syndrome.
>
> The half-life (the time it takes to get rid of half of the drug present in the body) of Prozac, a SSRI, is about one week. The other SSRIs have half-lives of about one day. Therefore, blood-levels of Prozac remain significant for a much longer period of time. With the other SSRIs, the washout waiting period before beginning a MAOI is usually considered to be two weeks. Because of its much longer half-life, switching from Prozac to a MAOI requires a washout period of more like 5 - 8 weeks.
>
> - ScottMy levels of nortriptyline were within the therapeutic range. Apparently I'm a rapid metabolizer. OK, here's a (more or less) complete rundown of the things I've tried over the past five years: every post-tricyclic available in the U.S (almost all at or exceeding the max doses for at least six weeks ... plus ad nauseum combos of them with Wellbutrin), lithium 600mg + serzone (did absolutely nothing), a brief trial of low dose Ritalin + Serzone (this deepened my depression), thyroid hormone, desipramine, nortriptyline, clomipramine and Parnate. The reason I keep trying is that a few of these things produced profound improvement (for a while at least). Luvox (probably my best response, stopped it after four months due to extreme drowsiness-a later attempt did nothing.) desipramine 300mg (response not as robust, but kept me functional for at about 8-10 months, nortriptyline (good four month response, then sudden poop-out.) The parnate (went up to 60mg) did give me a transient partial response, this and the fact that my depression is "atypical" lead me (and my doctor) to the conclusion that Nardil might be one of my last best chances. Besides the depression I have no other health problems. My experiences lead me to one conclusion: while we have some clues, our knowledge of the brain is crude and shamefully lacking.
Posted by Noa on February 11, 2000, at 13:46:28
In reply to Re: Anybody respond to Nardil after failing Parnate?, posted by Elizabeth on February 10, 2000, at 9:00:09
How are you?
Posted by Peter on February 11, 2000, at 15:14:20
In reply to Re: Anybody respond to Nardil after failing Parnate?, posted by Stephan on February 11, 2000, at 12:04:24
Stephan:
It seems that I have gone through a very similar experience to yours. I have tried all the SSRIs (except for Luvox), remeron, effexor, Lithium, stimulants, clomiprimine, nortrypt, and Parnate. As you described, I also had success with some drugs (Prozac- pooped out after 2 years, remeron and zoloft very briefly). These glimmers of a non-depressed reality are what have kept me going. I went to see a bigwig researcher who recommended Nardil and said I might try Neurontin and Lamictal. Tried both of these and was not impressed. So now I'm up against the great last resort of Nardil, the idea of which does not appeal, but I'm desperate! BTW I've also had years of therapy. I wish you the best of luck and keep us posted on your Nardil experience. Peter
ps. If you want to read a thought provoking book that is a good analysis of our lack of knowledge about the cause of mental illness as well as a critique of the pharmaceutical industry, take a look at "Blaming the Brain" (I forgot the author, but it is available on Amazon)
> My levels of nortriptyline were within the therapeutic range. Apparently I'm a rapid metabolizer. OK, here's a (more or less) complete rundown of the things I've tried over the past five years: every post-tricyclic available in the U.S (almost all at or exceeding the max doses for at least six weeks ... plus ad nauseum combos of them with Wellbutrin), lithium 600mg + serzone (did absolutely nothing), a brief trial of low dose Ritalin + Serzone (this deepened my depression), thyroid hormone, desipramine, nortriptyline, clomipramine and Parnate. The reason I keep trying is that a few of these things produced profound improvement (for a while at least). Luvox (probably my best response, stopped it after four months due to extreme drowsiness-a later attempt did nothing.) desipramine 300mg (response not as robust, but kept me functional for at about 8-10 months, nortriptyline (good four month response, then sudden poop-out.) The parnate (went up to 60mg) did give me a transient partial response, this and the fact that my depression is "atypical" lead me (and my doctor) to the conclusion that Nardil might be one of my last best chances. Besides the depression I have no other health problems. My experiences lead me to one conclusion: while we have some clues, our knowledge of the brain is crude and shamefully lacking.
Posted by jd on February 11, 2000, at 16:04:55
In reply to Stephan: Your story could be mine!, posted by Peter on February 11, 2000, at 15:14:20
Stephen,
Nardil does sound like a good bet, even if
you've tried Parnate already. But it
strikes me that, with a few exceptions such
as lithium and ritalin, most everything
you've tried is either
a serotonergic or noradrenergic (or combined
5HT/NE) med. If you were hesitant to try
Nardil right away, have you tried low-dose
selegiline, or newer mood stabilizers like
Neurontin or Lamictal?
best,
jd
> Stephan:
>
> It seems that I have gone through a very similar experience to yours. I have tried all the SSRIs (except for Luvox), remeron, effexor, Lithium, stimulants, clomiprimine, nortrypt, and Parnate. As you described, I also had success with some drugs (Prozac- pooped out after 2 years, remeron and zoloft very briefly). These glimmers of a non-depressed reality are what have kept me going. I went to see a bigwig researcher who recommended Nardil and said I might try Neurontin and Lamictal. Tried both of these and was not impressed. So now I'm up against the great last resort of Nardil, the idea of which does not appeal, but I'm desperate! BTW I've also had years of therapy. I wish you the best of luck and keep us posted on your Nardil experience. Peter
>
> ps. If you want to read a thought provoking book that is a good analysis of our lack of knowledge about the cause of mental illness as well as a critique of the pharmaceutical industry, take a look at "Blaming the Brain" (I forgot the author, but it is available on Amazon)
>
>
> > My levels of nortriptyline were within the therapeutic range. Apparently I'm a rapid metabolizer. OK, here's a (more or less) complete rundown of the things I've tried over the past five years: every post-tricyclic available in the U.S (almost all at or exceeding the max doses for at least six weeks ... plus ad nauseum combos of them with Wellbutrin), lithium 600mg + serzone (did absolutely nothing), a brief trial of low dose Ritalin + Serzone (this deepened my depression), thyroid hormone, desipramine, nortriptyline, clomipramine and Parnate. The reason I keep trying is that a few of these things produced profound improvement (for a while at least). Luvox (probably my best response, stopped it after four months due to extreme drowsiness-a later attempt did nothing.) desipramine 300mg (response not as robust, but kept me functional for at about 8-10 months, nortriptyline (good four month response, then sudden poop-out.) The parnate (went up to 60mg) did give me a transient partial response, this and the fact that my depression is "atypical" lead me (and my doctor) to the conclusion that Nardil might be one of my last best chances. Besides the depression I have no other health problems. My experiences lead me to one conclusion: while we have some clues, our knowledge of the brain is crude and shamefully lacking.
Posted by saint james on February 11, 2000, at 16:43:22
In reply to Re: Anybody respond to Nardil after failing Parnate?, posted by Stephan on February 11, 2000, at 12:04:24
> My levels of nortriptyline were within the therapeutic range. Apparently I'm a rapid metabolizer. OK, here's a (more or less) complete rundown of the things I've tried over the past five years: every post-tricyclic available in the U.S (almost all at or exceeding the max doses for at least six weeks ... plus ad nauseum combos of them with Wellbutrin), lithium 600mg + serzone (did absolutely nothing), a brief trial of low dose Ritalin + Serzone (this deepened my depression), thyroid hormone, desipramine, nortriptyline, clomipramine and Parnate. The reason I keep trying is that a few of these things produced profound improvement (for a while at least). Luvox (probably my best response, stopped it after four months due to extreme drowsiness-a later attempt did nothing.) desipramine 300mg (response not as robust, but kept me functional for at about 8-10 months, nortriptyline (good four month response, then sudden poop-out.) The parnate (went up to 60mg) did give me a transient partial response, this and the fact that my depression is "atypical" lead me (and my doctor) to the conclusion that Nardil might be one of my last best chances. Besides the depression I have no other health problems. My experiences lead me to one conclusion: while we have some clues, our knowledge of the brain is crude and shamefully lacking.James here....
I did not see you mention being on Effexor XR, so I would suggest you try the current "big gun" combo of Remeron and Effexor. I agree with John....time to try new classes of meds. I always use Atavin during the washout period, it really takes the edge off, so ask your doc. I do not see the reason of putting a mentally ill person thru a 1 week hell w/o some short term help.
Make sure you use Effexor XR. Start low and don't
worry about going above 200 mgs if you tolerate it.james
Posted by Mairwen on November 14, 2003, at 5:33:48
In reply to Re: Anybody respond to Nardil after failing Parnate?, posted by Stephan on February 11, 2000, at 12:04:24
Does anybody know the half-life of Parnate. I am taking it with more success than Nardil with which I had serious side effects. The only side effect I have with Parnate is that 4-5 hours after taking it I become very dizzy and tired and have to lie down or I would fall down. I then sleep for a couple of hours. What I am trying to work out is whether it is better to take the Parnate at night rather than in the morning. But if I do that, do I lose all the day time benefit of Parnate. I seem to react very quickly to Parnate. It worked in 48 hours which the doctors could not believe as they expected it to take 4-5 weeks to show any beneficial effect.
Mairwen
Posted by Liligoth on November 15, 2003, at 6:26:35
In reply to Re: Anybody respond to Nardil after failing Parnate?, posted by Mairwen on November 14, 2003, at 5:33:48
I believe parnate has some metabolites of speed or something like that. This is why it is immediately activating but this is not it's antidepressant effect. That will kick in after a few weeks & by then you will have built up a tolerance to the 'speedy' aspects of it. Once the speediness had worn off I found it best to take it at night because it knocked me out.
Hope it goes well for you
This is the end of the thread.
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