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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 2 to 26 of 44. Go back in thread:
Posted by zeugma on June 3, 2004, at 18:15:14
In reply to Would strattera treat depression and ADD??, posted by TenMan on June 3, 2004, at 17:34:03
> For those who have experience with strattera did it have an antidepressant effect? I have anergic depression along with inattention and have been looking for something to replace my wellbutrin. It just isn't cutting it.
>
> Also does anyone have any idea why many people report strattera makes them drowsy? By what mechanism does this take place?1st. Yes, it has an antidepressant effect. It also helps the ability to focus.
2nd. The speculated mechanism for drowsiness is stimulation of alpha-1 and -2 adrenergic receptors. The flaw in this explanation is that it causes more fatigue than nortriptyline, which is also a NE transporter inhibitor, and is more sedating than Strattera to boot (sedation as in increasing the propensity to sleep). This is a major limiting factor in the long-term usage of this medication, particularily for inattentive types, who are prone to suffer from fatigue anyway.
>
> Thanks
Posted by King Vultan on June 3, 2004, at 20:23:45
In reply to Would strattera treat depression and ADD??, posted by TenMan on June 3, 2004, at 17:34:03
> For those who have experience with strattera did it have an antidepressant effect? I have anergic depression along with inattention and have been looking for something to replace my wellbutrin. It just isn't cutting it.
>
Yes, it does have an antidepressant effect similar to other selective norepinephrine reuptake inhibitors I have tried, including nortriptyline, desipramine, and Vivactil (protriptyline).
> Also does anyone have any idea why many people report strattera makes them drowsy? By what mechanism does this take place?
>
> Thanks
It is kind of strange, but I believe it is just a characteristic of the molecule, in the same way that Paxil is sedating compared to other SSRIs despite the fact that this is completely unobvious from looking at its pharmacology and receptor blockades. The tricyclics desipramine and Vivactil both have histamine blockades that Strattera apparently completely lacks, and I found neither of them to cause the drowsiness that Strattera did. Speaking of Vivactil, this drug is easily the most stimulating of the tricyclics, but again, there is absolutely no explanation for this looking at its pharmacological profile. It is another case where it is just an intrinsic ability of the molecule.Todd
Posted by CareBear04 on June 3, 2004, at 23:07:40
In reply to Re: Would strattera treat depression and ADD?? ?TenMan, posted by King Vultan on June 3, 2004, at 20:23:45
speaking of strattera, i've read a lot about strattera dosages and how the recommended adult dosage may be too high. does body size/weight matter in dosing? if i'm about 5'5 and 105lbs, would it be too much to start at 40mgs and work up to 80? how much do you think is a good amount of strattera? i'd be taking it for ADD symptoms.
thanks, everyone!
Posted by Ktemene on June 4, 2004, at 4:34:51
In reply to Would strattera treat depression and ADD??, posted by TenMan on June 3, 2004, at 17:34:03
I also have anergic depression with inattentive ADD. (I wonder how many others there are on the board? I suspect there are a lot of us.) My experience has been that 80 mg Strattera has greater antidepressant effect than even the maximum dose of Wellbutrin (450 mg). And Strattera is more helpful for concentration and focus than Wellbutrin. I took Wellbutrin for more than a year, starting at 150 mg per day, and it was a much more effective AD for me than any of the SSRI's that I had tried. But I was still too sleepy and unfocused to be productive, so my Pdoc and I kept increasing the dosage of Wellbutrin until we finally hit the maximum and I had developed a number of nasty SE's (permanent neck pain, massive hair loss, etc). At that point, three months ago, I went off Wellbutrin and started Strattera, and the Strattera has definately worked better. (I am thinking of adding 5 or 10 mg Selegiline to my cocktail just to see whether more dopaminergic activity might allow me to stop taking Adderall.)
From what I have read Strattera does not cause drowsiness in most people; but it does make me drowsy. I deal with the Strattera sleepiness by taking 200 mg Provigil and 10 mg Adderall with the 40mg Strattera I take in the morning, and I take the same combination again in the afternoon when I begin to fade. (Actually, I sometimes skip the Adderall since the Provigil is so effective.)
Posted by zeugma on June 4, 2004, at 5:15:29
In reply to Re: Would strattera treat depression and ADD??, posted by Ktemene on June 4, 2004, at 4:34:51
> I also have anergic depression with inattentive ADD. (I wonder how many others there are on the board? I suspect there are a lot of us.) My experience has been that 80 mg Strattera has greater antidepressant effect than even the maximum dose of Wellbutrin (450 mg). And Strattera is more helpful for concentration and focus than Wellbutrin. I took Wellbutrin for more than a year, starting at 150 mg per day, and it was a much more effective AD for me than any of the SSRI's that I had tried. But I was still too sleepy and unfocused to be productive, so my Pdoc and I kept increasing the dosage of Wellbutrin until we finally hit the maximum and I had developed a number of nasty SE's (permanent neck pain, massive hair loss, etc). At that point, three months ago, I went off Wellbutrin and started Strattera, and the Strattera has definately worked better. (I am thinking of adding 5 or 10 mg Selegiline to my cocktail just to see whether more dopaminergic activity might allow me to stop taking Adderall.)
>
> From what I have read Strattera does not cause drowsiness in most people; but it does make me drowsy. I deal with the Strattera sleepiness by taking 200 mg Provigil and 10 mg Adderall with the 40mg Strattera I take in the morning, and I take the same combination again in the afternoon when I begin to fade. (Actually, I sometimes skip the Adderall since the Provigil is so effective.)
I think that anergic depression is a manifestation of severe, inattentive ADD. (A nasty dual manifestation.) Strattera does not cause drowsiness per se, as nortriptyline does. I don't know if it highlights the fatigue that inattentives feel by successfully 'alerting' the mind, but adding nothing in the way of energy, or whether, as King Vultan speculates, there is some intrinsic property of the molecule that is fatiguing. As he does not suffer from inattentive ADD but experienced this effect it adds weight to the latter theory.I have mixed feelings about Strattera, it has definitely helped me function and get a real job, but has robbed me of any desire to socialize or have a life because of the anergia! I literally fall asleep in the middle of dinner if I do not have at least one cup of strong coffee after 5 p.m. and that is no way to live.
Posted by Chairman_MAO on June 4, 2004, at 7:59:27
In reply to Re: Would strattera treat depression and ADD?? » Ktemene, posted by zeugma on June 4, 2004, at 5:15:29
You may have previously mentioned this, but have you ever given desipramine or Provigil a try? Another idea is to give some extra dopamine, perhaps with selegiline, which has some CNS alerting properties both intrinsically and via its metabolites. MAOIs, after all, deftly encourage insomnia. :)
Posted by TenMan on June 4, 2004, at 16:46:44
In reply to Would strattera treat depression and ADD??, posted by TenMan on June 3, 2004, at 17:34:03
Thank you to everyone for your replies. I think I am going to stay away from strattera for now and maybe switch over to the SR version of wellbutrin and talk to my doc about adding adderall or concerta.
Thanks agian
Posted by zeugma on June 4, 2004, at 17:08:51
In reply to Re: Would strattera treat depression and ADD?? » zeugma, posted by Chairman_MAO on June 4, 2004, at 7:59:27
> You may have previously mentioned this, but have you ever given desipramine or Provigil a try? Another idea is to give some extra dopamine, perhaps with selegiline, which has some CNS alerting properties both intrinsically and via its metabolites. MAOIs, after all, deftly encourage insomnia. :)
I definitely need a stimulant of some sort, my caffeine intake is getting out of hand and when I don't guzzle it I collapse.
The desipramine idea is a good one, I had a BIG argument with my pdoc last visit about nortriptyline, desipramine, and Strattera, in which he claimed that Strattera was more efficacious for ADD than either of these TCA's. I protested that it certainly was more effective than nortriptyline, but that I had seen no evidence, none whatever, to indicate that it worked better than the imipramine metabolite. That was when he brought out the claim that these TCA's worked more in the brainstem, and Strattera worked in the frontal lobes, hence greater efficacy in ADD. No one here has been able to provide the least substantiation of this claim, and there are some knowledgeable people here. Neither has any diligent search of my own on this topic yielded anything, granted I am no neuroscientist and I don't have unlimited access to medline. I'm at an impasse. I strongly suspect Strattera of aggravating my already severe fatigue. I believe that TCA's are superior to anything produced in their wake. I think E.Lilly and Co. would dispute this :)
How is the desipramine working? Don't worry, I will respond to your formidable post on minds and brains soon :)
Posted by Chairman_MAO on June 6, 2004, at 15:15:27
In reply to Re: Would strattera treat depression and ADD?? » Chairman_MAO, posted by zeugma on June 4, 2004, at 17:08:51
The desipramine seems to have started working somwhat since approximately day two for attention (esp. "executive function"), motivation, and depression. It's amazing how much "coarser" of a mood lift desipramine seems to provide for me. Unfortunately, I tossed the 75mg of Effexor to the wind for lack of efficacy, fatigue, emotional numbing, and worsening of ADD & anhedonia, so now I am dealing with a mild SSRI withdrawal syndrome while as the desipramine kicks in. I now cannot tease apart the withdrawal syndrome's cognitive dysfunction from my default state, and probably will not be able to do so for at least two more weeks. For the record, I find that Trileptal and desipramine both help deal with the withdrawl syndrome somewhat; it's definitely much more bearable than SSRI withdrawl's been in the past.
The constellation of side effects is a pain, particularly the impotence and dry mouth, which I hope my doctor is amenable to treating with Flomax and a muscarinic agonist (Salagen, Evoxac respectively. That said, I hope in two weeks my doctor lets me raise the dose to 150mg (from 75). I see a lot of promise with the desipramine and am eager to experience a full therapeutic dose.
Regarding Strattera vs. TCAs, I think your doctor's line of reasoning is a heap of Eli Lilly-sponsored you-know-what. I have no sources to cite at this time, so I cannot be sure but I seem to recall reading abstracts indicating that both atomoxetine and nortriptyline (and so presumably desipramine, too) block DA reuptake in the prefrontal cortex. There are no DA reuptake transporters there, leaving the NE reuptake transporter on "double duty" for both DA and NE. My suspicions are obviously supported by the fact that desipramine, imipramine, and nortriptyline all have been shown efficacious in treating ADD.
Regarding the fatigue: I've tried both desipramine and Strattera, and can tell you that desipramine does not cause the fatigue Strattera does. In fact, it's mildly activating. Were it not for desipramine's antimuscarinic side effects, a choice between the two would be a no-brainer; desipramine all the way!
Posted by zeugma on June 6, 2004, at 19:47:57
In reply to Re: Would strattera treat depression and ADD?? » zeugma, posted by Chairman_MAO on June 6, 2004, at 15:15:27
<Regarding Strattera vs. TCAs, I think your doctor's line of reasoning is a heap of Eli Lilly-sponsored you-know-what. I have no sources to cite at this time, so I cannot be sure but I seem to recall reading abstracts indicating that both atomoxetine and nortriptyline (and so presumably desipramine, too) block DA reuptake in the prefrontal cortex. There are no DA reuptake transporters there, leaving the NE reuptake transporter on "double duty" for both DA and NE. My suspicions are obviously supported by the fact that desipramine, imipramine, and nortriptyline all have been shown efficacious in treating ADD.
Regarding the fatigue: I've tried both desipramine and Strattera, and can tell you that desipramine does not cause the fatigue Strattera does. In fact, it's mildly activating. Were it not for desipramine's antimuscarinic side effects, a choice between the two would be a no-brainer; desipramine all the way!>
All NE reuptake inhibitors block DA reuptake too, with a higher affinity for taking up DA than NE itself. And as you point out, DA transporters are sparse in the prefrontal cortex, so NRI's finction as DRI's there as the NE transporter is the major source of DA reuptake in that region.
My pdoc did not deny this, but claimed that Strattera 'gravitated' to the PFC more than the TCA's. I think what this debate will hinge on ultimately will be head-to-head comparisons of atomoxetine vs. desipramine, which I doubt will happen, as desipramine has been off patent for many years and Lilly will benefit from the adverse publicity desipramine received in the last decade when four children died of unknown causes during DMI treatment. I had always assumed that it was DMI's proven effectiveness in treating ADD, coupled with the bad name TCA's earned through these unfortunate incidents, that inspired Lilly to pick up development on their drug as a 'safer' 'non-stimulant' alternative to Ritalin et al.I am sticking with nortriptyline for now, as it helps me sleep without giving me too much of a hangover (insomnia's one of my chronic complaints). I am going to get another plasma level done and I'll see if I can up the dose of NOR to 100 mg. I want to lower the Strattera as I raise the NOR, and eventually get a stimulant to replace the Strattera. That should doubly help the fatigue: not only will I be ridding myself of Strat, I'll be adding something that should actually help with this odious symptom (I spent most of the weekend in bed, typically).
Posted by zeugma on June 7, 2004, at 17:57:50
In reply to Re: Would strattera treat depression and ADD?? » Chairman_MAO, posted by zeugma on June 6, 2004, at 19:47:57
whether I am going to stay on strattera for the rest of the summer and whether my pdoc is simply parroting Lilly propanganda (odious thought) are open questions, but I looked thru the clinical trials info on package insert and saw that "fatigue" was more common on qd dosing than on BID. so I took 40 mg at 6 am and took the second 40 around 4 pm. Fatigue was a little better. Hopefully this will carry over tomorrow too, because I have been so fatigued for the past 6 months that I have not wanted to socialize, to talk to anyone, to do anything other than my job and then to collapse... I see a stimulant in my future and I am exercising my brains out and drinking protein shakes to maintain enough weight to tolerate a stimulant, am joining a gym soon and hopefully this plan will work.
Posted by Ktemene on June 7, 2004, at 19:15:25
In reply to BID dosing is a little better, posted by zeugma on June 7, 2004, at 17:57:50
The level of fatigue you have had to deal with while on Strattera is really awful. I was wondering whether you and your pdoc had decided not to do a trial of Provigil? I am sure you have already considered all of this, but it might make sense to try Provigil while you are taking a fairly high dose of Strattera, since many people have found that the two drugs work synergistically together. And trying Provigil would not preclude adding a stimulant as well if Provigil was not enough to eliminate your fatigue (I am currently taking Strattera, Provigil and Adderall to deal with my sleepy-and-tired depression + ADD). By the by, I have also found BID dosing of Strattera to be much better; taking 80 mg at a time just knocked me out. I sometimes wonder whether it would not be better to divide Strattera into four or even eight daily doses instead of two daily doses, especially given Strattera’s extremely short half life. Also, what about Chairman_Mao’s suggestion of adding a little selegiline to your cocktail? Even very low dose selegiline is a very activating augmentation for some people (I mention this because I started taking 2.5 mg selegiline three days ago and I am amazed at how energizing it is) and at least one person on this board found low dose selegiline a great augmentation for social phobia (his name is Rick and his post on selegiline and social phobia is at http://www.dr-bob.org/babble/19991001/msgs/9618.html).
Your suggestion that anergic depression is really a manifestation of severe inattentive ADD is very interesting, and if true would certainly make sense of a lot of things. Do you know of any literature on the subject?
By the way, when your pdoc tells you that Strattera ‘gravitated’ to the PFC more than the TCA’s does your pdoc mention what the evidence is for this claim? Or does your pdoc just expect you to believe whatever your pdoc tells you on your pdoc’s own personal authority? If the latter, it might be worthwhile to look for a new pdoc who is more invested in evidence-based medicine.
Posted by Ktemene on June 7, 2004, at 19:37:08
In reply to Re: Would strattera treat depression and ADD??, posted by CareBear04 on June 3, 2004, at 23:07:40
> speaking of strattera, i've read a lot about strattera dosages and how the recommended adult dosage may be too high. does body size/weight matter in dosing? if i'm about 5'5 and 105lbs, would it be too much to start at 40mgs and work up to 80? how much do you think is a good amount of strattera? i'd be taking it for ADD symptoms.
> thanks, everyone!
>
Hi CareBear,I have seen a number of warnings about starting Strattera at high doses, but the only explanation I have seen is the one that Jarod over at crazymeds.org provides. It is under his article on Strattera and he says his source for it is his pdoc. Jarod feels very strongly that people should start Strattera at 18-25 mg and build slowly from there, and he seems to be a reliable guy. That said, I should mention that my pdoc started me off at 60 mg (I weigh 120lb) and I did not have any more than the usual difficulties when starting a medicine. But, as always, YMMD. Good luck with Strattera. It has certainly helped lots of people, and I hope it turns out to be a good med for you.
Ktemene
Posted by zeugma on June 7, 2004, at 20:24:31
In reply to Re: BID dosing is a little better » zeugma, posted by Ktemene on June 7, 2004, at 19:15:25
Yes, I'm considering Provigil and also more conventional stimulants. I am very confused at the moment. My pdoc came with a high recommendation, he is a specialist in attention deficit disorder, and he stuck with me as I went through a very difficult period titrating up on nortriptyline. Even at that time (more than a year and a half ago), he seemed to have this idea that Strattera and nortriptyline would 'go well together,' despite the fact that they have similar pharmacologies and standard practice is to minimize redundancies. Strattera does feel very different as it hits my brain, it is a drug with a much more rapid absorption and does not have the antihistaminic effect nortriptyline has. I was willing to go along with all this as long as the results were good. The Strattera fatigue did not hit me all at once. At first it was mildly stimulating, then it became neutral, then finally I became so fatigued that I became vulnerable to a relapse of depression. It was only when I become seriously depressed again that I questioned him strongly on the combination (I had asked questions before about the rationale but the situation was less urgent so I accepted half-answers). This differential effect on the PFC as opposed to the other areas of the brain innervated by the NET is something I would need substantiation for, because in the past two months I have been juggling my meds trying to find what was aggravating my already prominent fatigue: I determined that it wasn't the nortrip , then I dropped the buspirone, with little change, and now it can only be the Strattera. Since fatigue is part of inattentive ADD as far as I am concerned, I would only want to keep the Strattera if I had a good reason for doing so, and I am definitely keeping the nortriptyline, even going through the ceremony of another plasma level later in the month to determine whether I'm in the therapeutic window.
He did not produce evidence, but I am going to ask him for evidence at the next session. Even if my fatigue lifts a little as a result of the BID dosing schedule, I am still going to need a stim, and it seems like absurdity to be on two NRI's plus a stimulant (and God knows what that would do to my brain) provided there is no evidence of real difference between the two NRI's and one of them is worsening my anergia. He alluded to Strattera's possible superiority to desipramine and I would *really* like to see ANY evidence of that.
The theory of anergic depression being synonymous with a severe inattentive ADD is simply my own reflection on the course my own symptoms have taken. I had become steadily more disengaged, drained, and anergic over the years and this lack of energy appeared to be related to my inability to carry out any actions on my own due to my increasingly fractured ability to perceive {myself and what was around me). I'm not aware of any literature on the subject, but I can tell you that I consider severe ADD to be a disorder that stikes at the heart of the self and its ability to relate to itself ( a kind of self-disconnection). The anergia may stem from the enormous expenditure in energy it takes to carry out any coherent activity in such conditions.
That's great that selegeline is working for you. I am probably going to try Provigil first, if I stay on Strattera, or some kind of amphetamine if not. Your post has given me a lot to think about.
Posted by zeugma on June 9, 2004, at 0:07:47
In reply to Re: BID dosing is a little better » Ktemene, posted by zeugma on June 7, 2004, at 20:24:31
I am finished with this drug, which has driven my anergia to the breaking point. I took my last 40 mg this afternoon. Even the fog of inattentive ADD would be punctuated by flashes of light, glimmers of energy. I feel completely wiped out on this drug. It is giving me insomnia now to boot. Or it could be the extravagant amounts of coffee I am forced to drink in order to stay focused and awake at work- which means the Strattera is useless for my ADD anyway.I am going to tell my pdoc- whoever he or she turns out to be- that I am suffering from a severe anergic depression, no appetite, severe ADD issues. I have no idea what i'll wind up on.
Posted by Viridis on June 9, 2004, at 6:20:46
In reply to strattera trial ends, posted by zeugma on June 9, 2004, at 0:07:47
Interesting... Strattera seemed to help me at first with focus and depression, but it completely destroyed my appetite. I had no interest whatsoever in food, became extremely dehydrated as well, and (strangely) began slurring my words (suggestive of cerebellum damage). All of these side effects stopped within a few days of discontinuing it (except the speech difficulties, which took a bit longer to subside). I liked it at first, but the benefits quickly diminished while the side effects just got worse.
Scary drug for me, but maybe good for others? My pdoc wanted me off it immediately when I told him this (although he was amenable to a taper schedule if necessary), and I had no trouble at all with sudden discontinuation after about 6 months (max dose 80 mg).
Posted by zeugma on June 9, 2004, at 18:34:16
In reply to Re: strattera trial ends » zeugma, posted by Viridis on June 9, 2004, at 6:20:46
> Interesting... Strattera seemed to help me at first with focus and depression, but it completely destroyed my appetite. I had no interest whatsoever in food, became extremely dehydrated as well, and (strangely) began slurring my words (suggestive of cerebellum damage). All of these side effects stopped within a few days of discontinuing it (except the speech difficulties, which took a bit longer to subside). I liked it at first, but the benefits quickly diminished while the side effects just got worse.
>
> Scary drug for me, but maybe good for others? My pdoc wanted me off it immediately when I told him this (although he was amenable to a taper schedule if necessary), and I had no trouble at all with sudden discontinuation after about 6 months (max dose 80 mg).That's the reason you are seeing the same pdoc while I am not. He was not interested in the worsening of my condition, he only advised me to take it at 4 pm and bedtime. I decided on hearing this that he was no longer my pdoc, and I suffered from an episode of insomnia last night (after my 4 pm dose) that gave me the familiar Strattera combination of 'alerting' and fatigue. Luckily I had some buspirone on hand which I took around midnight, and I was able to get a few hours of sleep last night.
The word-slurring is a disturbing effect. This drug is not as well studied as the tried-and-true AD's and ADD meds (TCA's, amphetamine et al.) and the drug reps are pushing it hard. What made up my mind was his seeming willingness to get me off every other drug first to determine what was causing my excess fatigue (as an inattentive ADD'er and probable narcoleptic I have fatigue enough at baseline, thank you) and his eagerness to, for instance, discontinue the tricyclic nortriptyline (which has been off patent for about 2 decades), in contrast to his response to my discovery that, in his words, Strattera was the 'culprit': no dose reduction at all, just change the time of administration! As if my am dose didn't wipe me out for the whole day anyway.
I am glad to hear your side effects abated quickly and hope that mine do so as well. I only needed one cup of coffee to get me through the day, plus some Coke in the afternoon. Hopefully the fatigue will continue to diminish.
Posted by Viridis on June 10, 2004, at 0:26:52
In reply to Re: strattera trial ends » Viridis, posted by zeugma on June 9, 2004, at 18:34:16
Hi Zeugma,
It's disturbing to hear (so often) how much some doctors listen to the drug reps instead of the patients. I'm certainly not trying to "demonize" Strattera, and in fact posted endorsements of it here early on. It could well be a great medication for some people. But I have come across anecdotal reports of reactions similar to mine and yours on the web, and if someone reports a bad reaction a doctor should take it seriously.
I had a situation somewhat like yours, when I reacted very badly to Wellbutrin, and my GP asserted that the new antidepressants do not cause side effects, period. He told me that the anxiety, extreme dizziness, light sensitivity etc. that I experienced must be "my imagination". When I started with my current pdoc shortly afterwards, he said oh yes, he's heard this from other patients and is cautious with this med because everything I described is consistent with his experience (for a minority of patients).
I should add that I'm not usually drug-sensitive or hypochondriacal, but do know when a med is working or not.
I think that in any profession, there are a few really awful practitioners, lots of mediocre ones, and a small proportion of truly skilled individuals. I've seen this with doctors, dentists, plumbers, electricians, auto mechanics, etc. etc. You 're the one paying for the service, and if the pdoc or whatever is unsatisfactory, then it's time to move on (as you have). Many people simply stick with the same doctor because they think that these people have the ultimate authority. But they don't -- you do, even if you're not a medical expert. Patients come to know what works and what doesn't, yet so many stay with the same doctor, regardless of "fit" or competency. Some are just stuck, I guess, and others find it too difficult to change, even when they should.
Anyway, enough ranting -- you know all of this, so I'm just speaking in general terms. As for Strattera, it might be wonderful for some people, but as with all these meds, no one size fits all and especially with the newer ones some caution is warranted.
All the best,
Viridis
Posted by Ktemene on June 10, 2004, at 0:36:15
In reply to strattera trial ends, posted by zeugma on June 9, 2004, at 0:07:47
The fact that you only needed a single cup of coffee and soft drink to get through the day is a strong indication that you did the right thing in stopping the Strattera. I know what you mean when you say that Strattera gives you a combination of ‘alerting’ and fatigue. When I take Strattera in the daytime I have just that feeling- it is as if I am really very tired but a layer of stimulation is lying just on top of the still clearly perceptible fatigue/somnolence. I have tried taking it at night to take advantage of its sleep-inducing properties, but it tends to disturb my sleep. It is a strange drug. Your experience is tempting me to try dropping Strattera altogether to see how I do on just Provigil and Adderall (and very low dose Selegiline if it continues to work well). I take it you are still using Nortriptyline? And it won’t be too difficult to find another pdoc? With a new pdoc at least you won’t have to worry about countering your former pdoc’s inordinate fondness for Strattera and you won’t have to listen to any unsupported claims that TCA’s work in the brainstem while Strattera works in the frontal lobes etc.
Another positive aspect of the situation is that you have been thinking through a lot of possible alternative meds, and, now that it is summer, you will be able to experiment without endangering your effectiveness in teaching your classes. By the way, I really like your idea about severe inattentive ADD and anergic depression being the same condition. I think you mentioned that one of your areas in philosophy is philosophy of mind. Your idea might make a very interesting and original addition to the philosophical literature. I have always wondered why so few philosophers write about the philosophical implications of depression, especially since so many philosophers suffer from depression.
I hope your withdrawal from Strattera continues to be smooth. Let us know how you are doing.
Posted by zeugma on June 10, 2004, at 20:17:07
In reply to Re: strattera trial ends » zeugma, posted by Ktemene on June 10, 2004, at 0:36:15
Thanks for the responses, Viridis and Ktemene.
I only needed about two and a half cups of coffee today- a fraction of my prior intake, and despite some more insomnia. I made a pot of coffee when i came home, mostly to keep up my focus as I installed my air conditioner. But I found that it made me somewhat nauseous, and that I didn't really need it.
I called my pdoc's office to tell his secretary I was cancelling my next appointment. When she learned I didn't want to reschedule she told me she'd have the dr. call me back. I agreed to this although I was worried he'd convince me to continue with him.
He called back and I told him I'd discontinued the strattera. His first question was whether I had enough meds on hand, especially clonazepam, as that has a serious discontinuation syndrome. He asked me what my plans were to treat my ADD. I told him I planned to try a stimulant, and he advised me to try a short-acting one, as my last stim trial was of a long-acting one (Cylert) and I was forced to discontinue because of weight loss. Ok, this was reasonable, he asked me if I would continue with him and I told him I would get back to him after a week but that I was doubtful. I thanked him for his concern and advice. I could comment more on this, both positively and negatively, but that's all I want to say right now about it.
About the nortriptyline: Yes, I am continuing with it. It has some similarities to strattera in that I recognize an 'alerting' feeling when it hits (much more slowly than Strat) but this is accompanied by, and almost completely muted by, a drowsiness that is clearly antihistaminic. These feelings are faint at 50 mg, unmistakable at 75 mg. By morning there is nothing but usual morning grogginess. It improves the quality of my sleep, especially when combined with buspirone, for some reason.
My plan this summer is to get on a TCA-stimulant combination (plus 1 mg clonazepam, and possibly regular use of 15 mg buspirone at night). It sounds like this pdoc is amenable, and he seemed to acknowledge his mistake. The whole experience is sobering, and as my emotions cool as the Strattera effects subside further I am going to weigh the whole matter carefully.
I have heard a lot about the synergism of Provigil and Strattera, but how much of that is simply provigil's countering the strattera fatigue? That is simply a thought I have had when I considered adding Provigil to strattera myself.
Why don't more philosophers write about the philosophical implications of depression? Maybe because they're too depressed to publish the results of their speculations- or too depressed to write at all.
Posted by zeugma on June 11, 2004, at 15:00:40
In reply to more strattera thoughts, pdoc called, posted by zeugma on June 10, 2004, at 20:17:07
I think I will be starting a stimulant trial as soon as possible.
Posted by Ktemene on June 13, 2004, at 4:26:32
In reply to Re: more strattera thoughts, pdoc called, posted by zeugma on June 11, 2004, at 15:00:40
It's good that your pdoc admitted being wrong about you and Strattera. What stimulant are you thinking of trying? Are you having any problems going off Strattera? I hope you're continuing to do OK.
Posted by zeugma on June 13, 2004, at 10:57:38
In reply to Re: more strattera thoughts, pdoc called » zeugma, posted by Ktemene on June 13, 2004, at 4:26:32
> It's good that your pdoc admitted being wrong about you and Strattera. What stimulant are you thinking of trying? Are you having any problems going off Strattera? I hope you're continuing to do OK.>
Thank you for the concern. My pdoc (yes, still the same one, I will see how much he can help me now that the strattera is not an issue) suggested a short-acting one: am I correct in supposing that plain old Ritalin is the shortest-acting one? What about d-amphetamine? Does Adderall come in an immediate release as well as XR version? I need something that will help with physical energy as well as mental focus, but that will wear off quickly enough so i can sleep (still experiencing some insomnia). I would appreciate any suggestions.
I am continuing to do OK. I was able to do my laundry this week and to go to the supermarket this weekend, which shows that I am getting some energy back.
I still feel disillusioned over medications. Strattera was supposed to be a wonder drug, and it seemed to be for me at first. I remember wondering at the time if Strattera would make the TCA's obsolescent. The stims have been around forever, they are not miracles, but if they can treat aspects of my disorder, that is all i am looking for. I may start on a stimulant as early as tomorrow. Any advice would be greatly appreciated.
Posted by Viridis on June 14, 2004, at 1:44:41
In reply to stimulants » Ktemene, posted by zeugma on June 13, 2004, at 10:57:38
I do well with Adderall (for ADD, but it also acts as an antidepressant). I take a pretty low dose (5-15 mg/day) and haven't had any problems with it. I've been taking it for a few years and can still skip it for a day or two without any withdrawal etc. I take the immediate-release generic made by Barr Labs, and haven't tried the XR version. For me at least, there's no "crash" of the kind that people describe for some stimulants, and it doesn't interfere with my sleep.
Good luck!
Posted by Ktemene on June 14, 2004, at 4:24:20
In reply to Re: more strattera thoughts, pdoc called, posted by zeugma on June 11, 2004, at 15:00:40
I agree with Viridis about Adderall; I had very much the same experience. I also take immediate release Adderall. My pdoc prescribes 20mg per day, but I often take only 10 mg. I have never experienced any sort of crash as the Adderall wears off, and I have never experienced any sort of euphoria when I first take it, although the energizing effect does feel like an antidepressant effect to me since my depression is of the extremely sleepy sort. Also, I have never had the impulse to take more than the prescribed dose. In fact, after I first started taking Adderall I asked my pdoc why Adderall was considered to have so much potential for addiction, since it struck me as having about as much addictive appeal as aspirin. And my pdoc told me that my response to Adderall was typical of people with ADD, for whom the medication's main effect was a distinctly noneuphoric calm-but-alert feeling. The energizing effect kicks in within a half an hour or so, and lasts several hours. (Although I should say that I always take my morning dose of Adderall with 200 mg Provigil and 200 mg caffeine, so I am not really sure which kicks in first.)
The other prescription stimulant I have been taking for some time is Provigil. As you know, Provigil really is a medication for narcolepsy, although it is widely used off-label for depression and ADD. This might be a point in its favor for someone like you who has a lot of narcolepsy symptoms. The best aspect of Provigil for me is that I can take it late at night and still get to sleep when I want to. Provigil takes away the need to sleep without taking away the ability to sleep. Provigil helped me a lot, but not quite enough, which is why my pdoc added Adderall to my cocktail.
It is a shame that Strattera was such a disappointment in your case after it appeared to be so promising. Strattera was not as disastrously soporific for me as it was for you, but it has certainly not been what I hoped for. Reboxetine might have worked better, but I gather that it will be a long while before Americans will be able to try it.
Good luck in finding the right stim!
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