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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 29. This is the beginning of the thread.
Posted by anxiety_free on August 16, 2004, at 6:57:15
Hi! I currenly take imipramine @150mgs/day, along with a stimulant, two benzos, and propranolol. My question really is about the tricylic: is there a better one? I'm not psychotically depressed, I just want the most bang for my psychiatric buck. For depression/anxiety, what's GOOD and what's GREAT? Can tricyclis be mixed for max. impact? (ex: Pamelor+Elavil). Thanks for your help!
Posted by zeebop on August 16, 2004, at 7:40:48
In reply to TRICYCLICS: Is there a best one?, posted by anxiety_free on August 16, 2004, at 6:57:15
> Hi! I currenly take imipramine @150mgs/day, along with a stimulant, two benzos, and propranolol. My question really is about the tricylic: is there a better one? I'm not psychotically depressed, I just want the most bang for my psychiatric buck. For depression/anxiety, what's GOOD and what's GREAT? Can tricyclis be mixed for max. impact? (ex: Pamelor+Elavil). Thanks for your help!
HI,
I took Imipramine 75 + Amitriptyline 25 for 2 years and they erased my severe depression + anxiety like no other AD since.
I stopped,because I was finally OK ,+ the weight gain started to increase (mainly dose-related and more because of Amitriptyline).P.S. I've tried lots of other AD's later,especially the new ones,but nothing worked effectively like this combo,and I know that if I ever enter an epesode of SEVERE melancholic depression,this is the way.
Posted by King Vultan on August 16, 2004, at 7:54:28
In reply to TRICYCLICS: Is there a best one?, posted by anxiety_free on August 16, 2004, at 6:57:15
> Hi! I currenly take imipramine @150mgs/day, along with a stimulant, two benzos, and propranolol. My question really is about the tricylic: is there a better one? I'm not psychotically depressed, I just want the most bang for my psychiatric buck. For depression/anxiety, what's GOOD and what's GREAT? Can tricyclis be mixed for max. impact? (ex: Pamelor+Elavil). Thanks for your help!
Imipramine is a good all around drug if you can tolerate the side effects, as it works on both serotonin and norepinephrine besides being anxiolytic. Elavil/amitriptyline is quite a bit more sedating and would have more of a tendency to induce weight gain. Pamelor/nortriptyline is approximately as sedating as imipramine but is selective for blocking NE reuptake, while having fewer side effects than either imipramine or amitriptyline. I guess my thought would be that if the imipramine is working for you, there's perhaps not a great deal of incentive to change. If a person is looking for something similar with less anticholinergic effects, nortriptyline would probably be a good alternative.Todd
Posted by SLS on August 16, 2004, at 8:45:02
In reply to Re: TRICYCLICS: Is there a best one?, posted by King Vultan on August 16, 2004, at 7:54:28
> I guess my thought would be that if the imipramine is working for you, there's perhaps not a great deal of incentive to change. If a person is looking for something similar with less anticholinergic effects, nortriptyline would probably be a good alternative.
>
> ToddI really prefer the way I feel on nortriptyline to desipramine. It feels like a more "whole" antidepressant effect. Unfortunately, there is no stable window of efficacy for me. I just can't use the drug. I wish I could.
I can't stress enough how important it is to aim for the bullseye with nortriptyline dosage. Too high a dosage is as bad as too low a dosage. Use blood tests as guide, but assess clinical effect through experimentation within the therapeutic range.
- Scott
Posted by Sad Panda on August 16, 2004, at 11:20:24
In reply to TRICYCLICS: Is there a best one?, posted by anxiety_free on August 16, 2004, at 6:57:15
> Hi! I currenly take imipramine @150mgs/day, along with a stimulant, two benzos, and propranolol. My question really is about the tricylic: is there a better one? I'm not psychotically depressed, I just want the most bang for my psychiatric buck. For depression/anxiety, what's GOOD and what's GREAT? Can tricyclis be mixed for max. impact? (ex: Pamelor+Elavil). Thanks for your help!
>
>I am actually thinking of Pamelor+Elavil for myself.
Clomipramine(Anafranil), Imipramine(Tofranil) & Amitriptyline(Elavil) are the best of the tertiary TCA's. Imipiramine is a good SRI & NRI with the least side effects of the three. Amitriptyline also is a good SRI & NRI + it adds a significant amount of 5-HT2A antagonism making it anxiolytic & improving sleep, it also has significant H1 antagonism to put you to sleep. Unforunately, it also has the worst side effects of all the TCA's. Clomipramine is a potent SRI & good NRI + it is a 5-HT2A antagonist. It's side effects are inbetween Imipramine & Amitriptyline. Since you are taking two benzos & a beta blocker, I would guess you have alot of anxiety, so both Clomipramine & Amitriptyline would be better choice & would lower your benzo intake, I would try Clomipramine.
Of the secondary TCA's, Desipramine & Nortriptyline(Pamelor) are probably the only two worth considering. Desipramine is an active metabolite of Imipramine, is stimulating with the least side effects, Nortriptyline is an active metabolite of Amitriptyline, it's is stimulating with 5-HT2A antagonism added making it like a stimulant & benzo in one. I am currently using Nort myself combined with Effexor.
Cheers,
Panda.
Posted by zeugma on August 16, 2004, at 19:41:43
In reply to Re: TRICYCLICS: Is there a best one?, posted by SLS on August 16, 2004, at 8:45:02
Scott,
I agree with you about the importance of dosing nortriptyline properly. 100 mg nortriptyline is giving me a much more robust response than 75 mg. It seems odd, though, that you would be able to tolerate 300 mg imipramine, but not be able to find a stable window for nortriptyline- i remember you mentioned that your doctor found that relatively common. Was it that side effects made it impossible to tolerate the dosage, or that suddenly the dosage would lose effect?
Also, if you'd care to speculate, why do you think nortriptyline is alone among the TCA's in having a curvilinear response window? Are the upper limits for imipramine etc. set at 300 mg simply because that's where the s/e burden gets too steep?
-z
Posted by SLS on August 16, 2004, at 22:59:37
In reply to Re: TRICYCLICS: Is there a best one? » anxiety_free, posted by Sad Panda on August 16, 2004, at 11:20:24
> I am actually thinking of Pamelor+Elavil for myself.
Interesting.
I'm thinking about adding nortriptyline to imipramine.
- Scott
Posted by SLS on August 16, 2004, at 23:13:58
In reply to Re: TRICYCLICS: Is there a best one? » SLS, posted by zeugma on August 16, 2004, at 19:41:43
Hi Z.
> Was it that side effects made it impossible to tolerate the dosage, or that suddenly the dosage would lose effect?
I suddenly lose the effect. One day I would take 75mg and lose the antidepressant effect. The next day I would take 100mg and regain the effect for a portion of the day, and then lose it. I would not regain it until I dropped back down to 75mg, and then only for a portion of the day. It was like I would get an antidepressant effect on the way up and on the way down, but nothing in the middle.
> Also, if you'd care to speculate, why do you think nortriptyline is alone among the TCA's in having a curvilinear response window?
That is a great question that I always thought might hold a clue as to why these drugs work at all. Nortriptyline might offer a unique look into what's going on. Maybe Panda can come up with a theory. It's things like this that have me question the necessity for neurogenesis to occur before experiencing an improvement of depression.
> Are the upper limits for imipramine etc. set at 300 mg simply because that's where the s/e burden gets too steep?
Yes. For extensive metabolizers, sometimes dosages above 300mg are necessary.
- Scott
Posted by SLS on August 16, 2004, at 23:16:10
In reply to Re: TRICYCLICS: Is there a best one? » anxiety_free, posted by Sad Panda on August 16, 2004, at 11:20:24
Hi Panda.
How does imipramine compare to the other TCAs with regard to 5-HT2a antagonism?
Thanks.
- Scott
Posted by Sad Panda on August 16, 2004, at 23:29:06
In reply to Re: TRICYCLICS: Is there a best one? » Sad Panda, posted by SLS on August 16, 2004, at 23:16:10
> Hi Panda.
>
> How does imipramine compare to the other TCAs with regard to 5-HT2a antagonism?
>
> Thanks.
>
>
> - Scott
>
>Very poorly, Imipramine & Desipramine stand out from the other TCA's due to being very weak 5-HT2A antagonists & having the least side effects. They are probably ideal if you don't suffer anxiety.
Cheers,
Panda.
Posted by Sad Panda on August 16, 2004, at 23:37:31
In reply to Re: TRICYCLICS: Is there a best one?, posted by SLS on August 16, 2004, at 22:59:37
> > I am actually thinking of Pamelor+Elavil for myself.
>
> Interesting.
>
> I'm thinking about adding nortriptyline to imipramine.
>
>
> - Scott
>
>That sounds interesting. Seems like no single TCA is ideal. I'm considering replacing 50mg of my Nort with Amitrip & then adjusting the Nort doseage with a blood test. I am currently taking 125mg of Nort & am thinking of going to 150mg. I have an order for a blood test here, but I don't think 125mg is there yet. I am still also taking 150mg of Effexor.
Cheers,
Panda.
Posted by SLS on August 17, 2004, at 6:08:43
In reply to Re: TRICYCLICS: Is there a best one? » SLS, posted by Sad Panda on August 16, 2004, at 23:37:31
> > > I am actually thinking of Pamelor+Elavil for myself.
> >
> > Interesting.
> >
> > I'm thinking about adding nortriptyline to imipramine.
> >
> >
> > - Scott
> >
> >
>
> That sounds interesting. Seems like no single TCA is ideal. I'm considering replacing 50mg of my Nort with Amitrip & then adjusting the Nort doseage with a blood test. I am currently taking 125mg of Nort & am thinking of going to 150mg. I have an order for a blood test here, but I don't think 125mg is there yet. I am still also taking 150mg of Effexor.
I was pretty impressed with what Effexor 300mg + nortriptyline 75-100mg did for me. Although, it proved impossible to find a single dosage of nortriptyline that produced a stable antidepressant effect, when I did manage to squeeze an antidepressant effect from it, it was quite robust with the Effexor on board. Good luck with it.
- Scott
Posted by linkadge on August 17, 2004, at 8:27:32
In reply to Re: TRICYCLICS: Is there a best one?, posted by SLS on August 17, 2004, at 6:08:43
"It's things like this that have me question the necessity for neurogenesis to occur before experiencing an improvement of depression."
I have come to beleieve that recovering from depression is biphasic. Think of it this way. You have a badly broken leg that causes you severe pain. Your doctor says that the pain will lesson as the bone regenerates and heals itself. That evening you pop a vicodin and notice that the pain is completely gone. You say to yourself, "screw bone healing, all I need is vicodin!" That evening the pill wears off and you realize that you really didn't fully recover.
What I am trying to saying is this. Antidepressants can act as both emotional analgesics and promoters of neurogenesis. The angalgesic part can be useful but misleading. For instance heroin brings prompt releif of depression without neurogenesis, but if you notice that at the end of the day you don't feel like you've got anywhere on cocaine. Antidepressants that promote neurogenesis are much more helpfull in the long run. They can heal the bone underneath so that breakage is less likely. Take lithium for example, this is like the oppsoite of cocaine in that it has zilch emotinal analgesic potenetial but it does promote neurogenesis. It is the neurogenesis that finds plausable ways to deal with the problems that contributed to the depression in the first place.
I think it is a double sided coin but that the neurogenesis certainly plays a part in restructuring the brain to make it more resilitan to emotional turmoil.
Just my thoughts.
Linkadge
Posted by SLS on August 17, 2004, at 8:43:06
In reply to SLS, posted by linkadge on August 17, 2004, at 8:27:32
> I think it is a double sided coin but that the neurogenesis certainly plays a part in restructuring the brain to make it more resilitan to emotional turmoil.
>
>
> Just my thoughts.And good ones they are, indeed.
:-)
- Scott
Posted by chemist on August 17, 2004, at 11:42:26
In reply to Re: TRICYCLICS: Is there a best one? » SLS, posted by Sad Panda on August 16, 2004, at 23:37:31
hello there, chemist here....just a test.....all the best, chemist
Posted by zeugma on August 17, 2004, at 14:33:56
In reply to Re: TRICYCLICS: Is there a best one? » zeugma, posted by SLS on August 16, 2004, at 23:13:58
Since you experienced positive results from combining a therapeutic dosage of nortriptyline with a high dosage of Effexor, would you say that in theory (I know this a hard question) it would be better to simply get onto a stable dosage of nortriptyline, seeing that it has a well-established window AND that the efficacy of AD's is presumed to lie in monoaminergic effects; and that adding Effexor is simply a second-best maneuver, since, presumably, it's just doing more of what nortriptyline is presumably doing?
I know that when I added Strattera, I eventually became severely dysphoric. This was due, I now think, to the unadvertised effects of its metabolite on the kappa opioid receptor. The experience I had was seriously disillusioning, because my pdoc seemed to put more trust in the unproven new drug than in the reliable alternative (an experience that has occurred to me before, with many other pdocs, and which has given me a thorough cynicism about the state of psychiatry as a branch of medicine). Anyaway, if nortriptyline's efficacy is mediated through reuptake inhibition, wouldn't adding another inhibitor make the therapeutic window irrelevant? Or is it possible that nortriptyline has a therapeutic mechanism that is as yet unidentified?
Posted by KaraS on August 17, 2004, at 14:55:11
In reply to SLS, posted by linkadge on August 17, 2004, at 8:27:32
> "It's things like this that have me question the necessity for neurogenesis to occur before experiencing an improvement of depression."
>
> I have come to beleieve that recovering from depression is biphasic. Think of it this way. You have a badly broken leg that causes you severe pain. Your doctor says that the pain will lesson as the bone regenerates and heals itself. That evening you pop a vicodin and notice that the pain is completely gone. You say to yourself, "screw bone healing, all I need is vicodin!" That evening the pill wears off and you realize that you really didn't fully recover.
>
> What I am trying to saying is this. Antidepressants can act as both emotional analgesics and promoters of neurogenesis. The angalgesic part can be useful but misleading. For instance heroin brings prompt releif of depression without neurogenesis, but if you notice that at the end of the day you don't feel like you've got anywhere on cocaine. Antidepressants that promote neurogenesis are much more helpfull in the long run. They can heal the bone underneath so that breakage is less likely. Take lithium for example, this is like the oppsoite of cocaine in that it has zilch emotinal analgesic potenetial but it does promote neurogenesis. It is the neurogenesis that finds plausable ways to deal with the problems that contributed to the depression in the first place.
>
> I think it is a double sided coin but that the neurogenesis certainly plays a part in restructuring the brain to make it more resilitan to emotional turmoil.
>
>
> Just my thoughts.
>
>
> Linkadge
>
>
>
Linkadge,
That's very impressive.-K
Posted by SLS on August 17, 2004, at 20:00:57
In reply to Re: TRICYCLICS: Is there a best one? » SLS, posted by zeugma on August 17, 2004, at 14:33:56
I neglected to mention that the pattern of non-response to nortriptyline began before I added the Effexor. We used blood levels to try to adjust the dosage, but to no avail. Although by no means common, this difficulty with nortriptyline does appear from time to time.
Thanks for the brainstorming.
- Scott
Posted by Sad Panda on August 18, 2004, at 7:33:45
In reply to any chance i can join???? » Sad Panda, posted by chemist on August 17, 2004, at 11:42:26
Hi Chemist, glad you are back :)
How was the holiday? :P
Taken any new drugs lately?
Cheers,
Panda.
Posted by chemist on August 18, 2004, at 8:55:31
In reply to Re: any chance i can join???? » chemist, posted by Sad Panda on August 18, 2004, at 7:33:45
> Hi Chemist, glad you are back :)
>
> How was the holiday? :P
>
> Taken any new drugs lately?
>
> Cheers,
> Panda.
>
hey panda, good to hear from you! my holiday was excellent, thank you....no new drugs, but if my anxiety kicks up, i'll know what to take :)......be well, and again, thanks for the hello.....chemist
Posted by Minnie-Haha on August 31, 2004, at 14:39:10
In reply to SLS, posted by linkadge on August 17, 2004, at 8:27:32
> Antidepressants that promote neurogenesis are much more helpfull in the long run.
I've been following this thread and it's making my head spin. I've been a psych patient for several years now, but still have much to learn about how these drugs work. Anyway, a couple of questions:
1. Which antidepressants promote neurogenesis?
2. Background: I was DXd as BP2 six years ago. Have since had reason to believe that anxiety was mistaken for manic agitation. My biggest symptoms are anxiety and depression. However, with the BP2 DX, it is hard to get psyhciatrists to treat the depression. First two years I was on Depakote and Effexor, but over time I gained weight, my menstrual cycle and metabolism changed, and I started getting depressed from that. I am currently taking 150mg Trileptal a.m. and 300mg p.m. Also taking 0.25-0.50mg Ativan at night to help me sleep. Depression and anxiety persist. New psychiatrist tried switching me to Ambien, as I was worried about getting hooked on Ativan (have been taking almost every night for about 10 months now). However, I seemed to sink into a deeper depression (I'm usually mostly dysthymic) within days of switching to Ambien. My PCP wants me to try a low dose of a tricyclic AD at night (10mg Elavil) cause she thinks it may help my insonia, which all agree is feeding the depression. (I get to sleep OK, but wake between 2 and 4 a.m. every night.) So my question: Any advice? I am desperate to feel better.
Posted by linkadge on September 2, 2004, at 16:21:24
In reply to Re: SLS » linkadge, posted by Minnie-Haha on August 31, 2004, at 14:39:10
Most mood stabalizers are neuroprotective. Most antidepressants and neurotrophic.
Linkadge
Posted by linkadge on September 2, 2004, at 16:25:22
In reply to Re: SLS » linkadge, posted by Minnie-Haha on August 31, 2004, at 14:39:10
What is your exact medicaiton right now, and what are your symptoms.
You could try to increase the elavil to see if it helps the insomnia. If you made a quick swich of the ativan/ambian for the amitryptaline, you may still get insomnia from that withdrawl.
Linkadge
Posted by Emme on September 2, 2004, at 17:10:51
In reply to Re: SLS, posted by linkadge on September 2, 2004, at 16:21:24
> Most mood stabalizers are neuroprotective. Most antidepressants and neurotrophic.
>
> LinkadgeLamictal would be neuroprotective b/c it inhibits glutamate release, wouldn't it?
Posted by Minnie-Haha on September 2, 2004, at 18:24:09
In reply to Re: SLS, posted by linkadge on September 2, 2004, at 16:21:24
> Most mood stabalizers are neuroprotective.
> Most antidepressants and neurotrophic.
>
> LinkadgeOK. I'm new to these terms, so I want to make sure I understand.
I found a definition for neurogenesis as "the formation of new neurons or nerve cells." I also found a discussion on neurotrophics that basically described them as being responsible for the growth and maintenance of neurons -- and possibly for the regrowth of damaged neurons. I was less lucky finding a definition for neuroprotective, though I could take some guesses.
Anyway, your original remark was that antidepressants that promote neurogenesis are much more helpfull in the long run. In your opinion then, do mood stabilizers (neuroprotective) and antidepressants (neurotrophic) both promote neurogenesis?
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