Psycho-Babble Medication Thread 378159

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Re: TRICYCLICS: Is there a best one? anxiety_free

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.

 

Re: TRICYCLICS: Is there a best one? SLS

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

 

Re: TRICYCLICS: Is there a best one?

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

 

Re: TRICYCLICS: Is there a best one? zeugma

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

 

Re: TRICYCLICS: Is there a best one? Sad Panda

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

 

Re: TRICYCLICS: Is there a best one? SLS

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.


 

Re: TRICYCLICS: Is there a best one? SLS

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.

 

Re: TRICYCLICS: Is there a best one?

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

 

SLS

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

 

Re: SLS

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

 

any chance i can join???? Sad Panda

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

 

Re: TRICYCLICS: Is there a best one? SLS

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?

 

Re: your views on recovering from depression linkadge

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

 

Re: TRICYCLICS: Is there a best one? zeugma

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

 

Re: any chance i can join???? chemist

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.

 

Re: any chance i can join???? Sad 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

 

Re: SLS linkadge

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.

 

Re: SLS

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

 

Re: SLS

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

 

Re: SLS 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.
>
> Linkadge

Lamictal would be neuroprotective b/c it inhibits glutamate release, wouldn't it?

 

Re: SLS

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.
>
> Linkadge

OK. 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?

 

Re: SLS

Posted by Minnie-Haha on September 2, 2004, at 19:45:48

In reply to Re: SLS, posted by linkadge on September 2, 2004, at 16:25:22

> What is your exact medication right now, and
> what are your symptoms...
>
> Linkadge

Poor devil... you asked, so here goes, with background info first.

In 1996, I was successfully treated for depression Zoloft. (I had a toddler and had been sleep deprived for the better part of two years.) A couple of years later, when grief over my mother's death morphed into depression, I was again treated with Zoloft, but after about 8 months I *apparently* went hypomanic and was DXd as Bipolar II. I was on Depakote and Effexor for a couple years and that worked OK, but I gained 30 pounds and started feeling depressed again.

By this time, I had a new psychiatrist and we tried various drug combos -- the last I think was Trileptal and Welbutrin -- but never really came up with anything that *felt* right. My chief complaints were depression and insomnia. I also started having menstrual problems and got severely anemic (which I now blame on the Depakote, which I believe caused metabolism problems). In 2003, my anemia was under control and I went on a doctor-sanctioned drug holiday. Things went well until last fall, when I awoke in the middle of the night with nausea. Thought it was the flu at first, but it persisted for weeks, with insomnia, chills and eventually depression. I lost like 20 pounds in a month! I had lots of medical tests done and nothing was discovered except thyroid nodules (which we're watching, but my thyroid hormones are in the normal range).

The whole experience made me start to question my original diagnosis because I realized that I was having ANXIETY and feeling exactly the same "weird" feelings I'd had six years before when I was DXd BP2... though at that time I didn't *realize* I was having anxiety! I went to a new psychologist, wanting to just talk about the possibilty that my DX might be wrong and after one session, she DXd me as OCD... and kept the BP2 DX, too!

Anyway, my gut feeling is that the root of my problem is anxiety, which causes insomnia, which causes me to get depressed. My old psychiatrist closed her practice, so I have a new one and he says he's willing to reconsider my DX, but he wants to proceed with caution, as do I.

So, to answer your question, I currently take 150mg Trileptal in the a.m. and 300mg in the p.m. I also take 0.25 to 0.50mg Ativan at night, as needed, to help me sleep a little better. (For instance, on nights when I take it, I'll wake up at 4 a.m. instead of 2 o'clock. I usually don't have trouble falling asleep, it's that I wake in the middle of the night.) I'm getting psychotherapy and I've made some lifestyle changes re: caffeine, exercise, night-time routines, etc. I'd say now on good nights I get 6 hours sleep, and on bad nights maybe 2-4.

I hate taking the Ativan, even at such a low dose, because I don't like the thought of getting addicted to it, so the psychiatrist tried switching me to Ambien. The first two nights went OK: I still woke a couple times, but I went back to sleep (although I didn't feel more rested upon rising). But after a few more nights my daytime mood went in the toilet... hopeless and tearful. I started back on the Ativan, and my daytime mood is better. I can't say I feel well, but I don't feel like crying all the time and I sometimes even find reasons to smile or laugh. Still... my chief complaints are depression and insomnia. I told my new PCP that if I could have one thing in the whole world, it would be to just go to bed at 10 o'clock every night and not wake up until 6 a.m. She's suggesting I take 10mg Elavil at night, not a dose you'd give for depression, but for insomnia. My psychiatrists -- the old one especially -- are reluctant to give me ANY antidepressant because of my BP2 DX, even though in the six years since I received it, I don't think I've had one manic/hypomanic episode. I'm at a loss about what to do next. I feel better, but I don't feel well, and I ask myself every day: Is this as good as it's gonna get for the rest of my life?

 

Re: SLS

Posted by linkadge on September 3, 2004, at 7:25:02

In reply to Re: SLS linkadge, posted by Emme on September 2, 2004, at 17:10:51

I would believe so.


Linkadge

 

Re: SLS

Posted by linkadge on September 3, 2004, at 7:35:18

In reply to Re: SLS, posted by Minnie-Haha on September 2, 2004, at 19:45:48

If you think your main problem is anxiety, then you might want to give buspar a try. Buspar is an antianxiety agent that is not classified as an antidepressant nor a benzodiazapine. It is not addictive. Some people have great sucess with it and others do not.

So if you don't think you're bipolar, what do you think that the mood stabalizers are doing for you? Does the trileptal make you depressed? I found trileptal did not help my anxiety one bit.

Generally the antidepressants all are promote neurogenesis, and are neurotrophic. Ie they can prompt new cell growth and extend the function of available neurons.

The mood stabalizers are more neuroprotective. They robustly protect the brain from dammage due to various insults. Some of them, lithium and epival have been shown to promote neurogenesis as well, (prompt new brain cell growth). Others mood stabalizers have not been tested as much, but may confer some of the same qualities.


Linkadge

 

Re: SLS

Posted by Minnie-Haha on September 3, 2004, at 16:17:15

In reply to Re: SLS, posted by linkadge on September 3, 2004, at 7:35:18

> So if you don't think you're bipolar, what do you think that the mood stabalizers are doing for you? Does the trileptal make you depressed? I found trileptal did not help my anxiety one bit.

I've wondered if it (Trileptal) depresses me somewhat, but I also think it might keep me from slipping into DEEP depression, if that makes sense. I don't think it helps my anxiety directly (hence the need for the Ativan), but when I have a few especially anxious/sleep-deprived nights (like when I try to go without the Ativan), I think it helps me to keep from getting so depressed during the day. (I've never got so deep that I've seriously thought about suicide, but I'll get to where I imagine that death would be such a relief. That kind of crap.)

Plus, mood stabilizers seem to be what my psychiatrists are most willing to give me. I was actually on Lamictal for a couple of months, ramping up on it very gradually, and thought I saw my depression starting to lift when I got a rash and my old psychiatrist yanked me off it, even though I'm convinced the rash was not life threatening. (We were on vacation and I had used a new sunscreen. Between the sun, which I'm super-sensitive to anyway, and the new sunscreen, I think that's what caused the rash -- just on my forearms and chest -- and when I stopped using the sunscreen and took an antihistamine for a couple days, it cleared up fine.)

Thanks for all your feedback, by the way.


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