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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 5 of 5. This is the beginning of the thread.
Posted by TamaraJ on June 24, 2005, at 16:27:35
I have been taking nortriptyline for a few months now, and am currently at 75mg. Wellbutrin was added about a month ago, and I am taking 200mg once a day. My question is would it be worthwhile to trial desimpramine (instead of nort) to see if it provides further energy and motivation? One thing that concerns me about Des is that it seems to have a worse side effect profile than nort. Anyway, I have to say that since adding the Wellbutrin, I feel like I am almost back to my old self, which is a relief.
On the anxiety side of things, my anxiety seems to be pretty much controlled, with the exception of "fearful anticipation" which, at times, almost paralyzes me. It's like a tape playing in my head that says - Be afraid, something is going to happen. I have tried Xanax, in a low dose, but it doesn't seem to shut that down. I had tried Klonopin a couple of months ago, but it seemed to exacerbate my depression. Although, at the time, the depression had not lifted much. Does anyone have any suggestions as to what would work well to shut down those gloom and doom tapes in my head? Perhaps a combo of Wellbutrin and Lamictal, with Klonopin for the anxiety. I don't particularly want to make too many changes, but am looking for some advice.
Thanks.
Posted by SLS on June 24, 2005, at 18:00:48
In reply to Desimpramine vs Nortriptyline, posted by TamaraJ on June 24, 2005, at 16:27:35
Hi.
I think the first thing you should do is to get a nortriptyline blood level and see if it makes sense to raise the dosage to 100mg. You might as well try pushing it now.
Some people respond better to desipramine than nortriptyline and vice versa. The initial anticholinergic side effects of desipramine might be a bit worse than nortriptyline because they are somewhat amplified by a more potent NE reuptake inhibition, but they do lessen over time, and are more tolerable than those of imipramine. In the case of desipramine versus nortriptyline, I wouldn't give side effects too much weight in making a decision. Desipramine could very well be the wrong drug for you, but if you are only a partial responder to nortriptyline, it might be worth a try.
All I can say about imipramine is, don't forget about it. It had been the gold standard by which others are compared. I don't know which is now used as the gold standard. Probably imipramine and Prozac. You haven't fully explored TCAs until you have tried imipramine or clomipramine. I wouldn't necessarily suggest them at this point because their anticholinergic side effects are so pronounced.
The nice thing about nortriptyline and desipramine is that they mix well with Parnate. With Nardil, I think I would limit the choice of TCA to desipramine. Even nortriptyline exerts too serotonergic an effect such that serotonin syndrome becomes a possibility with Nardil.
A few years ago, I found relief with a combination of nortriptyline + Effexor. Don't be afraid to mix TCA + SRI. You know, the more I think about alternatives for you, the more that seem to crop up. Wellbutrin + SRI can work very well. I have not heard so much about combining Wellbutrin + TCA. You can combine Wellbutrin with everything, even MAOIs. If you decide to go for Parnate at some point, definitely try adding Lamictal to it. Lithium too, in dosages of 300-600mg
One step at a time.
I am currently taking:Parnate 80mg
nortriptyline 100mg
Lamictal 150mg
Abilify 10mg
Trileptal 900mg
- Scott
Posted by TamaraJ on June 24, 2005, at 21:05:26
In reply to Re: Desimpramine vs Nortriptyline » TamaraJ, posted by SLS on June 24, 2005, at 18:00:48
> Hi Scott!
> I think the first thing you should do is to get a nortriptyline blood level and see if it makes sense to raise the dosage to 100mg. You might as well try pushing it now.
>
-- I asked my pdoc about a blood test the last time I saw him, but he didn't seem to want to do one. I will raise it again when I see him next week. I did, however, try 100mg a little over a month ago for a week or so, and it seemed to have an adverse effect on my mood, not to mention that it left me feeling sluggish and slow.
>
> Some people respond better to desipramine than nortriptyline and vice versa. The initial anticholinergic side effects of desipramine might be a bit worse than nortriptyline because they are somewhat amplified by a more potent NE reuptake inhibition, but they do lessen over time, and are more tolerable than those of imipramine. In the case of desipramine versus nortriptyline, I wouldn't give side effects too much weight in making a decision. Desipramine could very well be the wrong drug for you, but if you are only a partial responder to nortriptyline, it might be worth a try.
>
-- Yes, I had read somewhere that some people may get a partial response to Nort may do really well on Des, and vice versa. I am wondering if the fact that I have adjusted to the Nort might lessen the side effects I might experience on the Des and whether it would allow me to have a speedier trial of Des, should I decide to try it (and if the pdoc will agree).
>
> All I can say about imipramine is, don't forget about it. It had been the gold standard by which others are compared. I don't know which is now used as the gold standard. Probably imipramine and Prozac. You haven't fully explored TCAs until you have tried imipramine or clomipramine. I wouldn't necessarily suggest them at this point because their anticholinergic side effects are so pronounced.
>
-- I haven't tried Imipramine, but I did try Clomipramine, and couldn't get past a 75mg dose and even that was not particularly tolerable (really bad dizziness, even when I would be standing for a period of time like when I was doing dishes or walking my dog). But, it is nice to know that Imipramine is a good option should the one of either Nort/Wellbutrin or Des/Wellbutrin combo fail.
>
> The nice thing about nortriptyline and desipramine is that they mix well with Parnate. With Nardil, I think I would limit the choice of TCA to desipramine. Even nortriptyline exerts too serotonergic an effect such that serotonin syndrome becomes a possibility with Nardil.
>
-- Yes, the MAOIs are another good option. I am not sure how my pdoc would react to a request to try one. Although he is old and has been practising for many, many years, he seems to prefer the newer ADs. He wasn't particularly keen on me trialling either Nortriptyline or Wellbutrin. Last fall when I raised TCAs with him, I mentioned the low (compared to other TCAs) side effect profile of nortriptyline, but he wanted to prescribe Clomipramine.
>
> A few years ago, I found relief with a combination of nortriptyline + Effexor. Don't be afraid to mix TCA + SRI. You know, the more I think about alternatives for you, the more that seem to crop up. Wellbutrin + SRI can work very well. I have not heard so much about combining Wellbutrin + TCA. You can combine Wellbutrin with everything, even MAOIs. If you decide to go for Parnate at some point, definitely try adding Lamictal to it. Lithium too, in dosages of 300-600mg
>
-- Yes, that is another option. I had had such a great response to Paxil when I had my first depressive episode. I was disappointed when I tried it again and it didn't work. I wondered if I might have had a response to the CR version, but my pdoc didn't want to try another form of Paxil again, given my non-response. I didn't do well on Effexor. It seemed to have had some kind of destabilizing effect on my hormones. My doctor actually thought I was going into early menopause because of the problems I was having. All of the problems stopped when I stopped the Effexor. I think you are right, though, the possibilities are endless at this point. I do have many options available to me. I don't feel as discouraged as I had been, particularly since the Wellbutrin has been added. It has made a difference for sure.One thing that still needs to be addressed is the fearful anticipation, which, after months and months of isolating myself (meaning not going to much at all) has become entrenched. It seems I can't turn off the tape in my head that stops me cold with "what ifs" and "be afraid". Xanax calms me down, but doesn't address the thoughts that cause me to limit my activities. I am, by nature, a hyper person who is usually always on the go. I had thought about Zyprexa or Amulispride (sp?) (particularly after reading archived posts by JohnL and AndrewB), but I am a bit scared of the antipsycotics and don't think my pdoc would go for it.
I wouldn't mind knowing how others have found Lamictal in terms of suppressing obsessive, fearful thoughts.
> One step at a time.
>
-- Yes, that's all we can do. And, we need to make the most of the good days and try to be strong and try to let the good days sustain us during the bad days.> I am currently taking:
>
> Parnate 80mg
> nortriptyline 100mg
> Lamictal 150mg
> Abilify 10mg
> Trileptal 900mg
>
-- Are you still feeling hopeful about the Trileptal? Have you noticed any more improvement? I hope so. You deserve it, Scott, you really, really do.Take care, and thanks so much for the thoughtful and informative response. Much appreciated.
All the best to you.Tamara
Posted by SLS on June 25, 2005, at 0:35:34
In reply to Re: Desimpramine vs Nortriptyline » SLS, posted by TamaraJ on June 24, 2005, at 21:05:26
> > I think the first thing you should do is to get a nortriptyline blood level and see if it makes sense to raise the dosage to 100mg. You might as well try pushing it now.
> -- I asked my pdoc about a blood test the last time I saw him, but he didn't seem to want to do one. I will raise it again when I see him next week. I did, however, try 100mg a little over a month ago for a week or so, and it seemed to have an adverse effect on my mood, not to mention that it left me feeling sluggish and slow.
Your feeling worse at a higher dosage (100mg) is not an unexpected phenomenon with nortriptyline. This drug has a therapeutic window that is pretty narrow. There is a minimum and a maximum dosage that will be effective. Anything higher than that maximum will cause a relapse. The drug just stops working if the dosage is too high. I don't know whether or not it is worth retrying the higher dosage.
I find it unusual that an older psychiatrist should be so averse to using the older medications. Maybe he believes all of the hype surrounding the newer ones at the expense of all of the rest. Although it might not be time to try one, I hope he will not be adamant about not trying an MAOI. When I shop for a doctor, I use MAOIs as a litmus test. If they don't prescribe them, I don't bother seeing them. Actually, if they are unwilling to prescribe MAOI + TCA, I can't afford to see them. This combination, along with Lamictal, seems to be the only thing that helps. I can report, however, that for the past few days, adding Tileptal has given me a significant improvement for which I am very grateful. I am beginning to believe that this drug will be my magic pill when added to the others.
- Scott
Posted by TamaraJ on June 26, 2005, at 16:51:16
In reply to Re: Desimpramine vs Nortriptyline » TamaraJ, posted by SLS on June 25, 2005, at 0:35:34
> I find it unusual that an older psychiatrist should be so averse to using the older medications. Maybe he believes all of the hype surrounding the newer ones at the expense of all of the rest. Although it might not be time to try one, I hope he will not be adamant about not trying an MAOI. When I shop for a doctor, I use MAOIs as a litmus test. If they don't prescribe them, I don't bother seeing them. Actually, if they are unwilling to prescribe MAOI + TCA, I can't afford to see them. This combination, along with Lamictal, seems to be the only thing that helps. I can report, however, that for the past few days, adding Tileptal has given me a significant improvement for which I am very grateful. I am beginning to believe that this drug will be my magic pill when added to the others.
>
-- When I see him next week, I am going to raise MAOIs with him to see how he reacts and to see if, should the time arise when one would be the most viable option, whether he would be willing to prescribe one. I will also raise Lamictal with him to see what he thinks of it for a unipolar depressive with anxiety. This may sound crazy, but I think the change I am leaning towards is Wellbutrin (which I am on, and currently at 200mg) plus Zoloft. I have read that Zoloft is more activating than the other SSRIs, with the exception of Prozac I guess, and it is supposed to be good for panic and the fear of having another panic attack (which can lead to avoidant behaviours) as well as for obsessive thoughts. I did so well on Paxil that, perhaps, Zoloft may be the right med to combine with Wellbutrin, for me anyway. Nortriptyline hasn't been too bad, certainly better than Clomipramine which I couldn't even raise to a therapeutic dose because of the dizziness. But, it doesn't seem to touch the obsessive, fearful thoughts that seem to be entrenching avoidant behaviours in me. When I was on Paxil, I had been experiencing the same thing, and the Paxil took care of it.Anyway, thanks so much for taking the time to respond to my post. I really appreciate your sharing your knowledge and experience with me. And, I am so very happy that Tileptal is working well for you, and that you are seeing significant improvement. That is wonderful news. It must be very encouraging for you.
Take good care, Scott, and thanks again.
Tamara
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