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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 68 to 92 of 97. Go back in thread:
Posted by mattw84 on April 9, 2006, at 22:17:53
In reply to Blind Faith In A P Doc, posted by Phillipa on April 9, 2006, at 0:48:45
Why do we trust our doctors to such a great extent. This a great question you have posed. Could it be that they have the piece of paper that we don't, that says that they know more about how the body works than we? Possibly. . . Yet that is a fair argument against it, that we simply know our bodies better than they possibly could.
The difference being, that we know our symptoms, but it takes expertise to know what is causing it. Granted some of us believe that we have been through the hoops so many times that we just know it better by experience.
Often times we will request drugs, or specific treatments. This is insulting to a doctor, in any field. To imply that you have the solution and they weren't capable of coming to it. Other times it is likely just a great difference of opinion.
Bottom line, any good and caring doctor will be willing to see your point of view. If this is not the case then they have no business taking peoples lives into their hands. The point of a doctor-patient relationship is not for one person to run the show, if the patient runs the show who knows what could come of it. I don't think that is a chance any physician is willing to take. A balanced partnership, or team effort is what makes both parties satisfied. Unless the doctor has a "god" complex (which many do develop) you will find that more often than not, doctors are very open to suggestion. Just remember, that you are entitled to your opinion, but more importanly the doctor is entitled to his or hers as well. That is what they get paid for.
No doctor can force anyone to take a medication, or do anything for that matter. You are paying them, but it isn't for them to do everything you want them to do. Rather you are paying for them to help you, the opions on what course of action is necessary to help you may be different but clearly the goal is the same. Fighting a doctors opinion is more often than not counter productive. It will get you farther away from what you want, and leave you stuck with a half *ssed solution that only leaves you more pissed off about the situation. The key is to work with your doctor, not against. Otherwise you are just wasting time and money. Just my two cents.
Regards,
Matt
Posted by rvanson on April 9, 2006, at 22:28:15
In reply to Blind Faith In A P Doc, posted by Phillipa on April 9, 2006, at 0:48:45
> What I don't understand is so many come here to learn about others and their experiences with meds and combos ect. But in the end it seems like everyone thinks their pdoc is like a person to look up to and does whatever he says even though you know your own body better tnan anyone. Why do you spend time here and then do anything he tells you to do. It makes no sense to me you have a mind and a brain . Oh I understand if someone is psychotic or can't maked decisions for themselves but i think the decision to take a med is up to you the patient who pays their bill. Love Phillipa<
There are good Pdocs and bad Pdocs.
If you are your doctor don't "fit" as a team or talks down to you, you need to find another one.
Life is too short and there are lots of doctors willing to try a new med or whatever you might want, if the one you have now won't.
Posted by Phillipa on April 9, 2006, at 22:32:09
In reply to Re: Blind Faith In A P Doc, posted by mattw84 on April 9, 2006, at 22:17:53
Matt that's the key partnership. I have had good referrals to excellent medical care in my area. Where it falls short is in the pdoc area. And I don't think a medical doctor maybe surgeons have the God complex. The others especially the ER docs are very compassionate and want what is best for you. Now something must be wrong in this area as the pdocs won't and I say won't work with your medical doctor and have trashed info my medical doctor has sent to him. And this is a large practice and oh the God sydrome is very previlent here. only the pdocs. Do you think a single pdoc is better than a large practice? Love Phillipa
Posted by Phillipa on April 9, 2006, at 23:14:03
In reply to Last thing I should say on this thread, posted by Racer on April 9, 2006, at 21:52:08
Racer I'm sorry it's upsetting and I haven't had time to go through the archives. I will google Racer when I can and then maybe I will understand better. you're right I don't know your history. Love Phillipa
Posted by Racer on April 10, 2006, at 1:11:58
In reply to Re: Last thing I should say on this thread » Racer, posted by Phillipa on April 9, 2006, at 23:14:03
Posted by linkadge on April 10, 2006, at 12:40:51
In reply to Re: Blind Faith In A P Doc » linkadge, posted by gardenergirl on April 9, 2006, at 21:30:12
I think this study took that into account. Ie, it was considering the percentage of people in the workforce that you would expect to see on an SSRI.
Linkadge
Posted by linkadge on April 10, 2006, at 12:49:36
In reply to Re: Parnate is often augmented with Lithium, posted by SLS on April 9, 2006, at 21:01:50
While some doctors choose to augment a MAOI with lithium it I think it has generally been done so with distinct caution. Some reactions have been similar to MAOI-SSRI combinations. Ie serotonin syndrome / seizures.
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http://www.cpa-apc.org/Publications/Archives/CJP/2003/august/bauer.asp
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Effects of Lithium on the 5-HT System in Animals
There is consistent evidence from animal studies that lithium enhances 5-HTergic responsiveness by actions on turnover and release (40–42). Grahame-Smith and Green reported that an increase in 5-HT transmission, produced by enhancing the function of 5-HT neurons, could be demonstrated behaviourally by the appearance of “5-HT syndrome” in rats after short-term application of lithium (43). In their study, the combination of lithium and MAOIs produced a behavioural overactivity syndrome in rats that was indistinguishable from the overactivity evoked by MAOIs and tryptophan. This lithium-induced overactivity syndrome was blocked by prior administration of an inhibitor of 5-HT synthesis (43). Lithium administration was also shown to augment 5-HT release in the rats’ dorsal hippocampus (44) and to enhance 5-HT synthesis (45). Further, short-term administration of lithium also augmented the efficacy of electrically stimulating the ascending 5-HT pathway that suppresses firing of postsynaptic neurons in rats’ dorsal hippocampus (38)After adding 450mg lithium to parnate I experienced severe sweating, shivvering, diareah, confusion, etc. I should have gone to the hospital. I think I passed out, and came to (alive luckily)
Linkadge
Posted by Caedmon on April 10, 2006, at 14:20:35
In reply to Re: Parnate is often augmented with Lithium, posted by linkadge on April 10, 2006, at 12:49:36
Hi Link,
I can understand the need for caution but my understanding is that Li acts somewhat paradoxically on 5HT. I also believe that the combination is not uncommonly used.
I just find it an interesting circumstance that your pharmacist freaked out about it like that, and that you had such a negative reaction to the combination. I haven't heard of such a thing before.
Yes, I should think that all augmentation strategies for MAOIs should be done cautiously (450mg Li is probably a bit much in my view).
______________
Am J Psychiatry. 1988 Feb;145(2):249-50.
The combination of lithium carbonate and an MAOI in refractory depressions.Fein S, Paz V, Rao N, LaGrassa J.
Department of Psychiatry, Brookdale Hospital Medical Center, Brooklyn, NY 11212.
Lithium combined with phenelzine alleviated the symptoms of four severely depressed patients. Previously, all four patients had failed to respond to tricyclic antidepressants, and three had not responded to monoamine oxidase inhibitors.
____________
Am J Psychiatry. 1985 May;142(5):619-23.
Efficacy of lithium-tranylcypromine treatment in refractory depression.Price LH, Charney DS, Heninger GR.
Twelve inpatients with major depression refractory to at least two controlled antidepressant trials had tranylcypromine added to ongoing lithium treatment. Eleven patients showed reliable improvement in nurses' depression ratings compared with a prior trial of lithium added to an antidepressant that was not a monoamine oxidase inhibitor (MAOI). Eight patients were blindly judged much or very much improved, and all 12 patients improved sufficiently to be discharged. Preclinical studies of conjointly administered lithium and MAOIs suggest that central serotonergic pathways may mediate this robust clinical effect.
Posted by linkadge on April 10, 2006, at 15:24:19
In reply to Re: Parnate is often augmented with Lithium, posted by Caedmon on April 10, 2006, at 14:20:35
That study doesn't comment on the doses of the drugs used. Lithium is a 5-ht1b autoreceptor antagonist. It causes a release of serotonin in certain parts of the brain.
With less MAO-A to metaboloize it, the serotonin can accumulated to toxic levels leading to serotonin syndrome.
The pharmacy (shoppers drug mart) is geared with an interaction checker. This is a potential interaction. I'm sure you can find studies that suggest that certain populations respond to SSRI + MAOI combinations, but that doesn't negate the fact that there is a potential for interaciton.
I'm not saying never do it, I am just saying be carefull.
I guess the point I was trying to make was that my doctor was unaware that there was a *potential* for interaction. When the pharmacy questioned him he checked his books and decided not to go through with the combination.
Posted by linkadge on April 10, 2006, at 15:26:59
In reply to Re: Parnate is often augmented with Lithium, posted by linkadge on April 10, 2006, at 15:24:19
On two different ocasions, when I was hospitalized, there were inpatients with me who were there. One had a seizure from a Nardil Lithium combination (she was in a coma) and the other was hospitalized from serotonin syndrome due to a marplan, lithium combination.
Linkadge
Posted by gardenergirl on April 10, 2006, at 15:32:04
In reply to Re: Blind Faith In A P Doc » gardenergirl, posted by linkadge on April 10, 2006, at 12:40:51
Thanks for clarifying that. Not having seen the study, it was hard to interpret the statement.
Take care,
gg
Posted by Caedmon on April 10, 2006, at 16:04:40
In reply to Re: Parnate is often augmented with Lithium, posted by linkadge on April 10, 2006, at 15:26:59
It's just that, I couldn't find any case reports on PubMed re: MAOI + Li and negative interactions. I would expect this (semi-common) augmentation strategy would have at least one case report of seizure or serotonin toxicity associated with it in the literature, considering that you and at least two others who you know have experienced problems with it. Surely there would be something, but I can't find any. I may have entered the wrong search parameters. (Or I completely missed it, which is also possible.) Anyone have better skills than me, can find something?
It is good to know about nonetheless. I wonder about the MAOI + Lamictal combination having a small possibility of serotonin interactions as well, since it acts lightly on 5HT3 as well as some sigma opioid junk?
- C
Posted by linkadge on April 10, 2006, at 17:58:27
In reply to Re: Parnate is often augmented with Lithium, posted by Caedmon on April 10, 2006, at 16:04:40
I don't think there is reason for interaction between lithium and lamictal, since I don't think lamictal is potentiating serotoniergic function in any way. (I don't think it is going to add to increased post synaptic 5-ht1 activation)
I admit I am sensitive. (I was hospitalized with SS after lithium + zoloft.)
I don't know how the potential is viewed. I know many pages will not indicate interaction between SSRI + lithium, but then others will.
http://www.whatmeds.com/meds/lithium.html
claims: "MAO Inhibitors (within 14 days) with Lithium can cause serious, even fatal, interactions"
Heres a bit of an old thread (not too much)
http://www.dr-bob.org/babble/20030310/msgs/208815.html
Sorry, I will look more after I finish my exams.
You could be right that it has not been documented significantly.
Linkadge
Posted by Phillipa on April 10, 2006, at 17:59:37
In reply to Re: Parnate is often augmented with Lithium, posted by Caedmon on April 10, 2006, at 16:04:40
Oh the docs have little handheld computers now. Once when in the hospital I asked to get off xanax and go back to valium . At the time the other doc had me on chloral hydrate, klonopin, xanax, seroquel to sleep. He used the calculator to look up how he could get me off all the meds I didn't need. Which were too many for sleep as you could hit me with a basball bat and I'd still wake up after four hours of sleep. Anyway he came up with a formula with that computer thing. I went home and ended up in a neurologists office in withdrawal. The neurologist said who prescribed this withdrawal method I told him the doc in the hospital. He said well get another one who is not benzophobic. My BP was 180/ll0. My extremities were twitching and shaking so badly I couldn't sit. And I was talking gibberish. So if I had had blind faith in this pdoc I probably would be dead now. Love Phillipa
Posted by SLS on April 10, 2006, at 21:49:57
In reply to Re: Parnate is often augmented with Lithium, posted by linkadge on April 10, 2006, at 12:49:36
> After adding 450mg lithium to parnate I experienced severe sweating, shivvering, diareah, confusion, etc.
Yup. That sounds like serotonin syndrome.
> I should have gone to the hospital. I think I passed out, and came to (alive luckily)
Lucky for us too.
:-)
- Scott
Posted by TylerJ on April 11, 2006, at 11:35:51
In reply to Re: Parnate is often augmented with Lithium, posted by linkadge on April 10, 2006, at 12:49:36
> While some doctors choose to augment a MAOI with lithium it I think it has generally been done so with distinct caution. Some reactions have been similar to MAOI-SSRI combinations. Ie serotonin syndrome / seizures.
>
> --------
> http://www.cpa-apc.org/Publications/Archives/CJP/2003/august/bauer.asp
> --------
>
>
> Effects of Lithium on the 5-HT System in Animals
> There is consistent evidence from animal studies that lithium enhances 5-HTergic responsiveness by actions on turnover and release (40–42). Grahame-Smith and Green reported that an increase in 5-HT transmission, produced by enhancing the function of 5-HT neurons, could be demonstrated behaviourally by the appearance of “5-HT syndrome” in rats after short-term application of lithium (43). In their study, the combination of lithium and MAOIs produced a behavioural overactivity syndrome in rats that was indistinguishable from the overactivity evoked by MAOIs and tryptophan. This lithium-induced overactivity syndrome was blocked by prior administration of an inhibitor of 5-HT synthesis (43). Lithium administration was also shown to augment 5-HT release in the rats’ dorsal hippocampus (44) and to enhance 5-HT synthesis (45). Further, short-term administration of lithium also augmented the efficacy of electrically stimulating the ascending 5-HT pathway that suppresses firing of postsynaptic neurons in rats’ dorsal hippocampus (38)
>
> After adding 450mg lithium to parnate I experienced severe sweating, shivvering, diareah, confusion, etc. I should have gone to the hospital. I think I passed out, and came to (alive luckily)
>
> Linkadge
>
>
>
Is that a pretty high dosage of lithium you were on? That's scary...my pdoc, whom i consider to be extremely competent has mentioned adding lithium to parnate for augmentation purposes.
If lithium can cause serotonin syndrome when combined w/ maoi's, than surely adding TCA's, and SSRI's will too, or can too, right?Tyler
Posted by SLS on April 11, 2006, at 11:50:08
In reply to Re: Parnate is often augmented with Lithium » linkadge, posted by TylerJ on April 11, 2006, at 11:35:51
> If lithium can cause serotonin syndrome when combined w/ maoi's, than surely adding TCA's, and SSRI's will too, or can too, right?
SSRIs are absolutely off limits.
Some TCAs are okay. The safest ones to add are desipramine and nortriptyline. I responded very well to Parnate 60mg + desipramine 150mg. I think Parnate is a bit more forgiving than Nardil when it comes to adding TCAs. Nardil + desipramine is okay, but imipramine is not. You might possibly get away with nortriptyline, but the drug does have weak SRI properties compared to desipramine. Adding desipramine to either drug will produce side effects that are greater in degree. Hypotension and accelerated heart rates occur, but are for the most part of little consequence. These tend to lessen over time.
- Scott
Posted by linkadge on April 11, 2006, at 14:45:30
In reply to Re: Parnate is often augmented with Lithium » linkadge, posted by TylerJ on April 11, 2006, at 11:35:51
Yeah, I've been on a lot more lithium than that. I was at 1500mg at one point (used by itself though)
>If lithium can cause serotonin syndrome when >combined w/ maoi's, than surely adding TCA's, >and SSRI's will too, or can too, right?
You mean SSRI + MAOI's ? Definately. Or do you mean lithium + TCA's / lithium + SSRI's?
Lithium + SSRI's can cause serotonin syndrome too, I don't know how common, or how reported it is though.I think serotonin syndrome is due to overactivation of 5-ht1a. It seems that treatment resistant people seem to experience such reactions less, (and this is perhaps due to less responsive 5-ht1a receptors ?)
Sometimes serotonin syndrome is more likely after ECT. I think that ECT causes in increase in the number of 5-ht1 receptors.
Linkadge
Posted by TylerJ on April 11, 2006, at 15:21:33
In reply to Re: Parnate is often augmented with Lithium, posted by linkadge on April 11, 2006, at 14:45:30
> Yeah, I've been on a lot more lithium than that. I was at 1500mg at one point (used by itself though)
>
> >If lithium can cause serotonin syndrome when >combined w/ maoi's, than surely adding TCA's, >and SSRI's will too, or can too, right?
>
> You mean SSRI + MAOI's ? Definately. Or do you mean lithium + TCA's / lithium + SSRI's?
> Lithium + SSRI's can cause serotonin syndrome too, I don't know how common, or how reported it is though.
>
>
>
> I think serotonin syndrome is due to overactivation of 5-ht1a. It seems that treatment resistant people seem to experience such reactions less, (and this is perhaps due to less responsive 5-ht1a receptors ?)
>
> Sometimes serotonin syndrome is more likely after ECT. I think that ECT causes in increase in the number of 5-ht1 receptors.
>
>
>
> Linkadge
>
>
>I was thinking TCA's with MAOI's. Also, I see you mention Fish oil a lot. What can you tell me about fish oil, does it actually increase the release of some neurotransmitters? Anything you can tell me about fish oil would be appreciated.
Tyler
Posted by linkadge on April 11, 2006, at 16:04:08
In reply to Re: Parnate is often augmented with Lithium » linkadge, posted by TylerJ on April 11, 2006, at 15:21:33
A few years back, a guy working at Harvard (Dr. Andrew Stoll) wrote a book called the Omega-3 connection.
He basically explained how the omega-3 fatty acids, (which are scarcely consumed in the American diet) share some of the biochemical actions as commonly used mood stablizers lithium and valproate.
The omega-3's also seem to posess considerable antidepressant properties. A lot of the babblers on the alternitive board use omega-3's.
The use of omega-3 (contained in fish oil) is fairly mainstream now. Its not really a "snake oil" type of treatment. (Larry believes in omega-3, and he is one smart guy)
http://biopsychiatry.com/omega3dep.htm
The fatty acids seem to work in several ways. First they modulate the activity of PKC, an enzyme that is also modulated by the mood stablizers. In addition, the omega-3 supplementation increases brain serotonin, and dopamine content, notably in the frontal cortex, and lower brainstem. These fatty acids also are important in the functionality of the serotonin and dopaminergic neurons. (Ie, they seem to plump up the receptors and make them more sensitive and receptive to serotonin and dopamine.)
Thirdly, omega-3 supplementation seems to inrease the levels of endogenious cannabanoids, painkilling feelgood substances that are affected by marajuanna and exercise.
It can take a few weeks of suplementation before the brain can incorperate the fatty acids.
Countries with the highest consumption of fish also seem to have lower rates of depression and suicide.
You can ask questions on the alternitive board, since many people are well acustomed to its use.
Linkadge
Posted by TylerJ on April 11, 2006, at 17:37:29
In reply to Re: Parnate is often augmented with Lithium » TylerJ, posted by linkadge on April 11, 2006, at 16:04:08
> A few years back, a guy working at Harvard (Dr. Andrew Stoll) wrote a book called the Omega-3 connection.
>
> He basically explained how the omega-3 fatty acids, (which are scarcely consumed in the American diet) share some of the biochemical actions as commonly used mood stablizers lithium and valproate.
>
> The omega-3's also seem to posess considerable antidepressant properties. A lot of the babblers on the alternitive board use omega-3's.
>
> The use of omega-3 (contained in fish oil) is fairly mainstream now. Its not really a "snake oil" type of treatment. (Larry believes in omega-3, and he is one smart guy)
>
> http://biopsychiatry.com/omega3dep.htm
>
> The fatty acids seem to work in several ways. First they modulate the activity of PKC, an enzyme that is also modulated by the mood stablizers. In addition, the omega-3 supplementation increases brain serotonin, and dopamine content, notably in the frontal cortex, and lower brainstem. These fatty acids also are important in the functionality of the serotonin and dopaminergic neurons. (Ie, they seem to plump up the receptors and make them more sensitive and receptive to serotonin and dopamine.)
>
> Thirdly, omega-3 supplementation seems to inrease the levels of endogenious cannabanoids, painkilling feelgood substances that are affected by marajuanna and exercise.
>
> It can take a few weeks of suplementation before the brain can incorperate the fatty acids.
>
> Countries with the highest consumption of fish also seem to have lower rates of depression and suicide.
>
> You can ask questions on the alternitive board, since many people are well acustomed to its use.
>
>
> Linkadge
>
>
>
>
> You covered it well...thanks so much!Tyler
>
>
>
>
Posted by Caedmon on April 11, 2006, at 19:12:41
In reply to Re: Parnate is often augmented with Lithium » TylerJ, posted by linkadge on April 11, 2006, at 16:04:08
> The fatty acids seem to work in several ways. First they modulate the activity of PKC, an enzyme that is also modulated by the mood stablizers...
>
> Thirdly, omega-3 supplementation seems to inrease the levels of endogenious cannabanoids, painkilling feelgood substances that are affected by marajuanna and exercise.>Cool. I didn't know that stuff. I'm big on fish oil myself btw, I take 3 g epa/dha.
The nice thing about fish oil is, even if it's not a smashing hit for your depression, it's still very good for your cardiovascular system. And some other stuff too, I believe (like glucose regulation). The FDA recently approved a Rx-type of fish oil as treatment for, what was it, I think for cholesterol regulation?
- C
Posted by linkadge on April 11, 2006, at 19:32:52
In reply to Augmenting Parnate w/ fish oil » linkadge, posted by Caedmon on April 11, 2006, at 19:12:41
Thats true.
Linkadge
Posted by JaclinHyde on April 12, 2006, at 1:16:14
In reply to Re: Parnate is often augmented with Lithium, posted by Caedmon on April 9, 2006, at 20:48:47
I have found that the best augmenter for an MAOI is neurontin. It really helps and is fairly harmless..
JH
Posted by Caedmon on April 12, 2006, at 8:43:57
In reply to Re: Parnate is often augmented with Lithium, posted by JaclinHyde on April 12, 2006, at 1:16:14
> I have found that the best augmenter for an MAOI is neurontin. It really helps and is fairly harmless..
>
> JHReally? I was thinking of adding Neurontin to the mix, if Parnate doesn't work by itself. How has it helped?
- C
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Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
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