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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 17 of 17. This is the beginning of the thread.
Posted by Another Phil on June 22, 2006, at 21:13:41
I've done quite a bit of searching and I haven't come across any anecdotes about this particular problem. I've taken Dexedrine spansules for years to help my maintain mental focus. I've also been on various antidepressants during those years (with varying levels of effectiveness). This February, I started on the 6 mg/day Emsam patch. I also continued taking 75 mg of Effexor and 5 mg of Zyprexa.
I've been reluctant to stop the Emsam because it has been a great antidepressant. However, I *really* can't pay attention now (and I was ADD-like before). When something occurs to me that I have to do, I have to keep repeating it to myself out loud until I get to a pen and paper or computer so I don't lose the thought.
Has anyone else had similar problems? I'm nearing the end of a hellish week of tapering off of the Effexor in preparation for replacing the Emsam with Parnate.
I've also tried searching for information about Selegiline-Zyprexa interactions, but haven't come up with much.
Posted by Phillipa on June 22, 2006, at 21:43:38
In reply to Emsam and Attention Problems?, posted by Another Phil on June 22, 2006, at 21:13:41
Uhhh I don't think EMSAM was available in February. Love Phillipa
Posted by Another Phil on June 22, 2006, at 22:39:53
In reply to Re: Emsam and Attention Problems? » Another Phil, posted by Phillipa on June 22, 2006, at 21:43:38
> Uhhh I don't think EMSAM was available in February. Love Phillipa
Well, I started on oral Selegiline then switched to Emsam. Thanks though. You've been really helpful. Feel free to follow me around correcting my grammar and critiquing my posture too.
Posted by jealibeanz on June 22, 2006, at 23:31:12
In reply to Emsam and Attention Problems?, posted by Another Phil on June 22, 2006, at 21:13:41
You were taking both EMSAM and Effexor at the same time?
Posted by lymom3 on June 23, 2006, at 8:39:17
In reply to Re: Emsam and Attention Problems?, posted by Another Phil on June 22, 2006, at 22:39:53
That was a fairly rude comment and certainly won't make anyone want to respond to you. Maybe you should take your pen and paper and write this down "work on treating people the way that you would want to be treated."
Posted by Another Phil on June 23, 2006, at 8:53:30
In reply to Re: Emsam and Attention Problems?, posted by jealibeanz on June 22, 2006, at 23:31:12
> You were taking both EMSAM and Effexor at the same time?
Yes. I've very recently tapered off the Effexor. I've been off it completely for about two days and am still having some nausea, headaches, and intermittent anxiety.
Posted by Another Phil on June 23, 2006, at 9:17:38
In reply to Re: Emsam and Attention Problems?, posted by lymom3 on June 23, 2006, at 8:39:17
> That was a fairly rude comment and certainly won't make anyone want to respond to you. Maybe you should take your pen and paper and write this down "work on treating people the way that you would want to be treated."
Actually, treating people with the respect they deserve is very important to me. My wise-*ss comment was in response to the person whose only contribution began with a condescending "Umm...," and whose entire substance was a critique of the timeline of my original post. Well, I *did* say I was having problems paying attention. And if I began taking Emsam in March, not February, it doesn't change the question posed by my original post.
As far as treating people the way I would like to be treated, I would never answer a serious question with a snide, dismissive answer. And, in the context of my orignal question, replying--without addressing the central content of the question--simply to critique the timeline was far more rude than my wise-*ss retort.
P.S. I'm truly sorry if any of this has driven away serious responses. If anyone does have anything to share about Emsam and attention problems please respond. I promise I won't critique tangential details of your posts.
Posted by Pops_1 on June 23, 2006, at 12:29:37
In reply to Re: Emsam and Attention Problems?, posted by Another Phil on June 23, 2006, at 9:17:38
> Actually, treating people with the respect they deserve is very important to me. My wise-*ss comment was in response to the person whose only contribution began with a condescending "Umm...," and whose entire substance was a critique of the timeline of my original post. Well, I *did* say I was having problems paying attention. And if I began taking Emsam in March, not February, it doesn't change the question posed by my original post.
Hi Phil - Just to let you know, when I read your self-described wise-*ss response I thought - "Hmm, seems like an overreaction to a mild comment..."
I use email a ton for my work and I've found it's useful to presume goodwill on the part of others until demonstrated otherwise. Often I've seen what I thought was a rude comment and later discovered, after meeting the person, that they just have a different way of communicating than I'm used to and they meant nothing offensive. I think Phillipa's comments could easily have been interpretted as "I'm confused, are you sure you mean EMSAM?" or "Did you really mean February"? I really doubt she meant anything like "you're a liar" or "Get your facts straight!") (Although granted, she could have been less casual in her wording to reduce chance of confusion or risk of offending you.) For what it's worth.
But back to your question - I've been using EMSAM for almost 30 days to help primarily with motivation and attention. I used to use dexedrine (10mg a day - not much!) and EMSAM isn't >quite< as effective (so far), but I haven't noticed it excarebating attention problems. Maybe you're just noticing the absence of the stimulant?
I'm personally thinking about adding some dexedrine back to the EMSAM. This is contraindicated but I've seen some research articles that indicate adding stimulants to MAOI's can be done safely and effectively if done carefully with proper monitoring. See below for an abstract from pubmed.
Keep us posted on your experience...
J Clin Psychiatry. 2004 Nov;65(11):1520-4.
Combining stimulants with monoamine oxidase inhibitors: a review of uses and one possible additional indication.Feinberg SS.
Department of Psychiatry, Albert Einstein College of Medicine, Bronx, NY, USA. Shalomf@aol.com
BACKGROUND: Among antidepressant augmentation strategies, the addition of a stimulant to a monoamine oxidase inhibitor (MAOI) has received little attention in the literature in recent years because of the diminished clinical use of the latter and concerns of precipitating a hypertensive crisis or other serious complication. Despite that fact, experienced clinicians continue to use this combination for a variety of indications after other options have failed. This article reviews these reported uses and presents a case suggesting another possible indication. METHOD: A MEDLINE search was conducted for articles published from 1962 to December 2003 using relevant search terms (psychostimulant, stimulant, amphetamine, dextroamphetamine, pemoline or methylphenidate, atomoxetine, bupropion, monoamine oxidase inhibitor, and selegiline). A manual search was conducted of cross-references and other relevant recent psychiatric sources (2000-2003). RESULTS: The described uses of the MAOI-stimulant combination have included treatment of refractory depression and the MAOI-related side effects of orthostatic hypotension and daytime sedation. No documented reports were found in the recent literature of hypertensive crises or fatalities occurring when the stimulant was cautiously added to the MAOI. Also presented here is another possible indication for this therapeutic regimen: treatment of attention-deficit/hyperactivity disorder in an adult patient whose major depression had uniquely responded to the MAOI tranylcypromine. CONCLUSION: As in other fields of medicine, potentially hazardous medication combinations are utilized in psychiatry after cautiously weighing the danger of the treatment against the morbidity and risk of not adequately addressing the illness. Particularly, as the potential arrival of the apparently safer transdermal selegiline may increase the use of MAOIs, we feel this combination deserves additional controlled study.
Posted by Another Phil on June 23, 2006, at 14:04:42
In reply to Re: Emsam and Attention Problems?, posted by Pops_1 on June 23, 2006, at 12:29:37
Thanks, Pops_1. Actually, I never stopped taking Dexedrine. I'm still taking 15 mg spansules twice a day, which made a noticeable difference in my ability to concentrate before starting Selegiline/Emsam, but has no effect now. In fact, my ability to concentrate now (Selegiline, Dexedrine, and all) is much worse than my original baseline without stimulants. For what it's worth, I haven't had any negative physical side-effects while combining them either.
Also, is there anyone out there who has had any experience with Selegiline/Emsam in combination with Effexor or Zyprexa? I know the Effexor-Selegiline combination is warned against in the official literature, but my psychopharmacologist said it was OK, and I had been taking Effexor and Zyprexa beforehand with useful, but limited antidepressant effect.
Point taken on my possible overreaction. I just went back and re-read Phillipa's post and, although I still don't think it added anything constructive to my original query, I suppose my reaction didn't either.
Phil
Posted by Phillipa on June 23, 2006, at 19:50:59
In reply to Re: Emsam and Attention Problems?, posted by Another Phil on June 22, 2006, at 22:39:53
Oh oral seligline. Sorry about that. I'm considering starting EMSAM myself so I read all the info I can on it. I know everyone was waiting for it to come out so I was just aware I think wasn't it April they finally released it to the public? Why would I follow you? Love Phillipa
Posted by Phillipa on June 23, 2006, at 19:58:17
In reply to Re: Emsam and Attention Problems? » Another Phil, posted by Phillipa on June 23, 2006, at 19:50:59
Since I'm terrified of meds and all the sideeffects I seem to get from them I ask questions all the time. Sorry about the misunderstanding I meant no ill harm. And sorry about the concentration problems too. Love Phillipa
Posted by Another Phil on June 23, 2006, at 19:59:14
In reply to Re: Emsam and Attention Problems? » Another Phil, posted by Phillipa on June 23, 2006, at 19:50:59
> Oh oral seligline. Sorry about that. I'm considering starting EMSAM myself so I read all the info I can on it. I know everyone was waiting for it to come out so I was just aware I think wasn't it April they finally released it to the public? Why would I follow you? Love Phillipa
Just me overreacting. I apologize.
Posted by Phillipa on June 23, 2006, at 20:02:04
In reply to Re: Emsam and Attention Problems?, posted by Another Phil on June 23, 2006, at 19:59:14
No problem. Let's just say it never happened. My memory is short too!!!!Love Phillipa
Posted by Pops_1 on June 26, 2006, at 12:53:24
In reply to Re: Emsam and Attention Problems?, posted by Another Phil on June 23, 2006, at 14:04:42
> Thanks, Pops_1. Actually, I never stopped taking Dexedrine. I'm still taking 15 mg spansules twice a day, which made a noticeable difference in my ability to concentrate before starting Selegiline/Emsam, but has no effect now. In fact, my ability to concentrate now (Selegiline, Dexedrine, and all) is much worse than my original baseline without stimulants. For what it's worth, I haven't had any negative physical side-effects while combining them either.
>
> Also, is there anyone out there who has had any experience with Selegiline/Emsam in combination with Effexor or Zyprexa? I know the Effexor-Selegiline combination is warned against in the official literature, but my psychopharmacologist said it was OK, and I had been taking Effexor and Zyprexa beforehand with useful, but limited antidepressant effect.
Two things:1 - Dexedrine/EMSAM/Attention - Did you consider >reducing< your dexedrine dose to see if that helped? One of EMSAM's metabolites is itself an amphetamine, and maybe the stimulation producing by EMSAM and/or this metabolite is revving you up so much that you're more distracted than you were without any drugs. I know when I really upped my Dexedrine doses I was overexcited and distractable, maybe your combo is producing net negative effects at previously effective doses.
2. Effexor - Combining MAOI's with other ADs that affect serotonin is contraindicated to guard against "serotonin syndrome". I know effexor targets Serotonin (and norepinephrine), which would seem like the basis for contraindication. while I've seen doctors try contraindicated combos (MAOIs & wellbutrin, MAOIs + TCAs), usually this is for treatment resistant conditions or to counteract side effects. Given that the MAOI+SSRI prohibition is one rather religiously adhered to, I would personally be wary of combining Effexor + EMSAM given the risks. On the other hand, a qualified psychophamarcologist should know what they're doing...
Posted by Another Phil on June 28, 2006, at 15:12:03
In reply to Re: Emsam and Attention Problems?, posted by Pops_1 on June 26, 2006, at 12:53:24
> 1 - Dexedrine/EMSAM/Attention - Did you consider >reducing< your dexedrine dose to see if that helped? One of EMSAM's metabolites is itself an amphetamine, and maybe the stimulation producing by EMSAM and/or this metabolite is revving you up so much that you're more distracted than you were without any drugs. I know when I really upped my Dexedrine doses I was overexcited and distractable, maybe your combo is producing net negative effects at previously effective doses.
>
> 2. Effexor - Combining MAOI's with other ADs that affect serotonin is contraindicated to guard against "serotonin syndrome". I know effexor targets Serotonin (and norepinephrine), which would seem like the basis for contraindication. while I've seen doctors try contraindicated combos (MAOIs & wellbutrin, MAOIs + TCAs), usually this is for treatment resistant conditions or to counteract side effects. Given that the MAOI+SSRI prohibition is one rather religiously adhered to, I would personally be wary of combining Effexor + EMSAM given the risks. On the other hand, a qualified psychophamarcologist should know what they're doing...Actually, I've considered both of these. I often skip doses of Dexedrine on the weekend when I don't have much "thinking" work to accomplish. There hasn't been any effect on my ability to concentrate (as measured by my tendency to go from task-to-task on one long endless tangent).
#2 is the primary reason why I had been trying to wait it out for a while after Effexor withdrawal. However, my depression has gotten bad enough again that I don't think that's a good idea. After consulting with my psychopharmacologist yesterday, I've started tapering up on Parnate and stopping Emsam. Already, I'm experiencing the Parnate-induced insomnia (even at my starting dose of 10 mg). So, thanks for your help, but I think that since my mood was so good on Emsam that I waited too long to address the attention problems. In the intervening time, I've ignored dealing with some really important logistical issues in my life that just can't wait any longer.
I've been on pretty much every antidepressant (or, at least, representatives from each class). All have either had intolerable side effects or insufficient antidepressant effect. I did have a pretty good stretch (mood-wise) on Parnate many years ago, but stopped because the insomnia was making me unable to function. So, I hope my current doc can help me come up with an acceptable solution for the insomnia.
Thanks again.
Phil
Posted by Donna Louise on July 2, 2006, at 6:03:10
In reply to Re: Emsam and Attention Problems?, posted by Another Phil on June 28, 2006, at 15:12:03
> > 1 - Dexedrine/EMSAM/Attention - Did you consider >reducing< your dexedrine dose to see if that helped? One of EMSAM's metabolites is itself an amphetamine, and maybe the stimulation producing by EMSAM and/or this metabolite is revving you up so much that you're more distracted than you were without any drugs. I know when I really upped my Dexedrine doses I was overexcited and distractable, maybe your combo is producing net negative effects at previously effective doses.
> >
> > 2. Effexor - Combining MAOI's with other ADs that affect serotonin is contraindicated to guard against "serotonin syndrome". I know effexor targets Serotonin (and norepinephrine), which would seem like the basis for contraindication. while I've seen doctors try contraindicated combos (MAOIs & wellbutrin, MAOIs + TCAs), usually this is for treatment resistant conditions or to counteract side effects. Given that the MAOI+SSRI prohibition is one rather religiously adhered to, I would personally be wary of combining Effexor + EMSAM given the risks. On the other hand, a qualified psychophamarcologist should know what they're doing...
>
> Actually, I've considered both of these. I often skip doses of Dexedrine on the weekend when I don't have much "thinking" work to accomplish. There hasn't been any effect on my ability to concentrate (as measured by my tendency to go from task-to-task on one long endless tangent).
>
> #2 is the primary reason why I had been trying to wait it out for a while after Effexor withdrawal. However, my depression has gotten bad enough again that I don't think that's a good idea. After consulting with my psychopharmacologist yesterday, I've started tapering up on Parnate and stopping Emsam. Already, I'm experiencing the Parnate-induced insomnia (even at my starting dose of 10 mg). So, thanks for your help, but I think that since my mood was so good on Emsam that I waited too long to address the attention problems. In the intervening time, I've ignored dealing with some really important logistical issues in my life that just can't wait any longer.
>
> I've been on pretty much every antidepressant (or, at least, representatives from each class). All have either had intolerable side effects or insufficient antidepressant effect. I did have a pretty good stretch (mood-wise) on Parnate many years ago, but stopped because the insomnia was making me unable to function. So, I hope my current doc can help me come up with an acceptable solution for the insomnia.
>
> Thanks again.
>
> Phil
Hi Phil, I too had to do the effexor withdrawal which I did for a week before starting emsam. I am thinking it could be the effexor withdrawal giving you problems. My withdrawal was truly a nightmare from hell and I had all kinds of mental and physical dysfunctions, to put it mildy. Once all that cleared, I find my mental clarity better than it has been in a long time. One of the things the sri's did to me was muddy the mental waters.donna
Posted by Dr. Bob on July 7, 2006, at 1:42:34
In reply to Re: Emsam and Attention Problems? » Another Phil, posted by Donna Louise on July 2, 2006, at 6:03:10
> Hi Phil, I too had to do the effexor withdrawal which I did for a week before starting emsam. I am thinking it could be the effexor withdrawal giving you problems...
Sorry to interrupt, but I'd like to redirect follow-ups regarding effexor withdrawal to Psycho-Babble Withdrawal. Here's a link:
http://www.dr-bob.org/babble/wdrawl/20060627/msgs/664743.html
Thanks,
Bob
This is the end of the thread.
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