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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 42. This is the beginning of the thread.
Posted by SLS on August 4, 2006, at 8:48:06
What stage of treatment-resistance are you?
* Stage 1: Failure of an adequate trial of 1 class of major antidepressant* Stage 2: Failure of adequate trials of 2 distinctly different classes of antidepressant
* Stage 3: Stage 2 plus failure of a third class of antidepressant, including a tricyclic antidepressant (TCA)
* Stage 4: Stage 3 plus failure of an adequate trial of a monoamine oxidase inhibitor (MAOI)
* Stage 5: Stage 4 plus failure of an adequate course of electroconvulsive therapy (ECT)
- Scott
Posted by MidnightBlue on August 4, 2006, at 10:05:03
In reply to What stage of treatment-resistance are you?, posted by SLS on August 4, 2006, at 8:48:06
I guess three? Prozac, failed, desiprimine, failed, Wellbutrin, responded but later failed.
MB
Posted by mayzee on August 4, 2006, at 11:07:42
In reply to What stage of treatment-resistance are you?, posted by SLS on August 4, 2006, at 8:48:06
Scott,
1) What are the "distinctly different classes" of ADs? SSRI, MAOI, TCA, ...SNRI?, ??
Thank you for clarifying.2) If my Emsam trial fails, would I be Stage 3 even though I haven't tried a TCA yet? (went right to MAOI, having failed 5 SSRIs, Effexor, Wellbutrin, Cymbalta.)
I guess for now I'm Stage 2
--mayzee
Posted by SLS on August 4, 2006, at 12:15:31
In reply to Re: What stage of treatment-resistance are you?, posted by mayzee on August 4, 2006, at 11:07:42
> Scott,
>
> 1) What are the "distinctly different classes" of ADs? SSRI, MAOI, TCA, ...SNRI?, ??
> Thank you for clarifying.
My guess:SSRI
SNRI
NARI
TCA
MAOI
Wellbutrin
Remeron
Nefazodone/TrazodoneI'm sure I'm forgetting something.
> 2) If my Emsam trial fails, would I be Stage 3 even though I haven't tried a TCA yet? (went right to MAOI, having failed 5 SSRIs, Effexor, Wellbutrin, Cymbalta.)
>
> I guess for now I'm Stage 2I think the judges would give you a 2.5
:-)
- Scott
Posted by Phillipa on August 4, 2006, at 14:25:30
In reply to Re: What stage of treatment-resistance are you?, posted by SLS on August 4, 2006, at 12:15:31
Failed even to respond for a day on all the SSRI's SNRI's, Remeron, Wellbutrin,tried a TCA once. So I guess Stage 2? Love Phillipa
Posted by noelle on August 4, 2006, at 15:43:31
In reply to Re: What stage of treatment-resistance are you? » SLS, posted by Phillipa on August 4, 2006, at 14:25:30
AD never worked for me and I find that antipsychotics brought me back from a really scarey place, lithium has helped as well, I may be bipolar 11 but I've never been hypo manic. These meds are known for their antidepressant qualities why wouldn't these be part of the stages
Posted by nickguy on August 4, 2006, at 15:58:36
In reply to What stage of treatment-resistance are you?, posted by SLS on August 4, 2006, at 8:48:06
stage 3
failure to 3 ssri's
failure to 2 snri's
failure to wellbutrin
failure to TCA, desipramine(augmentation should be included in one of the stages, i.e-lithium, which i've failed)
Posted by SLS on August 4, 2006, at 17:27:09
In reply to Re: What stage of treatment-resistance are you?, posted by nickguy on August 4, 2006, at 15:58:36
> stage 3
> failure to 3 ssri's
> failure to 2 snri's
> failure to wellbutrin
> failure to TCA, desipramine
>
> (augmentation should be included in one of the stages, i.e-lithium, which i've failed)I understand what you are saying. I would have to agree with you. The STAR*D was supposed to help sort some of this stuff out. Unfortunately, they really don't have the money to do it properly.
This particular staging criteria was suggested by Michael Thase, MD, of the University of Pittsburgh. There are others. I guess if you were to use an augmentor of some sort, it would still be in combination with one of the listed drugs, so the staging criteria would still work in that sense. If you are to believe some doctors, 85% of people suffering from a biogenic depression can attain remission by using all of the currently available treatments in whatever permutations are necessary for any given individual. I am hoping they are wrong. I hope it is 100%.
- Scott
Posted by Racer on August 4, 2006, at 18:20:37
In reply to What stage of treatment-resistance are you?, posted by SLS on August 4, 2006, at 8:48:06
> What stage of treatment-resistance are you?
>
>
> * Stage 1: Failure of an adequate trial of 1 class of major antidepressant
>
> * Stage 2: Failure of adequate trials of 2 distinctly different classes of antidepressant
>
> * Stage 3: Stage 2 plus failure of a third class of antidepressant, including a tricyclic antidepressant (TCA)
>
> * Stage 4: Stage 3 plus failure of an adequate trial of a monoamine oxidase inhibitor (MAOI)
>
> * Stage 5: Stage 4 plus failure of an adequate course of electroconvulsive therapy (ECT)
>
>
> - Scott
Hm...See, what if you improve on some of them, but with intolerable side effects? Or some improvement, but not enough to make it worthwhile? Or some improvement, even adequate remission, that only lasts a few months?
I'm not sure what stage I'm in. I haven't tried MAOIs nor ECT. (I don't think I want to try ECT. I've never heard anything about it that would make me all that excited, you know? Sure, improvement, but not lasting improvement, you know?) My T would kick up a fuss if any pdoc prescribed an MAOI -- don't tell an eating disordered patient to restrict foods, you know?
As for me, I've tried a couple of TCAs -- hypotension, weight gain, constipation, sedation, and only just improved depression.
SSRIs -- ranged from weight gain/constipation/sedation/sexual dysfunction to out of control anxiety along with the others. Also insomnia.
SNRI -- Effexor and Cymbalta offered very limited relief, but not remission. Nothing quite like remission. Adding Prozad to the Effexor made it effective enough to stay on it -- not much alternative, anyway -- but it cr*pped out after less than a year. Cymbalta wasn't worth staying on as long as I did. Oh, yeah, and weight gain, constipation, sedation, anorgasmia, and insomnia from the Effexor. Cymbalta caused weight gain, anorgasmia, and the improved pain element faded after about six months.
NARI -- Strattera may have helped, but mixed with whatever it was mixed with -- Dr EyeCandy changed several meds at once each time, so it's hard to remember what I tried, since it was about eight drugs within six months -- increase anxiety way too much. I'd consider trying it again, though.
Wellbutrin -- it's helpful, but either does nothing or increases anxiety for me. It also leaves me with a great deal of residual depression.
Ritalin -- helps tremendously, but headaches, feel "high", and stimulates my appetite. That last part is what kept me from staying on it long enough to see if the other things went away, as I suspect they might.
Amphetamines -- Adderall was miserable, but Dexedrine was somewhat helpful. Not nearly as helpful as Ritalin, though.
Lamictal -- increased depression, sedation, etc.
Remeron -- let's not talk about my reaction to that one... (Could my attitude about taking it have made me more vulnerable to the rage reaction?)
Buspar -- improved anxiety a great deal, but increased depression.
I think they should make a new class for people like me: The SOL Club. Pretty much, we're [----] Outta Luck, you know?
(Thanks for posting this, though, Scott.)
Posted by fuchsia on August 4, 2006, at 19:56:19
In reply to What stage of treatment-resistance are you?, posted by SLS on August 4, 2006, at 8:48:06
> What stage of treatment-resistance are you?
>
>
> * Stage 1: Failure of an adequate trial of 1 class of major antidepressant
>
> * Stage 2: Failure of adequate trials of 2 distinctly different classes of antidepressant
>
> * Stage 3: Stage 2 plus failure of a third class of antidepressant, including a tricyclic antidepressant (TCA)
>
> * Stage 4: Stage 3 plus failure of an adequate trial of a monoamine oxidase inhibitor (MAOI)
>
> * Stage 5: Stage 4 plus failure of an adequate course of electroconvulsive therapy (ECT)
>
If one has a hypomanic response is that classed as'failure'?
Posted by SLS on August 4, 2006, at 22:04:55
In reply to Re: What stage of treatment-resistance are you? » SLS, posted by fuchsia on August 4, 2006, at 19:56:19
> If one has a hypomanic response is that classed as'failure'?
I guess such a response would be considered a failure if it could not be converted into a stable hypomania or a euthymic remission. My doctor and I would consider a stable hypomania to be a success in my case. A transient response of any sort would be a treatment failure, I should think.
I don't know how a persistent manic switch would be viewed. Ideally, such a switch could be treated without removing the antidepressant.
- Scott
Posted by Maxime on August 4, 2006, at 23:28:15
In reply to What stage of treatment-resistance are you?, posted by SLS on August 4, 2006, at 8:48:06
Stage 4 ... and I will never get to stage 5 to find out.
Maxime
What stage of treatment-resistance are you?
>
>
> * Stage 1: Failure of an adequate trial of 1 class of major antidepressant
>
> * Stage 2: Failure of adequate trials of 2 distinctly different classes of antidepressant
>
> * Stage 3: Stage 2 plus failure of a third class of antidepressant, including a tricyclic antidepressant (TCA)
>
> * Stage 4: Stage 3 plus failure of an adequate trial of a monoamine oxidase inhibitor (MAOI)
>
> * Stage 5: Stage 4 plus failure of an adequate course of electroconvulsive therapy (ECT)
>
>
> - Scott
Posted by SLS on August 5, 2006, at 1:48:28
In reply to Re: What stage of treatment-resistance are you? » SLS, posted by Maxime on August 4, 2006, at 23:28:15
> Stage 4 ... and I will never get to stage 5 to find out.
Would you consider repetitive transcranial magnetic stimulation (rTMS)?There is such a thing as magnetic seizure therapy (MST). It is still in its infancy. It applies a transcranial magnetic flux sufficient to induce a seizure. It is hoped that it will produce antidepressant efficacy comparable to ECT while sparing the patient the cognitive side effects of ECT.
I'm stage 5 by the way.
- Scott
Posted by cecilia on August 5, 2006, at 3:09:33
In reply to What stage of treatment-resistance are you?, posted by SLS on August 4, 2006, at 8:48:06
I guess I'm stage 4 and a half. I've tried rTMS but not ECT. I'm with Racer, I just can't see doing ECT, the long term risks seem to outweigh any possible short term benefits. But how exactly is an adequate trial defined? At least 6 weeks at a dose the PDR considers in a therapeutic range? Or the incredibly high doses some people here seem able to tolerate? If it's the latter I may have never had an adequate trial! If it's the former, I've had adequate trials on Trazodone, Wellbutrin (combined with Celexa), Celexa, Serzone, Zoloft, Paxil, Nortriptyline, Lamictal (combined with Celexa and Trazodone), Moclobemide, Tianeptine, Milnacipran, Marplan, Remeron, Gabapentin, Buspar (combined with Celexa), 5-HTP and St. John's Wort. Plus almost adequate (38 and 37 days) on Nardil and Emsam. Inadequate trials from one day to one month (due to unbearable side effects) on Desipramine, Doxepin, Imipramine, Prozac, Effexor, Clomipramine, Lithium, Methylphenidate, Dexedrine, Olanzapine, Parnate, Reboxetine, Luvox, Adrafinil, Cymbalta, and SAM-e. Cecilia
Posted by linkadge on August 5, 2006, at 3:48:34
In reply to Re: What stage of treatment-resistance are you?, posted by cecilia on August 5, 2006, at 3:09:33
Somewhere at stage 4. I didn't fail and MAOI, I just couldn't take it for long enough. Had a spontainious hypertensive crisis, and have since been refused a subsequent trial.
Parnate was kindof scarry though. (Intense), I don't know if Nardil is any lighter.
Linkadge
Posted by SLS on August 5, 2006, at 7:01:50
In reply to Re: What stage of treatment-resistance are you?, posted by linkadge on August 5, 2006, at 3:48:34
> Somewhere at stage 4. I didn't fail and MAOI, I just couldn't take it for long enough. Had a spontainious hypertensive crisis, and have since been refused a subsequent trial.
>
> Parnate was kindof scarry though. (Intense), I don't know if Nardil is any lighter.In some ways, Nardil is a lighter, more pleasant experience. Marplan is even more so, but is often thought of as a less effective drug. I guess that depends upon who you ask. If you really want to force the issue, I would try Nardil first, and then decide between Emsam and Marplan. Use Emsam is low energy is a major component of your illness. Marplan might be a better "mood-brightener", as is Nardil.
You *appear* to be doing better now than you had been in years previous. I know you have abstained from major antidipressants over this recent period. Perhaps reuptake inhibitors are not the way to go for you.
MAOIs are in some ways cleaner than reuptake inhibitors. Perhaps neurons are not forced to depolarize when no signal is to be propagated with these drugs. There is less noise. They might act more as amplifiers. Who knows? (Not me). If there comes a time when you wish to revisit antidepressant medication, and nothing new has captured your interest, you might want to go with one of the other MAOIs.
Maybe it will be a cannabinoid that gets us both well...
I wish you nothing but the best.
- Scott
Posted by Jost on August 5, 2006, at 12:32:47
In reply to Re: What stage of treatment-resistance are you?, posted by nickguy on August 4, 2006, at 15:58:36
SSRI: prozac, zoloft too sick to go more than three weeks and that was a huge effort):
SNRI: effexor also made me sick
Remeron (1 night) out cold in about three minutes, and slept for about 16 hours, felt awful, pdoc didn't want to try higher dose
Trazadone also sick
SNRI: cymbalta worked a little, but could only take v. low dose every other day, because more made me sick (serotonin syndrome), so somewhat better than nothing--had to stop about three months, because of other adverse reaction
MAOI : Parnate, worked somewhat, but made me feel so tired that, in retrospect, I' was functioning at a very low level, both mentally and physically. Couple of Ts I saw thought I had possible brain malfunction (?) and suggested neuropsych work-up. When the second one saw me after I stopped Parnate, said it must have been Parnate, because I seemed totally different.
Stopped doing a lot of things, because I was sleeping all day, and 10 hours a night, waking up and needing hours more sleep- but I guess just helped me feel less bad-- but again had adverse reaction eventually and had to stop
Welbutrin worked a little, not enough to be adequate AD effect, but also somewhat better than nothing
TCA never tried, my pdoc doesn't like them, and didn't think I would do well on them, after other reactions
now on Emsam.
So, SSRI, SNRI, Trazadone, Remeron--didn't work (or didn't work much)
MAOI (Parnate) not sure if it worked, or I was so wiped out, I didn't have energy to remember how I felt-- wouldn't do it again
If Emsam doesn't work, I'd probably try Welbutrin, and see if I could keep my head somewhat above water until something else comes out, if it does; or I might try combination of adderal and benzo--not sure
Won't ever do ECT, probably won't ever do TCA, unless new ones come out with fewer SE, and less effect on serotonin
My problem--possibly toxic reaction to anything that boosts serotonin too much, or out of proportion to other neurotransmitters.
Don't know how you would stage that.
Jost
Posted by Bob on August 5, 2006, at 16:54:21
In reply to Re: What stage of treatment-resistance are you?, posted by Jost on August 5, 2006, at 12:32:47
I'd classifiy myself as a stage 5+. I've failed countless trials of SSRIs, and all kinds of augmenting strategies with them. I took Anafranil, which was a quite unpleasant experience, and have also taken Depakote, Lamictal, along with many other anticonvulsants, including Topomax - which almost killed me. I've also tried ECT, which turned out to be an unmitigated disaster. The only thing from the "stages" I haven't tried is an MAOI, but not for lack of wanting. I don't think I could get through the washout period, and if the med turned out to be no good (an excellent chance) I don't think I could make it through the second washout. Coming on and off meds as become so difficult for me that it is almost impossible.
Posted by Maxime on August 5, 2006, at 17:29:07
In reply to Re: What stage of treatment-resistance are you? » Maxime, posted by SLS on August 5, 2006, at 1:48:28
rTMS doesn't work for most people. I don't even know if it's option in Canada. I would have DBS (deep brain stimulation) though.
Maxime
> > Stage 4 ... and I will never get to stage 5 to find out.
>
>
> Would you consider repetitive transcranial magnetic stimulation (rTMS)?
>
> There is such a thing as magnetic seizure therapy (MST). It is still in its infancy. It applies a transcranial magnetic flux sufficient to induce a seizure. It is hoped that it will produce antidepressant efficacy comparable to ECT while sparing the patient the cognitive side effects of ECT.
>
> I'm stage 5 by the way.
>
>
> - Scott
Posted by linkadge on August 5, 2006, at 21:21:13
In reply to Re: What stage of treatment-resistance are you? » linkadge, posted by SLS on August 5, 2006, at 7:01:50
I'm not doing to bad. I have had some suicidal feelings, but they seem to pass. I am pretty much the same on drugs or off drugs. I'm not really in any state of remission, but in order to go anywhere I'd need a doctor who was intent on things.
I have been intermittantly using turmeric, probably the strongest herbal MAOI, at doses that should theoretically inhibit MAO-A about 50%.
Turmeric inhibits MAO-A stronger than MAO-B, about 2-1. I read somewhere that Nardil too is stronger an inhibitor of MAO-A than MAO-B, but parnate has the slightly higher on MAO-B.
See the second table on this link.
http://www.bdbiosciences.com/discovery_labware/gentest/products/pdf/Fluor_A&B-ISSX02.pdf
Linkadge
Posted by exquilter on August 5, 2006, at 21:23:13
In reply to Re: What stage of treatment-resistance are you? » SLS, posted by Maxime on August 5, 2006, at 17:29:07
Stage 5+ for me, Scott.
Posted by linkadge on August 5, 2006, at 21:31:26
In reply to Re: What stage of treatment-resistance are you?, posted by linkadge on August 5, 2006, at 21:21:13
I would have to say that parnate "definately" had more umph to it than most of the ferry SSRI's. Even in the short time I used it, there seemed to be a very strong will to live that was emerging.
SSRI's never really made me want to live, they just stopped me from killing myself I guess.Parnate did some weird things to me though.
In hindsight some of the events that were passing may have been the precursors to a deeper response I don't know. (That may just be crazytalk) I felt the very strong urge (that I had to) clear my conscience, like I needed to tell people about all the things I had done wrong in my life, or perhaps all the lies I had told.
In hindsight, it may have been and induction of placiticity in the part of the brain that generates feelings of guilt.
Linkadge
Posted by JahL on August 7, 2006, at 20:22:45
In reply to What stage of treatment-resistance are you?, posted by SLS on August 4, 2006, at 8:48:06
> What stage of treatment-resistance are you?.
>.....
> * Stage 5: Stage 4 plus failure of an adequate course of electroconvulsive therapy (ECT)
Stage 6: not a f@cking hope.
J.
Posted by SLS on August 7, 2006, at 20:40:09
In reply to Re: What stage of treatment-resistance are you?, posted by JahL on August 7, 2006, at 20:22:45
> > What stage of treatment-resistance are you?.
>
> >.....
>
> > * Stage 5: Stage 4 plus failure of an adequate course of electroconvulsive therapy (ECT)Stage 6: Stage 5 plus failure of a 6 month course of aerobic exercise.
Stage 7: Failure to recognize that Stage 6 would be a waste of time.
- Scott
Posted by JahL on August 7, 2006, at 20:47:48
In reply to Re: What stage of treatment-resistance are you?, posted by SLS on August 7, 2006, at 20:40:09
> > > What stage of treatment-resistance are you?.
> >
> > >.....
> >
> > > * Stage 5: Stage 4 plus failure of an adequate course of electroconvulsive therapy (ECT)
>
> Stage 6: Stage 5 plus failure of a 6 month course of aerobic exercise.
>
> Stage 7: Failure to recognize that Stage 6 would be a waste of time.Is there a stage 8 then Scott?
I exercise regularly and would recommend that anyone physically capable does likewise, but I don't think it has any real lasting effect as regards Bipolar etc.
What's the final stage?
Ta,
J.
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