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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 11 of 11. This is the beginning of the thread.
Posted by PsychJ on January 30, 2008, at 18:41:14
Hi, I tried Emsam for around 14-15 weeks, with at least 6 weeks at 12mg with no benefit, only some side effects. I'm in the process of tapering myself off of it so when I see my doc in a couple weeks I can start something else right away. In the past few years I've tried Celexa, Zoloft, Cymbalta, BuSpar, Effexor, and now Emsam with no results, aside from the first couple of weeks on Cymbalta.
Any suggestions on where I should go from here? I have depression and social anxiety/GAD. I do have Xanax that I take occasionally when I'm really anxious and Seroquel 25mg for sleep (due to insomnia from Emsam).
Thanks,
j.
Posted by Racer on January 30, 2008, at 22:58:11
In reply to no luck with Emsam... what next?, posted by PsychJ on January 30, 2008, at 18:41:14
First of all, the STAR*D study showed that many of those patients who achieved remission did so after eight weeks or more at an adequate dose. It might be worth sticking it out a bit longer, until you can discuss it with your pdoc... (When you have trouble finding something to work, it's hard to stick it out -- but if something might work if you do stick it out a bit longer, it might be worth it, right?)
So far, you've tried medications from two and a half classes -- I'm counting EMSAM as half an MAOI, just because it's a little different from the conventional, oral MAOIs. Effexor and Cymbalta target both serotonin and norepinephrine. Sometimes that combination is more helpful than the SSRIs, which only target serotonin. Buspar is a whole different animal, and is not an antidepressant.
There are two different classes of antidepressant that you haven't tried -- TCAs and MAOIs -- and a number of kinda random antidepressants, only children, if you will. Which one would work best for you depends on your specific symptoms -- some are better for melancholic depression, others for atypical depression -- which is actually the most common type -- others help more for depression combined with anxiety. Nearly all of them will take at least four to six weeks to kick in -- probably eight weeks or more to get full benefit.
For depression and anxiety, a lot of people have had good luck with Nardil, which I haven't tried. It comes with some side effects, which you may or may not be willing to deal with. Another option is Remeron, which is helpful for a lot of people. Wellbutrin is more activating, but a lot of people find that it's not enough on its own -- it needs something to augment it.
It's hard for me to make anything like a real suggestion, because I don't know what your experience was with the various drugs you've tried. It's clear that they didn't work, but did you have any effect whatsoever? Adverse effects? Mild benefits? Anything at all that might offer a direction to go from here?
Also, it might be worth trying some combinations -- add Lamictal to an antidepressant that maybe thought about helping a little bit; combine Wellbutrin with Zoloft; Remeron and Effexor; there are a lot of combinations that can be very helpful.
I'm sorry I can't offer anything more helpful.
Posted by Phillipa on January 30, 2008, at 23:53:11
In reply to Re: no luck with Emsam... what next?, posted by Racer on January 30, 2008, at 22:58:11
What is your pdocs next suggestion? Does he have one? Phillipa
Posted by PsychJ on January 31, 2008, at 6:19:13
In reply to Re: no luck with Emsam... what next?, posted by Phillipa on January 30, 2008, at 23:53:11
> What is your pdocs next suggestion? Does he have one? Phillipa
He did mention last time that if Emsam wasn't effective he may want to try an older TCA. I've never tried any of those, but he said they have more side effects than most of the SSRIs.
Racer, thanks a lot. As far as I can remember, Zoloft, BuSpar, and Effexor made me tired, without any benefits at all, and the fatigue didn't improve over time. I had a bad reaction to Celexa, I was extremely anxious, jumpy, and kind of obsessive about things. When I took Cymbalta I actually felt really well for the first couple weeks, but after that it just didn't do anything at all (at least it didn't make me tired).
Thanks!
Posted by Racer on January 31, 2008, at 10:43:38
In reply to Re: no luck with Emsam... what next?, posted by PsychJ on January 31, 2008, at 6:19:13
> >
> As far as I can remember, Zoloft, BuSpar, and Effexor made me tired, without any benefits at all, and the fatigue didn't improve over time. I had a bad reaction to Celexa, I was extremely anxious, jumpy, and kind of obsessive about things. When I took Cymbalta I actually felt really well for the first couple weeks, but after that it just didn't do anything at all (at least it didn't make me tired).
>Aha! So the drugs *did* do something! Just -- uh -- not *quite* what you had in mind...
BuSpar is an anxiolytic, so it's not too surprising that it made you "tired." (Question: tired? Or apathetic, lethargic, amotivated, any of those sorts of things? Did they affect your sleep, or only your wakefulness?)
Based on what you had to say about the antidepressants you've tried, I would first recommend trying one of the TCAs -- and I'd suggest desipramine as a first one, since it's got fewer side effects for most people. Other options that come to mind are Remeron or Wellbutrin -- they're different from the other medications you've tried, and while both have side effects, many people seem to tolerate them better than the old TCAs.
On the other hand, the TCAs are often pretty robust medications, and many have a known therapeutic window which can be monitored by blood levels. That's kinda nice, because if you don't respond, your doctor might find out it's because you need three times the dose he anticipated. It may be worth trying one or two.
Hope that helps, good luck!
Posted by PsychJ on January 31, 2008, at 14:57:00
In reply to Re: no luck with Emsam... what next? » PsychJ, posted by Racer on January 31, 2008, at 10:43:38
> > >
> > As far as I can remember, Zoloft, BuSpar, and Effexor made me tired, without any benefits at all, and the fatigue didn't improve over time. I had a bad reaction to Celexa, I was extremely anxious, jumpy, and kind of obsessive about things. When I took Cymbalta I actually felt really well for the first couple weeks, but after that it just didn't do anything at all (at least it didn't make me tired).
> >
>
> Aha! So the drugs *did* do something! Just -- uh -- not *quite* what you had in mind...
>
> BuSpar is an anxiolytic, so it's not too surprising that it made you "tired." (Question: tired? Or apathetic, lethargic, amotivated, any of those sorts of things? Did they affect your sleep, or only your wakefulness?)
>
> Based on what you had to say about the antidepressants you've tried, I would first recommend trying one of the TCAs -- and I'd suggest desipramine as a first one, since it's got fewer side effects for most people. Other options that come to mind are Remeron or Wellbutrin -- they're different from the other medications you've tried, and while both have side effects, many people seem to tolerate them better than the old TCAs.
>
> On the other hand, the TCAs are often pretty robust medications, and many have a known therapeutic window which can be monitored by blood levels. That's kinda nice, because if you don't respond, your doctor might find out it's because you need three times the dose he anticipated. It may be worth trying one or two.
>
> Hope that helps, good luck!You've been very helpful, thanks. I have some options to talk to my doc about.
J.
Posted by former trx resistant on February 2, 2008, at 2:52:35
In reply to Re: no luck with Emsam... what next?, posted by PsychJ on January 31, 2008, at 14:57:00
Hello
I hope you will look at my journey with EMSAM, go to archives, if necessary. Stay the course a bit is my advice for at least 16 weeks if necessary as literature suggests. Tried all the SSRIs you tried, less helpful for me than it sounds like for you. Except my first drug was Wellbutrin then added dexidrine not as smooth as EMSAM and all I got on 9 months of WELLButrin is 11 seizures in 5 hours, brain damage, lost DL for awhile and forever know as "epileptic" which affects insurance rates, work, etc. So try to gives this a chance. It takes a bit of tinkering perhaps, but really worth it!!
Good Luck
Posted by former trx resistant on February 2, 2008, at 2:55:15
In reply to Re: no luck with Emsam... what next?, posted by PsychJ on January 31, 2008, at 14:57:00
forgot to tell you but I tried 8 weeks on Lamictil this past summer before EMSAM and I almost killed myself . . .worst experience of my life, worse than all those seizures . . .so be careful!
Posted by PsychJ on February 2, 2008, at 8:42:15
In reply to Re: no luck with Emsam... what next?, posted by former trx resistant on February 2, 2008, at 2:52:35
> Hello
> I hope you will look at my journey with EMSAM, go to archives, if necessary. Stay the course a bit is my advice for at least 16 weeks if necessary as literature suggests. Tried all the SSRIs you tried, less helpful for me than it sounds like for you. Except my first drug was Wellbutrin then added dexidrine not as smooth as EMSAM and all I got on 9 months of WELLButrin is 11 seizures in 5 hours, brain damage, lost DL for awhile and forever know as "epileptic" which affects insurance rates, work, etc. So try to gives this a chance. It takes a bit of tinkering perhaps, but really worth it!!
> Good LuckThanks for your input. It's interesting you should mention Wellbutrin, since I was thinking that a combination of WB and Klonopin (or Neurontin) may be effective for my depression and social anxiety/phobia. From reading tons of archived messages it seems like the consensus is that Klonopin is the best for SA/SP (and Neurontin is also good for this), and I'm not really concerned with the whole dependency issue. Wellbutrin could help with energy/motivation and balance out the depressive tendencies of the Klonopin.
Your experience certainly makes me a little wary of WB, although from reading the archives it doesn't seem like that was a normal reaction. I'll def. mention it to my doc, though.
Maybe another couple weeks of Emsam would've made a difference, but I decided it had been long enough and I was tired of the side effects- insomnia, extremely dry skin and irritation at application sites, and anorgasmia (doesn't seem like a common SE for Emsam).
So I'm hoping my doc will agree that my idea of Wellbutrin plus Klonopin or Neurontin may do the trick.
Posted by former trx resistant on February 2, 2008, at 22:22:18
In reply to Re: no luck with Emsam... what next?, posted by PsychJ on February 2, 2008, at 8:42:15
As we all know our brains are wired quite individually. But as to seizures, I don't know what you found reading up on Wellbutrin but listen to TV ads-what they tell you is biggest most common risk - seizures. I was told >than 1 in a thousand.
That is very high when you think of the millions on this drug. My dr. says just within his small group of patients he had, within weeks of my episode he had 3 other patients have same thing. different ages & genders. That's >than 1 in 1000!!! I have no family history, quite healthy, about 45 when it happened.
Neurontin made me nuts, couldn't stand up, slept for 4 weeks-can't live like that. But that's my brain.
Klonopin - given to sleep. Does nothing for me.
good luck and keep posting.
Posted by Larry Hoover on February 3, 2008, at 14:54:11
In reply to Re: no luck with Emsam... what next?, posted by former trx resistant on February 2, 2008, at 22:22:18
> As we all know our brains are wired quite individually. But as to seizures, I don't know what you found reading up on Wellbutrin but listen to TV ads-what they tell you is biggest most common risk - seizures. I was told >than 1 in a thousand.
> That is very high when you think of the millions on this drug. My dr. says just within his small group of patients he had, within weeks of my episode he had 3 other patients have same thing. different ages & genders. That's >than 1 in 1000!!! I have no family history, quite healthy, about 45 when it happened.The seizure threshold is reduced by Wellbutrin in a dose-dependent fashion. Wellbutrin will give anybody seizures, if the dose is high enough. At 300 mg/day, the risk is 0.1%. At 450 mg/day, the risk is 0.4% (4 per 1,000). At 600 mg/day, the risk is 2.3% (23 per thousand; based on t.i.d. dosing). The increase in risk is exponential with dose. Those who take it (immediate release format) b.i.d. are probably more likely to seize than these numbers suggest. Extended release preparations would presumably be similar to t.i.d. dosing.
The 1 in 1,000 risk only applies to 300 mg/day dosing.
Lar
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