Psycho-Babble Medication Thread 833832

Shown: posts 1 to 24 of 24. This is the beginning of the thread.

 

Rocket Fuel Failed; What Magic Combo Is Next?

Posted by BGB on June 9, 2008, at 16:40:05

I have bipolar I and am currently in a horrible depressive state. Honestly, I can't think about anything other than suicide. It's all that goes through my mind.

Anyway, I'm on a ton of meds and none of them are helping. I've tried "California Rocket Fuel" with both Effexor and Cymbalta (separately), to no avail. Here's what I'm on now:

Cymbalta 120mg
Remeron 60mg
Wellbutrin SR 600mg
Trileptal 1200mg
Lamictal 200mg
Valium 5-10mg PRN
Trazodone 150mg (for sleep)
Cytomel 50mcg (for AD augmentation-my thyroid is normal)
Propranolol 120mg PRN for tremors

Over the 10 years that I have been taking meds, I have taken the following AD's:

Prozac
Paxil
Zoloft
Celexa
Remeron
Wellbutrin SR
Effexor XR
Effexor XR + Remeron
Cymbalta + Remeron + Wellbutrin SR

Would anyone like to make any recommendations as to what I should try next? I've never tried a tricyclic before; should I try one, or should I go straight for an MAOI?

I have no energy and no desire to do anything. I could just sit and watch tv and sleep 24 hours a day. I truly find pleasure from nothing. Getting up and going to work each day is becoming more and more difficult. I can't get anything done because I can't form a complete thought without thoughts of death interrupting me. I have got to find something better.

Thanks, everyone, for your input! =)

P.S. I have ordered some Temgesic tablets, which are 0.2mg buprenorphine sublingual tablets. I am thinking about augmenting my current regimen with 0.2mg buprenorphine twice a day.

 

Re: Rocket Fuel Failed; What Magic Combo Is Next?

Posted by med_empowered on June 9, 2008, at 18:25:52

In reply to Rocket Fuel Failed; What Magic Combo Is Next?, posted by BGB on June 9, 2008, at 16:40:05

have you tried a stimulant or an MAOI?

 

Re: Rocket Fuel Failed; What Magic Combo Is Next?

Posted by bleauberry on June 9, 2008, at 20:13:04

In reply to Rocket Fuel Failed; What Magic Combo Is Next?, posted by BGB on June 9, 2008, at 16:40:05

I don't know you or your history so this could be all wrong, but I gotta say I think that is too many meds and one or two of them are actually causing you to feel worse than you would otherwise. Actually, if you were still on all those same meds, my bet is you would feel a lot better than now if they were half the dose they are now.

If it were me, I would not even consider adding another med. I mean, if you feel horrible on these meds, they aren't working, ok? Not only are they not working, there is a decent chance one of them is doing enough of something bad that is negating any good the others might have. For all we know, your body and liver might be having such a hard time overloaded with all these chemicals you just might be in toxic overload from a physiological viewpoint, with its unavoidable impact on the brain.

Since I don't know you I couldn't begin to say which meds to wean off of or in what order.

For sure I know from reading posts here for over a decade that the people that were in the worst shape had a huge laundry list of drugs they were one. Coincidence? My gut feeling is that even though they were in bad shape before the drugs, they weren't as bad as they were with all the drugs piled on top.

If two or three meds can't get the job done, they need to be changed, not added to. Just the way I see it.

I'm not saying you should or should not do it, but if it were me, I would cut the wellbutrin in half, valium in half, trazodone in half, stabilize there, and then whittle them down some more. If there were any one drug I would point a guilty finger at, it would be wellbutrin. Valium would take a close second, with trazodone right behind it.

Replace wellbutrin straight across one-for-one, not add on, with modafinil. Replace remeron, one-for-one, not add on, with zyprexa. If there absolutely has to be a benzo, replace valium with xanax. Have abilify on a watch list. Have ritalin on a watch list. If you ever go an maoi route, it's going to be a journey to get the effexor and remeron down to zero and wash out.

I know the mindset is to add another med. Sometimes the opposite makes more sense. Either eliminate or replace.

 

Re: Rocket Fuel Failed; What Magic Combo Is Next? » bleauberry

Posted by Bob on June 9, 2008, at 20:16:56

In reply to Re: Rocket Fuel Failed; What Magic Combo Is Next?, posted by bleauberry on June 9, 2008, at 20:13:04

If there were any one drug I would point a guilty finger at, it would be wellbutrin. Valium would take a close second, with trazodone right behind it.
>


Why do you suspect Welbutrin?

 

Re: Rocket Fuel Failed; What Magic Combo Is Next? » bleauberry

Posted by Bob on June 9, 2008, at 20:23:39

In reply to Re: Rocket Fuel Failed; What Magic Combo Is Next?, posted by bleauberry on June 9, 2008, at 20:13:04

If there absolutely has to be a benzo, replace valium with xanax.

What is your rationale behind this? I assume you aren't keen on benzos? Why is Xanax your first choice?

 

Re: Rocket Fuel Failed; What Magic Combo Is Next? » Bob

Posted by Phillipa on June 9, 2008, at 21:20:35

In reply to Re: Rocket Fuel Failed; What Magic Combo Is Next? » bleauberry, posted by Bob on June 9, 2008, at 20:23:39

Good question really although xanax has a slight mood elevating property it needs to be taken frequently and valium lasts a long time. Phillipa

 

Re: Rocket Fuel Failed; What Magic Combo Is Next? » Bob

Posted by bleauberry on June 10, 2008, at 17:53:20

In reply to Re: Rocket Fuel Failed; What Magic Combo Is Next? » bleauberry, posted by Bob on June 9, 2008, at 20:16:56

I instinctively suspect wellbutrin for a couple reasons.

First of all, while all psych drugs can induce a worse depression (percentage 5% to 15%), wellbutrin anecdotally seems significantly more guilty than the others. More frequent reports of worsened depression compared to others. No way to measure it. No proof. Just what my eyes have seen. And when wellbutrin does make depression worse, it makes it tons worse. It doesn't mess around. Depression is one of the common side effects of people who take it for smoking cessation.

The other reason is that I have seen reports that while wellbutrin has some mild dopamine reuptake inhibition (it is rather weak actually), it also slows down the metabolism of dopamine and slows down the release of dopamine.
Not cool if someone's depression has a dopamine deficit involved.

The other drugs in the cocktail are very strong on serotonin, norepinephrine, and gaba, which are all anti-dopamine. Any positive dopamine effects from effexor, remeron, lamictal, or wellbutrin are likely miniscule compared to the nuclear forces being generated on serotonin and norepinephrine.

Too much norepinephrine can make someone very depressed. Too much dopamine can make someone very depressed. Too much serotonin can make some very depressed. It isn't a matter of how much, but rather the balance. After all, they call it a chemical imbalance. I suspect this cocktail has thrown the balance out of whack in a worse way, leaving dopamine squashed out.

> If there were any one drug I would point a guilty finger at, it would be wellbutrin. Valium would take a close second, with trazodone right behind it.
> >
>
>
> Why do you suspect Welbutrin?

 

Re: Rocket Fuel Failed; What Magic Combo Is Next? » Bob

Posted by bleauberry on June 10, 2008, at 17:57:46

In reply to Re: Rocket Fuel Failed; What Magic Combo Is Next? » bleauberry, posted by Bob on June 9, 2008, at 20:23:39

Assuming I am not keen on benzos would be wrong.

I prefer xanax to valium simply because it has some inherent antidepressant qualities that the other benzos do not have. Valium and klonopin can be very depressing. Hundreds of reports right here over the years can testify to that, not to mention the side effect label. But with xanax, those reports are not nearly as common. Xanax has even been clinically used as a stand-alone antidepressant. It is different than its benzo family members. Depression with xanax is still a risk, as it is with any psych drug, but just seems less than the other benzos.

> If there absolutely has to be a benzo, replace valium with xanax.
>
> What is your rationale behind this? I assume you aren't keen on benzos? Why is Xanax your first choice?

 

Re: Rocket Fuel Failed; What Magic Combo Is Next? » bleauberry

Posted by Bob on June 10, 2008, at 21:08:21

In reply to Re: Rocket Fuel Failed; What Magic Combo Is Next? » Bob, posted by bleauberry on June 10, 2008, at 17:57:46

> Assuming I am not keen on benzos would be wrong.
>

I figured you might not like benzos when you said, "... if you absolutely must use a benzo"

 

Re: Rocket Fuel Failed; What Magic Combo Is Next? » bleauberry

Posted by bissie66 on June 11, 2008, at 12:39:29

In reply to Re: Rocket Fuel Failed; What Magic Combo Is Next? » Bob, posted by bleauberry on June 10, 2008, at 17:57:46

bb - your posts are really interesting. i just wanted to say Amen to klonopin being depressing. i took it habitually for about 5 years and i was pretty miserable the whole time. i'm so glad i'm off it. in fact, i used to cut myself regularly. and yet i haven't done it since i quit the klonopin over a year ago. no big deal, just haven't had the urge to. i think it's partly bc i got out of the cocoon, if that makes any sense. i had this constant numbed inner pain and pressure back then. cutting was a way to release it but i think klonopin kept me so numb and dull that it caused the problem to begin with.

> Assuming I am not keen on benzos would be wrong.
>
> I prefer xanax to valium simply because it has some inherent antidepressant qualities that the other benzos do not have. Valium and klonopin can be very depressing. Hundreds of reports right here over the years can testify to that, not to mention the side effect label. But with xanax, those reports are not nearly as common. Xanax has even been clinically used as a stand-alone antidepressant. It is different than its benzo family members. Depression with xanax is still a risk, as it is with any psych drug, but just seems less than the other benzos.
>
> > If there absolutely has to be a benzo, replace valium with xanax.
> >
> > What is your rationale behind this? I assume you aren't keen on benzos? Why is Xanax your first choice?
>
>

 

Re: Rocket Fuel Failed; What Magic Combo Is Next?

Posted by BGB on June 11, 2008, at 16:49:11

In reply to Re: Rocket Fuel Failed; What Magic Combo Is Next? » bleauberry, posted by bissie66 on June 11, 2008, at 12:39:29

Thanks to everyone that responded! What great advice! I am going to give my current p-doc one more shot to get me off some of this medication, and if he continues to refuse, I am finding a new one. This has been an excellent lesson for me--just because a doctor has awards all over his walls, and other psychiatrists (and patients) think that he's god's gift, doesn't mean he's a good doctor for me. Believe it or not, my p-doc has even been discussed and praised here on this very board (mostly due to his rTMS clinic). I don't know how I'm going to find another one...but something has to change!

Thanks again to everyone for your responses. I really do appreciate the time and thought that you put into your replies.

Take care,
B =)

 

Re: Rocket Fuel Failed; What Magic Combo Is Next? » BGB

Posted by aaaaalex on June 12, 2008, at 1:05:25

In reply to Rocket Fuel Failed; What Magic Combo Is Next?, posted by BGB on June 9, 2008, at 16:40:05

I would agree that this is too many meds. Are these all prescribed by the same doctor? Keeping in mind that I have no special expertise, I would say:

Try to cut the propranolol. It has depression as a potential side effect, and its method of action may interfere with some of your NRIs. Also, you're taking both Remeron and Wellbutrin - I'd give one up. Since it sounds like you're avolitional, I'd say give up the Remeron. Alternatively, you could lower the Remeron dose a bit and get rid of the Trazodone, since the Remeron at night should help you sleep. I'm mostly suspicious of the propranolol, though.

 

Re: Rocket Fuel Failed; What Magic Combo Is Next?

Posted by elanor roosevelt on June 15, 2008, at 23:23:47

In reply to Rocket Fuel Failed; What Magic Combo Is Next?, posted by BGB on June 9, 2008, at 16:40:05

i would dump the wellbutrin (it makes a lot of people feel all flat) and the remeron (i think it has a negative effect on quality of sleep)

lose the valim for xanax
this is why
xanax has an almost immediate effect so you can take a small dose and see where it puts you pretty quickly
especially if you chew it ( bad habits from my dark past)

because it kicks in so quickly you can put off taking it until you are sure you need it
i am very pro-benzo

definitely try some celexa or lexapro to snap out of it

good luck

 

Re: Rocket Fuel Failed; What Magic Combo Is Next? » BGB

Posted by dcruik518 on June 16, 2008, at 18:20:42

In reply to Rocket Fuel Failed; What Magic Combo Is Next?, posted by BGB on June 9, 2008, at 16:40:05

> I have bipolar I and am currently in a horrible depressive state. Honestly, I can't think about anything other than suicide. It's all that goes through my mind.
>
> Anyway, I'm on a ton of meds and none of them are helping. I've tried "California Rocket Fuel" with both Effexor and Cymbalta (separately), to no avail. Here's what I'm on now:
>
> Cymbalta 120mg
> Remeron 60mg
> Wellbutrin SR 600mg
> Trileptal 1200mg
> Lamictal 200mg
> Valium 5-10mg PRN
> Trazodone 150mg (for sleep)
> Cytomel 50mcg (for AD augmentation-my thyroid is normal)
> Propranolol 120mg PRN for tremors

Dear BG:

I've taken a lot of the meds you have and I have to say I believe you've somehow gotten off track with your meds. Several of the ones you are taking--such as Wellbutrin and Trileptal--hardly work for ANYONE! Others tend to make you feel lazy, tired and apathetic--Propranolol, especially, but also, Cymbalta, in my opinion, because without any dopaminergic support it tends to induce a state apathetic yet pleasant sit-on-the-couch-all-day-dullness. Also who takes valium anymore? It's one of the least effective benzos.

Here's what I would suggest. You probably have a case of treatment-resistant-depression that may only be responsive to dopaminergic stimulation. That's the one neurotransmitter that none of the drugs you list seem to boost. Unfortunately, not many of the standard psyschiatric drugs do. You may have to order them online. Since you have bipolar one drug you might start with is abilify. At low doses it actually stimulates dopamine release and is a bit activating; just don't go above 10mg or it will turn into a typical anti-psychotic. Here are some other ideas:

A. Dopamine and serotonin stimulating atypical antipsychotics:
1. Abilify
2. Amisulpride

B. Dopamine and Serotonin releasing anticonvulsant and mood stabilizer:
1. Zonisamide (like Topamax this one also helps you lose weight!)

C. Dopamine agonists used primarily for Parkinson's disease, but recently being tried for bipolar depression, restless leg sydrome, anxiety, sexual side effects of antidepressants and more:

1. Requip this stuff has worked great for me, even though I made the mistake of taking too high a dose. It has a definite anti-depressant effect and for me a definite anti-anxiety effect. I suspect it would also eliminate any movement problems you might have such as hand tremors, hence enabling you to get rid of the deadening propranolol. This would also be a great drug to try out with a good anti-depressant.

2. Mirapex--I haven't tried this yet but it's very similar to Requip, used for both Parkinson's and Restless Leg Syndrom. I believe there have also been promising early trials suggesting it's beneficial use in bipolar disorder.

3. Bromocriptine: this drug works directly on the D2 receptor, which is believed to be the one most responsible for mood and anxiety disorders. I just tried some today and I have to say I think this may work even better than Requip. Makes me feel very calm yet mentally focused. It also has a number of VERY COOL side benefits: in normal subjects in decreases prolactin levels and boost human growth hormone levels naturally. The net effect? You lose weight, gain muscle, your chances of diabetes goes way down, and you live longer!

D. Stimulants boost dopamine and norepinephrine; however, if you're bipolar it's possible they could induce a manic state. If you do try them take a tiny dose!!

1. Adderall--in my opinion this the best stimulant med out there. It has a smooth long last effect and it's potent. It has much better mood lifting effect than ritalin which tends to make people irritable.

1. Dexedrine--this is a little more potent than adderall, and gives a bit more kick, but the pay off is when it wears off you feel crappy, so this is more likely to lead ot addictive type behavior, or pill popping.

E. Anti-depressants: what works for the treatment resistant:

1. most of the SSRI's do not. However, some have promise, especially when they are combined with one or two of the drugs above. Cymbalta, for instance, can be a great anti-depressant, if you add a dopamine agonist; but alone it actually depletes dopamine. Forget Effexor--it causes too much anxiety, even if it does boost dopamine a tiny bit. Another great anti-depressant that boosts both serotonin and dopamine is actually Zoloft, but again, I'd recommend augmenting it with one or more of the above. Probably the greatest antidepressant of all time for atypical or treatment resistant depression is the MAOI, Nardil. It's worked wonders for me and for everyone I know who's given it a fair trial. It's like a using a bomb instead of a guided missile. It affects everything in your brain and you just end up feeling great. However, it has terrible, terrible weight gain, which causes most people to stop after six months or so. The newest MAOI is EMSAM which is a patch and is supposed to have fewer side effects and be less dangerous. It will definitely boost dopamine. Worth a try.

F. Finally the benzodiazepines. Only two option here worth mentioning.
1. Clonazepam: a powerful, long-lasting, non-habit forming very effective anti-anxiety drug that can be tolerated at very high doses. It also used for epilepsy and has a half life of 35 hours or something.

2. Xananx XR: the old xanax was a great drug, extremely effective at relieveing anxiety without causing too much drowsiness, but the problem was it was too effective for the five hours it lasted, and it lead to pill popping and addiction among certain people. The new formula, while very expensive, is even better than clonazepam in my opinion; That's partly because it tends to have an anti-depressant effect as well as relieving practically all anxiety. However, the new stuff lasts just as long as the clonazepam, so it doesn't lead to pill popping or addictive withdrawal.

So here's a possible scenario:

1. ZONISAMIDE AND ABILIFY TO STABILIZE YOUR MOOD
2. EMSAM FOR DEPRESSION
3. REQUIP OF BROMOCRIPTINE TO AUGMENT THE EMSAM(FREEDOMPHARMACY) AND HELP WITH TREMOR
4. XANAX XR FOR ANXIETY, DEPRESSION, AND TO HELP WITH TREMOR.
5. IF AFTER A MONTH OR SO, YOU STIL FEEL LETHARTHIC, CONSIDER SLOWLY ADDING A TINY DOSE OF ADDERALL.

My humble advice after 25 years of this,
D.C.


 

Re: Rocket Fuel Failed; What Magic Combo Is Next? » Phillipa

Posted by Crotale on June 17, 2008, at 21:02:27

In reply to Re: Rocket Fuel Failed; What Magic Combo Is Next? » Bob, posted by Phillipa on June 9, 2008, at 21:20:35

> Good question really although xanax has a slight mood elevating property it needs to be taken frequently and valium lasts a long time. Phillipa

As I understand it, this isn't really correct: Valium has a long elimination half-life; however, it doesn't actually have a very long *duration of action*. The reason has to do with volume of distribution. Valium is taken up into the CNS quickly but then gets redistributed rather quickly throughout the body. It doesn't do you much good if it's sitting in your big toe.

A neuropharmacologist could explain this better. Anybody?

 

Re: Rocket Fuel Failed; What Magic Combo Is Next?

Posted by Crotale on June 17, 2008, at 21:16:29

In reply to Re: Rocket Fuel Failed; What Magic Combo Is Next? » Phillipa, posted by Crotale on June 17, 2008, at 21:02:27

BTW I do agree that Xanax might be a better benzo for the depressed than Valium or Klonopin. In terms of duration of action, Klonopin or Xanax XR would be the longest-lasting one. (I'm not sure about Xanax XR.)

I take Buprenex which is a formulation of buprenorphine. It is a very effective (and fast-acting) antidepressant in my experience *but* it does have a lot of side effects.

Whether to try TCAs or go straight to MAOIs depends, I'd say, on your symptoms: for example TCAs aren't supposed to work as well for atypical depression and social anxiety, whereas MAOIs are known to be effective for both conditions.

 

P-doc says only options are rTMS + ECT!!

Posted by BGB on June 18, 2008, at 14:00:37

In reply to Rocket Fuel Failed; What Magic Combo Is Next?, posted by BGB on June 9, 2008, at 16:40:05

First of all, thanks to everyone for your helpful posts. I really do appreciate all of the great advice.

I saw my p-doc yesterday, and according to him, my only options left are rTMS (conveniently, he has a clinic) and ECT. When I heard that I was really devastated. When I asked about other drug options, like MAOI's, he told me that he was comfortable prescribing them, but that my best options were rTMS and ECT. So, I am weaning down off of Remeron and Wellbutrin in anticipation of starting an MAOI next month.

In the mean time, I think I need to find a new p-doc! I can't believe that he did not even mention tricyclic AD's or MAOI's. I feel like I should see someone who doesn't own an rTMS clinic for a second opinion. Considering that rTMS has a very questionable record, and even my doctor himself says it has only a forty percent success rate, I am crossing it off the list. That's WAY too much money to pay ($2,500-$4,000) for something that more than likely won't work. I would like to put off ECT for as long as I can, so I would like to try to find a drug-based therapy first.

Well, I just wanted to thank everyone again and let you know what's up. I'll keep everyone posted!

 

Re: P-doc says only options are rTMS + ECT!!

Posted by dcruik518 on June 18, 2008, at 17:39:06

In reply to P-doc says only options are rTMS + ECT!!, posted by BGB on June 18, 2008, at 14:00:37

I think trying an MAOI makes great sense. They often work when nothing else does. However, if you're going to try one, try Nardil first, because it has the best track record; it's also the only one that's also really good for social phobia. Also keep in mind that MAOI's sometimes take longer before they really begin to work. Part of that has to do with the gradual increase in dose over a few weeks. My guess is that you'll probably need to be on 90mg for 3 weeks before you really start to notice a difference. So be patient, it's worth it. Also, don't worry too much about the dietary restrictions, I've never needed to avoid any foods. The real dangers are drug interactions with certain cough medicines, etc., so always check your pills. And hey, ECT has an excellent success rate, too, if this doesn't work.

Good luck!

 

Re: P-doc says only options are rTMS + ECT!!

Posted by blueboy on June 19, 2008, at 7:51:30

In reply to Re: P-doc says only options are rTMS + ECT!!, posted by dcruik518 on June 18, 2008, at 17:39:06

> I think trying an MAOI makes great sense. They often work when nothing else does. However, if you're going to try one, try Nardil first, because it has the best track record; it's also the only one that's also really good for social phobia. Also keep in mind that MAOI's sometimes take longer before they really begin to work. Part of that has to do with the gradual increase in dose over a few weeks. My guess is that you'll probably need to be on 90mg for 3 weeks before you really start to notice a difference. So be patient, it's worth it. Also, don't worry too much about the dietary restrictions, I've never needed to avoid any foods. The real dangers are drug interactions with certain cough medicines, etc., so always check your pills. And hey, ECT has an excellent success rate, too, if this doesn't work.
>

Let me second most of that. It was the only thing that worked for me out of a gazillion meds over several decades.

BTW it turned out I am bipolar, so the AD's were acting like one would expect. Definitely see another doctor, preferably one with a diagnostic specialty at a major clinic/research facility, and ask for a diagnostic consult. I suggest you write down your symptoms in two forms, one chronologically and one by symptom group.

Also, get your thyroid, liver, and blood chemistry tested. It's fairly inexpensive.

The reason: my experience. You have to consider the possibility that you have been misdiagnosed, if you have tried numerous AD's with no effect.

Nardil worked for me, though, so I guess it has an effect on some bipolar patients. It has worked for a lot of people who had no success with SSRI/SSNI and tricyclic drugs.

BTW I leveled out at 60mg/day.

> Good luck!

Good luck indeed.

 

Re: P-doc says only options are rTMS + ECT!! » BGB

Posted by Zeba on June 19, 2008, at 21:26:09

In reply to P-doc says only options are rTMS + ECT!!, posted by BGB on June 18, 2008, at 14:00:37

I think it would be a good idea to try the MAOI route and if that doesn't work, then rTMS. If at all possible I would avoid ECT. It does not have a good success rate from more recent stat's. Much of it's success is attributable to memory loss and confusion such that a person often buys into the maintenance route often reommended. I had ECT last year and stopped after number 7 as I could tell my memory was really getting screwed up. Plus I was so disoriented and had word finding difficulties, could not spell simple words, and it goes on and on. I still cannot read something or write something and remember what I read or wrote by a couple of days later. Plus, though I can find my way to work now, I still can't find my way to the homes of friends in my county without making myself a very detailed map. Even then I am screwed if it is night time. I don't know why my then pdoc pushed ECT but he had pushed it from day one. I was not suicidal and I was going to work everyday. I had to take off work for six weeks and then fake it alot when I went back. Worst decision of my life to get ECT.

 

Re: P-doc says only options are rTMS + ECT!!

Posted by Crotale on June 20, 2008, at 18:48:47

In reply to Re: P-doc says only options are rTMS + ECT!! » BGB, posted by Zeba on June 19, 2008, at 21:26:09

I agree that MAOI should come before ECT, but the claim that ECT's success rate is just an artifact of memory loss is just incorrect. I would say this post is biased and that you are better off listening to someone who hasn't had ECT. The poster "Zeba" has admitted that his/her ECT was botched. Obviously you should not have any sort of invasive procedure performed by a doctor for whom you have anything short of 100% respect and trust.

I will freely admit I may be biased as well, as I have had ECT and it has benefited me (for severe treatment-resistant depression, which has an extremely low placebo response rate) and I have not suffered any memory loss (other than the expected inability to remember anything that happened while I was under general anaesthesia). However, I will also point out that I was a staunch defender of ECT before I'd had it, based on its well-documented high success rate.

rTMS is the treatment with a questionable success rate. It is still quite experimental.

 

Re: P-doc says only options are rTMS + ECT!! » Crotale

Posted by Zeba on June 20, 2008, at 20:06:07

In reply to Re: P-doc says only options are rTMS + ECT!!, posted by Crotale on June 20, 2008, at 18:48:47

My ECT was done at one of the top 10 University Hospitals in the country. I would not say the procedure was botched, and neither did the doctor who did the other six ECT's. He said my problems "might" have been the result of the longer seizure, but that is it. He and my pdoc agreed I should stop. In fact I noted problems after number six ECT treatment.

Secondly, I researched thoroughly through the journals about ECT. The more recent literature acknowledges there will be memory loss. Sometimes is it not noted right away. I know several people who had ECT and maintenance ECT and swore by it until they went for neuropsych testing and learned they had memory deficits and other problems.

Obviously it is your right to do as you chose. I believed and trusted my doctor too. He has published a lot in the area of ECT. At least he is honest when he says it can cause memory problems. I even still like the guy, but I would never let anyone do ECT to me ever again. Do you know the parameters of what they do when they give you ECT?? Do you work at a job?

If you look at the archives here on babble (under ECT) you will see that there are many people here who have had ECT and have been harmed by it. Finally, I am not depressed anymore even though I was when I stopped the ECT. Parnate and psychoananalysis are what I need and what works for me. I have down days, but I have more up days.

 

Re: Rocket Fuel Failed; What Magic Combo Is Next? » BGB

Posted by yxibow on June 21, 2008, at 3:34:30

In reply to Re: Rocket Fuel Failed; What Magic Combo Is Next?, posted by BGB on June 11, 2008, at 16:49:11

> Thanks to everyone that responded! What great advice! I am going to give my current p-doc one more shot to get me off some of this medication, and if he continues to refuse, I am finding a new one. This has been an excellent lesson for me--just because a doctor has awards all over his walls, and other psychiatrists (and patients) think that he's god's gift, doesn't mean he's a good doctor for me. Believe it or not, my p-doc has even been discussed and praised here on this very board (mostly due to his rTMS clinic). I don't know how I'm going to find another one...but something has to change!
>
> Thanks again to everyone for your responses. I really do appreciate the time and thought that you put into your replies.
>
> Take care,
> B =)


I would personally try a second opinion, not necessarily a second doctor, at first -- for one reason, every time you establish a relationship with a doctor, it is a personal repartee and the doctor is aware (hopefully) of what has been tried in a journal.

For a second opinion, I wouldn't send a diagnosis necessarily, that is up to you, but I would have your doctor include what has been tried.

Under HIPAA and under various state laws, if you're in the US, you will have to sign a bidirectional agreement form, that is your doctor will fax a signature of release of records to the second opinion doctor, and vice versa.

What you noted was important -- "you are on a ton of medications..." Sometimes simplification is better than polypharmacy, sometimes not.

That is an awful lot of serotonin going on -- Cymbalta as said in general has a 6:1 serotonin to NE ratio -- you're on Remeron at a dose far beyond the alpha range into the 5HT blockade, the Lamictal may boost the serotonergic effects, its hard to say what it does exactly, and 150mg of Trazodone is just on the cusp of serotonergic activity.


Some who have tried MAOIs will say go straight to an MAOI -- I personally disagree with using MAOIs first, they, and perhaps this is a generalization across the board, but they do share black box properties not quite like Clozaril, but there are definite informed consent that one needs to know before going ahead.

It is noted by the manufacturer that the lowest dose of EMSAM (selegeline transdermal) does not have have the tyramine problem. But one may need greater than the lowest dose, and that does have similar issues to standard MAOIs.

This may be really offensive, and I apologize if it is, because I know that there are people with treatment resistent depression -- and you could certainly be one of them, but to take one myself (this is a projection -- I know, I have been told this before -- we all project at times because we have memories of what has happened to ourselves) strikes me vicerally, because its almost like creating PKU or diabetes I/II for yourself.

You have to be careful about going out to eat and how much of a restricted item is in the meal you're about to eat -- and if there is a language barrier, you may not know at all. If you're a vegetarian, it creates a larger problem (which is why I personally couldn't take an MAOI -- yes, projection.)

At home, favorite foods may have to be forgone, labels may have to be read (okay, as a vegetarian I read labels too just for ethical reasons, so I can resonate there...)

I guess if it is a choice between "Honestly, I can't think about anything other than suicide. It's all that goes through my mind." as an ideation and... I won't go further... then there are perhaps certain things one has to forgo and be careful of and maybe a second opinion will have a list of medications that include MAOIs. Its like my yet eternal choice of Clozaril that hasn't materialized for a lot of personal and pharmaceutical reasons.


So for whatever medication, sometimes you have to either choose side effects, or live with a condition. This is true for all things in life. The benefits have to outweigh the risks -- and if the risks are actual suicide then there are a few types of medications that do lessen that -- APs (neuroleptics) and Lithium, in some cases.


There have been days in the past and days recent when I have also had ideations. I am clinically depressed on top of a major condition that has no single point of solution. But I choose not to add yet more serotonin to the mixture, and I think my doctor would agree. I also think personally that raising SSRIs could hasten things I don't want to think of but are always at the back of my mind with the AP I am on.

So long story short -- I would advocate a tricyclic before going to MAOIs. They vary widely in their effectiveness -- Doxepin is probably the least effective for what you are suffering from just from a wild guess. Imipramine or Amitriptyline are probably more effective.

They are also not without their risks -- anticholinergic at the top, and mm... excess dosage, I hate to say that to a depressed person or anyone on the board for that matter, but I was told that too, in a roundabout way.

But since you haven't tried anything in that spectrum, you could.


Also, on another subject, addressing "over the 10 years..." Some people will disagree, but I do believe very strongly that most cases of mental illness are due to some biochemical disorder or genetic tendency.

And this is fluid and a moving target... so a retrial of a medication that you used 10 years ago may produce different effects now than it did before. Of course visiting the laundry list of medications that really didn't work is daunting, so I'm not saying to go back to everything, but maybe the one that did a little inch to things.


As for the buprenorphine -- I would be careful of interactions with that large list... yes, a number of individuals have discussed this one the board.

I even have thought about it. At least in this country under the Drug Addiction Treatment Act of 2000, only a psychiatrist who specializes in addiction medicine and has the additional training can do such trials if they even have done so in their practice.

It could be a double edged sword, not to mention your doctor does not know you're taking it. Adding an opiate (and this doesn't contain naloxone) could initially create euphoria, but could also increase depression.

As for rTMS that is still an "Investigational Device Exemption" under the FDA. There have not been a lot of placebo effect studies. This and its status may be changing in the near future.

ECT I would reserve for last resort, even over an MAOI. Although at an institution I am familiar with, no patient has ever died of it in modern times, there are a littany of memory effect issues (and cost of it, which may not be insurance covered) that have been discussed before so I won't go into them, but they can be minor to major. And there is also the possibility of having to do it multiple times.

So in this rambling discussion as I am probably known for I would say:

Get a second opinion. Have an open mind, but it would be good not to place "magical expectations", for a lack of better words -- there will be some results and presumably some different list of medications, but some may include some you have tried and some that may be contraindicated at the moment, it is certainly possible. Do include and maybe write down your own list of things you want to bring up and any health issues, and other things you want to point out.


Try a tricyclic, or other tricyclics. They do have more drug interactions, so combinations with other therapies may have to be considered.


If that fails, and a good number of weeks have to have passed before consideration, I would possibly try maybe the low dose EMSAM patch, if warranted by whatever doctor you have.


Beyond that, there are augmenters, you have tried one, there is Deplin, which for a certain small set of people does work, but may cause some anxiety.

And yes, beyond that there are MAOIs. For that I leave up to your choice.

People have different definitions of "magic combinations", "magic medications" -- for me, I have been told there is no "magic bullet." It's true, there is nothing that will knock all the multifaceted things that are going on at the same time in 2008. On the other hand, some people think that a medication or a set of them are "magic", that is, a feeling of success.


But beyond all of this, I wouldn't also rule out psychotherapy, because there are psychological components to depression as well. Taking a medication is not the only thing in life that will rule out things. Yes, there are "cocktails" for HIV/AIDS (not without serious side effects), etc.

About the only thing I can think fore example that is a sure fire "cure" in any medical situation is perhaps an antibiotic (if not overused and become useless to the general population which is increasingly the case) for a known strep infection (provided one doesn't have allergies to the drug).


Anyhow I wish you luck on whatever decision you do go with.

-- best wishes

-- tidings


- Jay

 

Re: Rocket Fuel Failed; What Magic Combo Is Next?

Posted by newdaydawning on July 2, 2008, at 0:48:27

In reply to Re: Rocket Fuel Failed; What Magic Combo Is Next? » BGB, posted by dcruik518 on June 16, 2008, at 18:20:42

I was on Cymbalta for a period of time. It made things worse for me. I urge you to be cautiutous of how many medications you are taking. These medications (most of them) are metabolized in the body by the liver. In some cases if you are thowing in too many at once, you could (doesnt mean you have) but you could stop your liver from properly detoxifying the drugs correcly. They may do a liver blood test, but this doesnt necessarily show the health of the liver...it mainly shows IF the liver is functioning. Even if it is, the more drugs you put into your body the more stress you will put on your liver. If your liver slows down or cant metabolize all these drugs at once, the drug themselves will store in the fat cells of the central nervous system. It sounds crazy but it happened to me. I almost died from it. This is why people die from drugs and not from eating apples. So I caution you to find a doctor who is going to help you but not one who is going to put you on more than 3 drugs at once. Bi-Polar is very serious, but I don't think putting someone on 10 different drugs is going to help them out. Personally I believe it will make thigns worse. In the long run it could hurt the person. These drugs are chemicals. They have a chemical structure. When working theraputically they can really help people. But again this is coming from a college student who has suffered extensivly because of drugs...persciption drugs. Which the doctors had no prolem handing out like candy. Unfortunatly many doctors do not see these drugs as toxic, but the simple matter is they CAN be if your not careful..This is why they have warning lables on the drugs for "liver damage. The other thing is side effects of anti-depressants can be major depression. Not just in young adults but adults as well. And on a side note...particularly with cymbalta I have heard that some people who are bi polar and take cymbalta it can actually induce mania and depression.

Again I am not saying stop your drugs. Talk this though with your doctor, but what I am saying is, dont let doctors fix you. You suffer from Bi-polar, but that doesnt difine you and having doctors give you tons of pills to pop...more than 5 I would think would have adverse effects. I hope you find the right combination for you. But I also hope that not as many will be needed.


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