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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 7 to 31 of 31. Go back in thread:
Posted by dbc on September 28, 2008, at 20:31:41
In reply to Re: Do SSRIs Trump Stimulants? » azalea, posted by Phillipa on September 28, 2008, at 19:54:01
More serotonin = more GABA = a blunting in stimulant effectiveness.
Posted by azalea on September 28, 2008, at 20:44:29
In reply to Re: Do SSRIs Trump Stimulants? » azalea, posted by Phillipa on September 28, 2008, at 19:54:01
I believe Zoloft affects dopamine reuptake at 150-200mg/day, but I don't have a source to reference that. Just remember reading that somewhere; can't quite remember where.
Here's a few sentences from Manual of Clinical Psychopharmacology relating to this topic:
"Sertraline also appears to block the reuptake of dopamine and may be more potent in this regard than bupropion . . . Therapy is usually initiated at 50 mg/day, although, as with the other SSRIs, a lower starting dosage is sometimes required. The 50-mg dose may be continued for 2 weeks, and if no response is seen, the dosage may then be increased weekly by 50 mg/day until a maximum dosage of 200 mg/day is achieved."> Azalea how high a dose? Thanks Phillipa
Posted by azalea on September 28, 2008, at 20:50:08
In reply to Re: Do SSRIs Trump Stimulants?, posted by qbsbrown on September 28, 2008, at 19:47:39
If you don't mind sharing what medications you're currently taking, some posters might have some suggestions for options to consider in the future. Bipolar with ADHD is a challenge to balance, but it's possible. Just have to find the right combination. Best wishes.
> I'm assuming that antipsychotics have the same effect to stimulants? Because they block the dopamine that the stimulants are trying to increase?
>
> I'm bipolar w/ adhd (and ocd tendancies), so it's a tough juggling act.
Posted by qbsbrown on September 28, 2008, at 21:01:10
In reply to Re: Do SSRIs Trump Stimulants? » qbsbrown, posted by azalea on September 28, 2008, at 20:50:08
I'm starting from scratch w/ meds.
I believe that lexapro is the only antidepressant that helps my depression (w/in 3-4 days), and actually allows me to focus and concentrate. All other ssris i can't even read a book with or understand what someone is saying to me.
But lexapro will put me into a mixed mood/irratability (BP II) after about a week or so.
Hopefully to counter this will be seroquel. This will help w/ my severe insomnia and racing thoughts that are constant. Seroquel on the other hand makes the adhd horrible. Then add a stimulant.So
lexapro+seroquel+dexedrine or ritalin.
All of these meds alone make one thing better, but other aspects much worse. So I'm hoping that combined might work out.
Regards,
Brian
Posted by Phillipa on September 28, 2008, at 21:02:37
In reply to Re: Do SSRIs Trump Stimulants? » Phillipa, posted by azalea on September 28, 2008, at 20:44:29
That's what I thought as Son was on it for a few weeks didn't need it anymore. Thanks Phillipa
Posted by azalea on September 28, 2008, at 21:17:01
In reply to meds, posted by qbsbrown on September 28, 2008, at 21:01:10
Have you tried Lamictal (lamotrigine)? It's a mood stabilizer that is generally considered 1st line treatment for bipolar maintenence.
Seroquel is also a mood stabilizer, but has a worse side effect profile than Lamictal. Seroquel blocks dopamine so that makes sense that your ADHD would be worse on it. For ADHD, you want something that increases dopamine.
Difficulty with concentration and focus can occur with SSRIs. Hypothetically, as you increase serotonin, you get a relative deficiency of dopamine. Adding the Dexedrine increases dopamine, balancing the increase in serotonin from the SSRI.
Your proposed combo lexapro+seroquel+dexedrine or ritalin might work, but it seems like you've got several meds working against each other. Ideally you want a combo of meds that work with each other. Does your doctor have experience treating patients with bipolar and ADHD?
It's tough starting from scratch, but it also is a great opportunity to find a regimen that works.
Also, have you tried Wellbutrin (bupropion)? It is an antidepressant that is good for people with bipolar disorder. It's also used off-label for ADHD as it improves focus and concentration.
I hope this post isn't too overwhelming with all the questions and suggestions.
> I'm starting from scratch w/ meds.
>
> I believe that lexapro is the only antidepressant that helps my depression (w/in 3-4 days), and actually allows me to focus and concentrate. All other ssris i can't even read a book with or understand what someone is saying to me.
>
> But lexapro will put me into a mixed mood/irratability (BP II) after about a week or so.
> Hopefully to counter this will be seroquel. This will help w/ my severe insomnia and racing thoughts that are constant. Seroquel on the other hand makes the adhd horrible. Then add a stimulant.
>
> So
>
> lexapro+seroquel+dexedrine or ritalin.
>
> All of these meds alone make one thing better, but other aspects much worse. So I'm hoping that combined might work out.
>
> Regards,
>
> Brian
Posted by qbsbrown on September 28, 2008, at 21:28:48
In reply to Re: meds » qbsbrown, posted by azalea on September 28, 2008, at 21:17:01
Yes, tried and tried with Lamictal. Was my docs first suggestion. Makes my anxiety horrible, and was vomiting every day, severe insomnia etc. I generally don't tolerate anticonvulsants well at all.
Wellbutrin didn't do anything for me.
The only meds that I felt made me feel better was Provigil and the stimulants (at least makes the racing thoughts pleasant ones).So I know that Lexapro doesn't affect my concentration and focus. Thus needing something for racing thoughts and sleep.
I had failed at every job that I had ever had until I had tried Ritalin.
It's also a consideration that I could just take the stimulant during the day (being a little manic, but i can function well at a job), then take the Seroquel after to slow things down.
Brian
Posted by elanor roosevelt on October 2, 2008, at 23:07:28
In reply to Re: Do SSRIs Trump Stimulants?, posted by dbc on September 28, 2008, at 20:31:41
absolutely
true for effexor
Posted by qbsbrown on October 3, 2008, at 0:24:44
In reply to Re: Do SSRIs Trump Stimulants?: absolutely, posted by elanor roosevelt on October 2, 2008, at 23:07:28
For me it seems to wean out the racing thoughts, that are part of my BPII/ADHD
Does the Depakote lessen the effect of the Dexedrine?
The only articles I could find on treating bipolar and adhd, it seemed that Depakote was the BP med of choice along with a stimulant (only one i could find was adderall, but assumed all the same).
Although my Lexapro is allowing me to be much more personable and sociable, is causing too much mood instability.
Regards,
Brian
Posted by azalea on October 3, 2008, at 13:40:42
In reply to What does Depakote ER do to Stimulants?, posted by qbsbrown on October 3, 2008, at 0:24:44
From the study below, it appears that Depakote (valproate) may have more of a canceling-out effect on stimulants than Lithium. Keep in mind this is only one study. If the combo of Depakote + Dexedrine is working for you, stick with it.
European Neuropsychopharmacology. 2005 Dec;15(6):633-9.
Valproate attenuates dextroamphetamine-induced subjective changes more than lithium.
Willson MC, Bell EC, Dave S, Asghar SJ, McGrath BM, Silverstone PH.
Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada.
Dextroamphetamine administration in healthy controls produces a range of subjective and physiological effects, which have been likened to those occurring during mania. However, it is uncertain if these can be attenuated by lithium since conflicting results have been reported. To date there have been no previous studies examining the effects of valproate on dextroamphetamine-induced mood and physiological changes. The current study was a double-blind, placebo-controlled, study in which volunteers received either 1000 mg sodium valproate (n=12), 900 mg lithium (n=9), or placebo (n=12) pre-treatment for 14 days. Subjective and physiological measures were then obtained prior to administration of a 25 mg dose of dextroamphetamine, and at two time points after administration. Differences in the response to dextroamphetamine were assessed between the three treatment groups. The results of this study show that pre-treatment with lithium only significantly attenuated dextroamphetamine-induced change in happiness, while valproate pre-treatment significantly attenuated the effects of dextroamphetamine on happiness, energy, alertness and on the diastolic blood pressure. These results suggest that lithium and valproate do not have the same mechanism of action on dextroamphetamine-induced changes, and this finding may relate to differences in their mechanism of action in mood disorders.
> For me it seems to wean out the racing thoughts, that are part of my BPII/ADHD
>
> Does the Depakote lessen the effect of the Dexedrine?
>
> The only articles I could find on treating bipolar and adhd, it seemed that Depakote was the BP med of choice along with a stimulant (only one i could find was adderall, but assumed all the same).
>
> Although my Lexapro is allowing me to be much more personable and sociable, is causing too much mood instability.
>
> Regards,
>
> Brian
Posted by qbsbrown on October 3, 2008, at 14:12:22
In reply to Re: What does Depakote ER do to Stimulants? » qbsbrown, posted by azalea on October 3, 2008, at 13:40:42
Interesting story. For me, it actually seems to smooth out the stimulants, more linear thinking, where w/o it, i don't have 2 congruent thoughts on stimulant alone.
I have noticed that the stimulant effect is little. I am still receiving the happy/euphoric/social feeling from dexedrine w/o the racing thoughts.
Plus on 600mgs of Lithium, i barely had a trace of it in my blood.
Now I'm dropping my Lexapro from 10mgs to 5, praying it'll help stability, while maintaining socialbility. Although on 10mgs, I causes me quite racing thoughts as well.
oddly enough for me too, ssris make my obsessions worse! What is that all about? I guess a characteristing of the BPII
Brian
Posted by qbsbrown on October 3, 2008, at 17:11:22
In reply to Re: Do SSRIs Trump Stimulants?: absolutely, posted by elanor roosevelt on October 2, 2008, at 23:07:28
I'm finding the same thing with lexapro, canceling out the stimulant effects. Bummer because the lexapro is making me more social, but making me obsess more (hence writing on here, lol).
Rock and a hard place here.
Brian
Posted by qbsbrown on October 3, 2008, at 20:41:15
In reply to Re: What does Depakote ER do to Stimulants? » qbsbrown, posted by azalea on October 3, 2008, at 13:40:42
> From the study below, it appears that Depakote (valproate) may have more of a canceling-out effect on stimulants than Lithium. Keep in mind this is only one study. If the combo of Depakote + Dexedrine is working for you, stick with it.
>
> Valproate attenuates dextroamphetamine-induced subjective changes more than lithium.I took my dose of depakote in the morning (cause i sleep terrible when taken at night), along with 5 mg of lexapro, and i had to take more than double my regular dexedrine dose!
Looks like I'll stick to depakote at night, and try 2.5 of lexapro before dropping it. It's tough to give up cause it's making me myself and very social, but is keeping the night time racing thoughts up, and obsessions are worse.
Dexedrine alone, im non social (except online), and I have a hard time leaving the house because it seems my brain wants to hyper focus on one thing. I go all quiet, and thoughts inwards.Is that normal?
Brian
Posted by azalea on October 3, 2008, at 21:51:25
In reply to Re: What does Depakote ER do to Stimulants?, posted by qbsbrown on October 3, 2008, at 20:41:15
You might find inositol supplementation beneficial for depression and OCD-type symptoms. The studies used 12g inositol daily. This ends up being a lot of pills as most inositol comes in 500mg tablets or capsules. Some health food stores sell inositol powder which make it easier to get the recommended dosage.
Just a thought of something you could try if you haven't already.Eur Neuropsychopharmacol. 1997 May;7(2):147-55.
Controlled trials of inositol in psychiatry.
Levine J.Inositol is a simple polyol precursor in a second messenger system important in the brain. Cerebrospinal fluid inositol has been reported as decreased in depression. A double-blind controlled trial of 12 g daily of inositol in 28 depressed patients for four weeks was performed. Significant overall benefit for inositol compared to placebo was found at week 4 on the Hamilton Depression Scale. No changes were noted in hematology, kidney or liver function. Since many antidepressants are effective in panic disorder, twenty-one patients with panic disorder with or without agoraphobia completed a double-blind, placebo-controlled, four week, random-assignment crossover treatment trial of inositol 12 g per day. Frequency and severity of panic attacks and severity of agoraphobia declined significantly with inositol compared to placebo. Side-effects were minimal. Since serotonin re-uptake inhibitors benefit obsessive compulsive disorder (OCD) and inositol is reported to reverse desensitization of serotonin receptors, thirteen patients with OCD completed a double-blind controlled crossover trial of 18 g inositol or placebo for six weeks each. Inositol significantly reduced scores of OCD symptoms compared with placebo.
> > From the study below, it appears that Depakote (valproate) may have more of a canceling-out effect on stimulants than Lithium. Keep in mind this is only one study. If the combo of Depakote + Dexedrine is working for you, stick with it.
> >
> > Valproate attenuates dextroamphetamine-induced subjective changes more than lithium.
>
> I took my dose of depakote in the morning (cause i sleep terrible when taken at night), along with 5 mg of lexapro, and i had to take more than double my regular dexedrine dose!
>
> Looks like I'll stick to depakote at night, and try 2.5 of lexapro before dropping it. It's tough to give up cause it's making me myself and very social, but is keeping the night time racing thoughts up, and obsessions are worse.
>
> Dexedrine alone, im non social (except online), and I have a hard time leaving the house because it seems my brain wants to hyper focus on one thing. I go all quiet, and thoughts inwards.
>
> Is that normal?
>
> Brian
Posted by qbsbrown on October 4, 2008, at 12:42:15
In reply to Re: What does Depakote ER do to Stimulants? » qbsbrown, posted by azalea on October 3, 2008, at 21:51:25
Would a low dose like 25mgs of Zoloft have less of an effect on Dexedrine than Lexapro?
Posted by qbsbrown on October 8, 2008, at 15:00:19
In reply to Re: What does Depakote ER do to Stimulants? » qbsbrown, posted by azalea on October 3, 2008, at 21:51:25
Would/does Trileptal affect the Dexedrine?
Unfortunately as my history shows, after being on top of the world for a couple of days with dexedrine, depakote, and lexapro, the lexapro threw me in to a mixed episode. Then I think that having a mixed episode w/ a stimulant almost throws me in to psychosis.
So that's it w/ antidepressants with me, although they make me so much more personable and social like my normal self.
Any suggestions other than Lamictal or Lithium?
If only these anticonvulsants didn't make me stupid and more depressed.
HHMM. What to do.
Brian
Posted by azalea on October 8, 2008, at 15:10:49
In reply to azalea: How about Trileptal with Dexedrine?, posted by qbsbrown on October 8, 2008, at 15:00:19
Many of the anticonvulsants do cause cognitive impairment, especially in higher doses. I'm not too familiar with Trileptal, however a quick PubMed search of trileptal + stimulant brought up the study below. Looks promising!
Eur J Clin Pharmacol. 1993;44(6):529-33.
Memory and psychomotor effects of oxcarbazepine in healthy human volunteers.
Curran HV, Java R.
Department of Psychiatry, Institute of Psychiatry, UK.Cognitive and psychomotor impairments can be unwanted adverse effects of antiepileptic drugs. The present double-blind, cross-over study with healthy volunteers was designed to assess the effects of two doses of oxcarbazepine (OXCZ) (150 mg b.i.d.; 300 mg b.i.d.) and a placebo, each given over a two week period. Twelve subjects completed a battery of tests before and 4 h after morning doses on days 1, 8 and 15. Results of objective tests indicated that OXCZ improved performance on a focussed attention task and increased manual writing speed. Subjective ratings showed OXCZ increased feelings of altertness, clear-headedness and quickwittedness. OXCZ had no effect on the range of long-term memory processes assessed in this study. It is concluded that at the doses employed, OXCZ has a slightly stimulant effect on some aspects of psychomotor functioning.
> Would/does Trileptal affect the Dexedrine?
>
> Unfortunately as my history shows, after being on top of the world for a couple of days with dexedrine, depakote, and lexapro, the lexapro threw me in to a mixed episode. Then I think that having a mixed episode w/ a stimulant almost throws me in to psychosis.
>
> So that's it w/ antidepressants with me, although they make me so much more personable and social like my normal self.
>
> Any suggestions other than Lamictal or Lithium?
>
> If only these anticonvulsants didn't make me stupid and more depressed.
>
> HHMM. What to do.
>
> Brian
Posted by azalea on October 8, 2008, at 15:17:28
In reply to azalea: How about Trileptal with Dexedrine?, posted by qbsbrown on October 8, 2008, at 15:00:19
Brian,
Wanted to add that it would be ideal to get up to a therapeutic dose on a mood stabilizer AND THEN add-on a stimulant or SSRI if needed. It seems like your mixed episodes may be triggered by starting multiple meds at the same time. If you could get a mood stabilizer on board first, perhaps this would prevent the feel good and then crash cycling pattern from occurring. Just a thought. You might even find that you do quite well on a mood stabilizer alone, especially if Trileptal has stimulant properties.
Best wishes.
Posted by qbsbrown on October 8, 2008, at 15:41:31
In reply to another comment » qbsbrown, posted by azalea on October 8, 2008, at 15:17:28
I agree with your advice. My only problems are that I can't function at my job w/o a stimulant, and all the mood stablizers, including antipsychotics, make my ADD worse, and make working a job very difficult. The only time that I go into mixed moods are usually when i'm taking an antidepressant. Although at times I will still have racing thoughts.
So ideally i'd like to be on a mood stablizer w/ minimal congnitive/personality effects, a stimulant, and possibly someday an SSRI.
It seems like the leading experts in bipolarity are saying in general that antidepressants are destablizing, and not to be used, even after therapeutic doses are reached.
So this is all confusing to me, lol.
I was on 1000mgs of depakote during this last mixed episode. For me to reach a blood "therapeutic" dose, I have to be at about 1750-2000mgs, in which i can't hold a job with.
So it almost comes down to me being stable equals not having a job, or stay hypomanic and work well at a job.
Brian
Posted by qbsbrown on October 8, 2008, at 18:35:55
In reply to another comment » qbsbrown, posted by azalea on October 8, 2008, at 15:17:28
I would generally assume that the antipsychotic would cancel out the stimulant. But I read that Seroquel works on a different dopamine receptor than Dexedrine.
Zyprexa worked well for me, minus the 40 lbs of weight gain. I wonder if the newer Zydis you don't gain as much.
I did well on Zyprexa+Celexa+Provigil combination. I would imagine that I would only do better with substituting dexedrine for provigil. I experience much more concentration, focus, well being, and confidence on dexedrine.
Thanks for the advice.
Regards,
Brian
Posted by azalea on October 9, 2008, at 15:51:04
In reply to azalea: Antipsychotics with stimulants??, posted by qbsbrown on October 8, 2008, at 18:35:55
This gets messy. Here's my understanding (which may be incomplete). Atypical antipsychotics such as Seroquel and Zyprexa block dopamine receptors POST-synaptically. Stimulants like Dexedrine bind to PRE-synaptic dopamine transporters inhibiting reuptake and promoting dopamine release. So it seems like an antipsychotic and a stimulant would cancel out each other. The stimulant will increase dopamine in the synapse but the antipsychotic will prevent this dopamine from binding to the post-synaptic neuron.
With regard to Zyprexa-induced weight gain, I think the Zydis form will cause the same weight gain. Currently, beta-histine is being studied as a potential agent to prevent Zyprexa-induced weight gain. Here's the clinical trial if you're interested in reading more . . .
http://clinicaltrials.gov/ct2/show?cond=%22Body+Weight%22&rank=5Perhaps the decision is which mood stabilizer to use. Lithium and Lamictal are out; Zyprexa worked but caused weight gain; Depakote has cognitive side effects at therapeutic doses for you. So Trileptal or Seroquel seem like good options to consider.
> I would generally assume that the antipsychotic would cancel out the stimulant. But I read that Seroquel works on a different dopamine receptor than Dexedrine.
>
> Zyprexa worked well for me, minus the 40 lbs of weight gain. I wonder if the newer Zydis you don't gain as much.
>
> I did well on Zyprexa+Celexa+Provigil combination. I would imagine that I would only do better with substituting dexedrine for provigil. I experience much more concentration, focus, well being, and confidence on dexedrine.
>
> Thanks for the advice.
>
> Regards,
>
> Brian
Posted by qbsbrown on October 9, 2008, at 17:46:55
In reply to Antipsychotics with stimulants?? » qbsbrown, posted by azalea on October 9, 2008, at 15:51:04
Trileptal had me dumber than a sack of rocks, and depressed. Seroquel will block out the dexedrine.
I think that I'm going to give a therapeutic dose of depakote it's first fair trial, which is 2000mg for me. I spoke to my neurologist and he said i could break it into as many doses as i wanted. So i might try to do 500x4. That way i could just take my dexedrine with it 10mgx4.
Hopefully then after stability, i can add the lexapro and get back on top of the world feeling well like i was last week before slipping into a mixed state.
I appreciate your help.
Regards,
Brian
Posted by azalea on October 9, 2008, at 20:10:30
In reply to Re: Antipsychotics with stimulants??, posted by qbsbrown on October 9, 2008, at 17:46:55
Sounds like a good plan. Keep us posted on how it goes!
> Trileptal had me dumber than a sack of rocks, and depressed. Seroquel will block out the dexedrine.
>
> I think that I'm going to give a therapeutic dose of depakote it's first fair trial, which is 2000mg for me. I spoke to my neurologist and he said i could break it into as many doses as i wanted. So i might try to do 500x4. That way i could just take my dexedrine with it 10mgx4.
>
> Hopefully then after stability, i can add the lexapro and get back on top of the world feeling well like i was last week before slipping into a mixed state.
>
> I appreciate your help.
>
> Regards,
>
> Brian
Posted by qbsbrown on October 9, 2008, at 22:51:35
In reply to Re: Antipsychotics with stimulants??, posted by qbsbrown on October 9, 2008, at 17:46:55
Ok Azalea, now I'm a little worried.
I have an interview, well actually a 2 day job onsite shadow/interview on Tues and Wed.
That gives me 5 days to get stable on the meds (10mg lexapro, 2000 mg depakote, 30mg dexedrine).
So i might need to start the lexapro tomorrow, so it'll be in full effect in 5 days (will make me normal and social, outgoing). If a mixed mood does occur, it would be after those 2 days.
Here's my question though. I need to be at the top of my game for the job.
Depakote gives me the terrible cognitive dulling/slowness, even at 1000mgs. Could I take the 2000mgs for 5 days, which would be a steady serum level, and then SKIP my Tuesday (I'll take mondays early), so hopefully I won't be affected on tue and wed? Perhaps even lower mondays to 1000mgs so I will be clear for Tuesday?
Unfortunately my PDOC is out of town, so it's going to be up to me how to decide this.
I appreciate the advice!
Brian
Posted by azalea on October 10, 2008, at 0:25:56
In reply to Question azalea, posted by qbsbrown on October 9, 2008, at 22:51:35
IMHO, you're asking for trouble starting, stopping, restarting Lexapro, especially with your recent mixed episode.
With regard to Depakote, messing with the dosage and timing of a mood stabilizer defeats the purpose of the ultimate goal of mood stability.
Sometimes, short-term sacrifice is required for long-term success and stability.
While on vacation, your pdoc likely has another pdoc on call.
> Ok Azalea, now I'm a little worried.
>
> I have an interview, well actually a 2 day job onsite shadow/interview on Tues and Wed.
>
> That gives me 5 days to get stable on the meds (10mg lexapro, 2000 mg depakote, 30mg dexedrine).
>
> So i might need to start the lexapro tomorrow, so it'll be in full effect in 5 days (will make me normal and social, outgoing). If a mixed mood does occur, it would be after those 2 days.
>
> Here's my question though. I need to be at the top of my game for the job.
>
> Depakote gives me the terrible cognitive dulling/slowness, even at 1000mgs. Could I take the 2000mgs for 5 days, which would be a steady serum level, and then SKIP my Tuesday (I'll take mondays early), so hopefully I won't be affected on tue and wed? Perhaps even lower mondays to 1000mgs so I will be clear for Tuesday?
>
> Unfortunately my PDOC is out of town, so it's going to be up to me how to decide this.
>
> I appreciate the advice!
>
> Brian
This is the end of the thread.
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