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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 52. This is the beginning of the thread.
Posted by CaptainAmerica1967 on January 11, 2009, at 1:30:55
Good article. Also another one I posted before.
http://www.psychiatricannalsonline.com/showPdf.asp?rID=20772
Posted by JadeKelly on January 11, 2009, at 13:24:41
In reply to MAOI TX in Severe+Resistant Depression, posted by CaptainAmerica1967 on January 11, 2009, at 1:30:55
> Good article. Also another one I posted before.
>
> http://www.psychiatricannalsonline.com/showPdf.asp?rID=20772
>
> http://www.thecarlatreport.com/documents/general/TCR.pdfGreat article!
Thanks for sharing that, I think it will help me with some dosing decisions.
~Jade
Posted by Sissy35 on January 11, 2009, at 17:38:36
In reply to MAOI TX in Severe+Resistant Depression, posted by CaptainAmerica1967 on January 11, 2009, at 1:30:55
I thank you also. The more information the better.
thanks for taking the time
Sissy35
Posted by Phillipa on January 12, 2009, at 0:23:48
In reply to MAOI TX in Severe+Resistant Depression, posted by CaptainAmerica1967 on January 11, 2009, at 1:30:55
I still have two sample boxes of Ensam as my pdoc thought at the time that about a sixth of a patch might work for me. Then she started using it and said to stimulating for me. I was crushed as had wanted a med in patchform to bypass intestional tract. Somehow the price must come down for it to be accessible to all as last posting were talking about it costing up to $500 a month. I did like the part of the article that said if new versions without the risks are developed maois may be used more. Asked about me when saw pdoc and she said she'd only use them in atypical depression which is what article states I think. Please correct me if wrong. But thanks Captain informative. Love Phillipa
Posted by Sissy35 on January 12, 2009, at 0:53:51
In reply to MAOI TX in Severe+Resistant Depression, posted by CaptainAmerica1967 on January 11, 2009, at 1:30:55
I read the articules you suggested they were great and what I already believed to be true.
I was DXed with atypical depression way back in the late 70s and had been useing nardil until recently to switch to parnate.My only question is what is double depression? I have never heard of that.
Great pics on the one site too.Thank you again
Sissy35
Posted by desolationrower on January 12, 2009, at 1:11:18
In reply to Re: MAOI TX in Severe+Resistant Depression » CaptainAmerica1967, posted by Sissy35 on January 12, 2009, at 0:53:51
> I read the articules you suggested they were great and what I already believed to be true.
> I was DXed with atypical depression way back in the late 70s and had been useing nardil until recently to switch to parnate.
>
> My only question is what is double depression? I have never heard of that.
> Great pics on the one site too.
>
> Thank you again
> Sissy35regular depression superimposed over dysthymia. botha are depression, and the dysthymia doesn't really go away just because things go worse.
-d/r
Posted by JadeKelly on January 12, 2009, at 11:56:03
In reply to MAOI TX in Severe+Resistant Depression, posted by CaptainAmerica1967 on January 11, 2009, at 1:30:55
> Good article. Also another one I posted before.
>
> http://www.psychiatricannalsonline.com/showPdf.asp?rID=20772
>
> http://www.thecarlatreport.com/documents/general/TCR.pdfHi Capt' Jeff,
wondering if I could get your opinion. I know you coorespond with a Doc in NY re tr/mdd and his first trials (or best trials) involve MAOI + tca or stim + lithium. Iv'e been on 60mg for 4 weeks, 10mg ritalin for 3 1/2 weeks, low dose lithium (doesnt agree with me) maybe a week. I've been on Parnate a total of 3 months. I had a ten day period in December that felt like remission. It started the second day I was on 5mg Ritalin. When it faded I added 5mg rit (total 10mg) and it didn't come back. I do get small A/D boost but not close to where I was.
Any ideas as to my next move? Increase Parnate seems like its time, not sure about safety of raising ritalin to 15mg. Can't find dosing info on that anywhere. Any suggestions would be most appreciated!
Thanks,
~Jade
Posted by CaptainAmerica1967 on January 12, 2009, at 14:44:22
In reply to Re: MAOI TX in Severe+Resistant Depression » CaptainAmerica1967, posted by Phillipa on January 12, 2009, at 0:23:48
Unfortunately, I don't think selegiline in pill form (I had tried it at a dosage of 40-60mgs when it first came out) or patch will ever be effective in treating severe depression as it's primarily an MAOI type B inhibitor and type B mainly works on dopamine and phenylethylamine (the bodies natural aphrodisiac). It did boost my sex drive.
The other reversible MAOI's like moclobemide isn't very effective in my opinion either even though it's a type A, it is very weak, and is a short-acting. It did nothing for me.
Unfortunately, the drug companies cannot get past the fact that they should be working on making better MAOIs like Parnate, Nardil and Marplan, but they continue to focus on the reversible ones that they think the physicians will feel more comfortable in prescribing having less potential for a hypertensive crisis or serotonin syndrome. There's a new reversible MAOI going through clinical trials called Tyrima, but will probably be as only as effective as moclobmide.
(http://www.neurotransmitter.net/newdrugs.html)However, were the drug companies to develop medications like Parnate and Nardil in the patch form, they most likely would sell very well.
Posted by CaptainAmerica1967 on January 12, 2009, at 15:11:28
In reply to Re: MAOI TX in Severe+Resistant Depression » CaptainAmerica1967, posted by Sissy35 on January 12, 2009, at 0:53:51
"Double Depression" is basically is major depression coupled with something called dysthymia. Dysthymia is considered to be a "chronic depression" and sometimes a low grade depression or mild one although the low grade may not be true.
So you have a life long chronic depression (dysthymia) and then get symptoms or eipsodes of an even worse depression (major depression) and it's called doulbe depression. However, if you have treatment resistant depression your entire life (like myself since the age of 15) and your depression is chronic anyways, you still can get episodes of depression being more severe so I'm not sure how they distinguish the double depression from treatment resistant depression unless the dysthymia was diagnosed in childhood or early adulthood.
Posted by CaptainAmerica1967 on January 12, 2009, at 15:39:50
In reply to Re: MAOI TX in Severe+Resistant Depression » CaptainAmerica1967, posted by JadeKelly on January 12, 2009, at 11:56:03
I think the best choice may be to increase the Parnate dose. As you can see from the article, they've used up to 120mgs of Parnate, and I think there was a clinical trials where they tried up to 120mg of Parnate and if that dose failed then they added Dexedrine (40mgs) and if that failed they added thyroid. You may have to experiment a bit with your physician on dosages and increase the Parnate; if it doesn't work maybe increase the TCA or try another TCA or trazodone or remeron (both suppose to be ok with MAOI according to the MAOI psych guru in other article); if the Ritalin isn't helping at the increased dose maybe try a different stimulant like Adderall or Dexedrine.
I take 80mgs of Parnate and a small dose of Lithium Orotate (over the counter), and gave up the nortriptyline (side effects of dry mouth during my workouts was just too much) and instead use amineptine (dopamine TCA with no adverse side effects except energy and libido enhancement), but may try a small dose of trazodone (to help me sleep plus serotonin effects) and reboxteine (norepinephrine reuptake inhibitor which I tried two years ago while on Cymbalta, but haven't used with an MAOI yet).
Good luck,
Jeff
...have you tried cold showers for mood enhancement?
Posted by JadeKelly on January 12, 2009, at 16:34:33
In reply to MAOI TX in Severe+Resistant Depression, posted by CaptainAmerica1967 on January 12, 2009, at 15:39:50
> I think the best choice may be to increase the Parnate dose. As you can see from the article, they've used up to 120mgs of Parnate, and I think there was a clinical trials where they tried up to 120mg of Parnate and if that dose failed then they added Dexedrine (40mgs) and if that failed they added thyroid. You may have to experiment a bit with your physician on dosages and increase the Parnate; if it doesn't work maybe increase the TCA or try another TCA or trazodone or remeron (both suppose to be ok with MAOI according to the MAOI psych guru in other article); if the Ritalin isn't helping at the increased dose maybe try a different stimulant like Adderall or Dexedrine.
>
> I take 80mgs of Parnate and a small dose of Lithium Orotate (over the counter), and gave up the nortriptyline (side effects of dry mouth during my workouts was just too much) and instead use amineptine (dopamine TCA with no adverse side effects except energy and libido enhancement), but may try a small dose of trazodone (to help me sleep plus serotonin effects) and reboxteine (norepinephrine reuptake inhibitor which I tried two years ago while on Cymbalta, but haven't used with an MAOI yet).
>
> Good luck,
>
> Jeff
>
> ...have you tried cold showers for mood enhancement?Hi Jeff,
Thanks for answering my post. I promise my next shower will be a cold one. I'll report back to you tomorrow with my results!
Btw- I'm not taking a TCA, just Parnate, Ritalin, Klonopin, and 225mg Lithium. I really like Ritalin, I took it for years for ADD. What I really wanted to know is what a safe dose of Ritalin would be combined with 70mg Parnate. I currently take 10mg Ritalin. Would 15mg be safe?
Posted by sissy35 on January 12, 2009, at 17:00:41
In reply to Re: MAOI TX in Severe+Resistant Depression » CaptainAmerica1967, posted by JadeKelly on January 12, 2009, at 16:34:33
Who is going to take away my goose bumps. burrrrr
sissy35
Posted by JadeKelly on January 12, 2009, at 17:41:38
In reply to Re: MAOI TX in Severe+Resistant Depression » JadeKelly, posted by sissy35 on January 12, 2009, at 17:00:41
> Who is going to take away my goose bumps. burrrrr
>
> sissy35Sissy, I don't think you're depressed enough to resort to cold showers are you? And it's not just one!! As to who is going to take away your goose bumps....I'll get working on that (Me first tho)
~Jade tlj*
Posted by CaptainAmerica1967 on January 12, 2009, at 18:52:15
In reply to Re: MAOI TX in Severe+Resistant Depression » CaptainAmerica1967, posted by JadeKelly on January 12, 2009, at 16:34:33
I would expect that 15mgs of Ritalin would be safe as it's not much different than 10mgs.
Here's another aritcle from PsychTropical Research that says there's never been a death using MAOIs and Ritalin together as Ritalin really doesn't have any serotonin effects just noradrenaline.
http://www.psychotropical.com/CNS_stimulants_with_MAOIs.shtmlMethylphenidate and MAOIs have been in use together for 40 years, so it would be surprising if someone had not ingested the combination by now: death, or morbidity, from such an event has not been reported (whereas it has with amphetamine). Methylphenidate is most widely used as a treatment for attention-deficit hyperactivity disorder (ADH) in children. It has been supposed to have serotonergic effects; if that is so it would be predicted to be at high risk of precipitating serotonin toxicity if combined with MAOIs. There are no definite case reports indicating serotonin toxicity with methylphenidate in combination with MAOIs, or other serotonergic drugs (see above) [17-20].
Also, as with mirtazapine and amitriptyline, methylphenidate does not produce serotonergic side effects, or signs of serotonergic toxicity in over-dose or if combined with MAOIs (see Markowitz). Eg the Sherman case was not serotonin toxicity, but blood pressure elevation [21-28].
These observations of serotonergic side effects, and signs of serotonergic toxicity in over-dose, or if combined with MAOIs, have been proposed as a measure of a drugs clinically significant serotonergic effect in humans. If these effects are not produced clinically significant serotonergic effects are unlikely. [29-32].
Methylphenidate also appears safe in combination with MAOIs; see Feinbergs recent and helpful review of MAOIs and CNS stimulants.[1-33-35].
This is in keeping with its negligible 5-HT transporter affinity (>10,000 nmol) and apparent inability to raise brain serotonin levels. Unfortunately Rothmans data does not include methylphenidate so there is no releaser potency data. If methylphenidate acts as a releaser in humans then it would be predicted that its effect would be lessened by selective serotonin reuptake inhibitors (SSRIs)s [21-23-36].
Amphetamine
Amphetamine and MAOIs have also been in use together for 40 years and there are few deaths from apparent serotonin toxicity reported with amphetamine. Amphetamine has weak serotonergic effects; and there seems little risk of precipitating serotonin toxicity if combined with MAOIs. All the case reports with MAOIs and Amphetamine were prior to 1969. The only fatalities have been with MAOIs [37-44].
Amphetamine itself does not seem to produce typical serotonergic side effects, or signs of serotonergic toxicity in over-dose, except hyperreflexia, hyperkinesia (agitation) and hyperpyrexia. Deaths from hyperpyrexia and other causes, but without classic features of serotonin toxicity, have been described. [45-46].
Amphetamine may not be safe in combination with MAOIs (see Feinbergs and Markowitzs recent and helpful reviews of MAOIs and CNS stimulants). It seems to produce noradrenergic toxicity; presumably in the same way as tyramine does, by acting as a releaser. None of these cases were reported to exhibit features that would suggest serotonin toxicity. Several of these cases were fatalities (2 of these below are not cited in the Markowitz paper) [38-41-44].
However, chlorpromazine appears to ameliorate the toxicity symptoms with amphetamine / MAOI as it does with serotonin toxicity.[47].
Amphetamine is 50-100 times less potent for serotonin, both as a releaser and reuptake inhibitor, than for dopamine or noradrenaline (see table). Its 5-HT transporter affinity (~3800 nmol) is extremely weak. However, unlike methylphenidate there is animal work indicating amphetamine does increase serotonin levels [9-22].
In summary, amphetamine definitely has been involved in deaths with MAOIs, and exhibits significant toxicity with venlafaxine (probably serotonin toxicity, as opposed to noradrenergic toxicity). To what degree the toxicity with MAOIs is serotonergic remains uncertain, but most fatalities have been from intra-cerebral bleeding, not serotonin toxicity [2].
If CNS stimulants are to be used to augment monoamine oxidase inhibitors methylphenidate is probably safe; amphetamine is more risky, and can produce moderate noradrenergic toxicity, even at therapeutic doses and perhaps serotonergic side effects, and even serotonin toxicity in over-dose.
MDMA (Ecstasy) 3,4-methylenedioxymethamphetamine
Ecstasy is the street name for 3,4-methylenedioxymethamphetamine (MDMA). Large doses of MDMA cause a rapid release of endogenous serotonin from the stores in the presynaptic nerves; so much so that a substantial MDMA dose will deplete about eighty percent of the serotonin stores. The "half life" of endogenous serotonin is short and the usual duration of symptoms does not frequently allow the development of hyperthermia, although this is influenced by ambient temperature and physical activity.[48-49]
MDMA will occasionally produce, among other things, a picture which is essentially that of serotonin toxicity; however serotonin toxicity sufficiently severe to cause death with MDMA alone is rare.
However such reports as do exist conform with predictions from the spectrum concept of serotonin toxicity and the data in Rothman (see table). No cases of serotonin toxicity with MAOIs had been reported in the literature till 2003. There have been one or two cases where people taking moclobemide, presumably to enhance effects, have been too successful and have experienced severe reactions. I know of one death (unpublished) seemingly from cerebral infarction secondary to arterial spasm. The Vuori report is of four deaths, probably from serotonin toxicity [50].
Posted by CaptainAmerica1967 on January 12, 2009, at 19:10:33
In reply to Re: MAOI TX in Severe+Resistant Depression » sissy35, posted by JadeKelly on January 12, 2009, at 17:41:38
Cold showers work for me, but it doesn't mean it'll help everyone and it may be tough to force yourself to take cold showers. It's kind of like those that are really depressed find it hard to force themselves to work out or exercise to get the benefits from it both short term and long term (increases nerve growth).
Here's one article on the cold shower for depression from Discovery.
http://dsc.discovery.com/news/2007/12/18/depression-cold-shower.html
Posted by sissy35 on January 12, 2009, at 19:24:04
In reply to MAOI TX in Severe+Resistant Depression, posted by CaptainAmerica1967 on January 12, 2009, at 19:10:33
Didn't they use the cold water baths in the so called asyulums years and years ago? Or am I off on this?
Sissy
Posted by CaptainAmerica1967 on January 12, 2009, at 19:54:56
In reply to Re: MAOI TX in Severe+Resistant Depression » CaptainAmerica1967, posted by sissy35 on January 12, 2009, at 19:24:04
Well, in instituitional patients when psychiatry was becoming a science prior to drilling holes in one's head to release the demons, they didn't use cold showers, but experimented some extracts of some plant based medicines (like rauwolfia serpentina or reserpine..used for blood pressure, reduces agitation, but causes depression) and eventually newer medicines (note Freud used cocaine both personally for himself and his patients..it works but long term effects weren't good..it was even in the original Coca Cola).
The earlier smarter practitioners used cold water therapy (rivers, lakes), exercise, certain herbs as well as having their patients bath in lithium rich streams.
Posted by Phillipa on January 12, 2009, at 20:09:00
In reply to MAOI TX in Severe+Resistant Depression, posted by CaptainAmerica1967 on January 12, 2009, at 14:44:22
Definitely a patch as pschologically for me can see it and hence if bad reaction remove even if intellectually know the med is still active in body but it's the knowing it's gone so to speak is a way to help my med phobia. Also both Shawn and JR Becker post here occasionally. Love Phillipa
Posted by sissy35 on January 12, 2009, at 20:31:08
In reply to MAOI TX in Severe+Resistant Depression, posted by CaptainAmerica1967 on January 12, 2009, at 19:54:56
I live in NY near Clifton Springs. Many famous people used to come here for the sulfer baths including Elvis and Betty Davis She left a baby girl here that was less than perfect. It was at that time supposed to heal all types of ills. The psycharitic unit was just next door. Still is. So there have been a lot of attempts to help. You can keep the lobadamy. I would go for deep brain stimulation first.
Better than goose bumps lol
Sissy35
Posted by JadeKelly on January 12, 2009, at 20:42:52
In reply to MAOI TX in Severe+Resistant Depression, posted by CaptainAmerica1967 on January 12, 2009, at 18:52:15
Wow,
Thanks for the response. I'm going to be the resident expert on Amphetamines and MAOI's when you're not around! Well, I feel okay about raising my ritalin then. Not sure what the New York Doc you've talked about uses as stim with MAOI but I'm assuming now its something like Ritalin.
Thanks!
~Jade
Posted by sissy35 on January 12, 2009, at 20:54:22
In reply to Re: MAOI TX in Severe+Resistant Depression » CaptainAmerica1967, posted by JadeKelly on January 12, 2009, at 20:42:52
Jade I used provigil for a long time with nardil.
Tried it with parnate couple of times and no ill effects.Sissy
Posted by JadeKelly on January 12, 2009, at 21:02:09
In reply to e: MAOI TX in Severe+Resistant Depression » JadeKelly, posted by sissy35 on January 12, 2009, at 20:54:22
> Jade I used provigil for a long time with nardil.
> Tried it with parnate couple of times and no ill effects.
>
> SissyHi Sissy, yep, I think they do use that alot too, I tried it once, the only kind of stim that agrees with me is Ritalin.
Jade tlj*
Posted by CaptainAmerica1967 on January 13, 2009, at 0:23:06
In reply to Re: MAOI TX in Severe+Resistant Depression » CaptainAmerica1967, posted by sissy35 on January 12, 2009, at 20:31:08
I live in Houston and tried getting into a DBS study in Dallas and qualified as far as refractory ( over 70 ECT's when I was 19, have tried over 50 psychotherapeutic drugs), but because I had some seizures while on trazodone, I was excluded.
Psychopharmacology is still the best treatment in my opinion.
Posted by Cseagraves on January 13, 2009, at 16:39:32
In reply to MAOI TX in Severe+Resistant Depression, posted by CaptainAmerica1967 on January 12, 2009, at 15:39:50
Hi Captain!!
Am thinking about trying parnate. Have put several posts on here asking about others experiences with parnate. Read both of the articles you posted also.
When I asked my pdoc about parnate he said the rule is that you have to be off all ssri's two weeks prior to beginning. When I asked him about trazodone, he told me I had to be off that also.
I was going to take remeron to help me get through anxieties the next two weeks. Is remeron O.K.?
My biggest concern is my BP. It's controlled with BP med, and while my systolic usually runs between 120-130, my diastolic usually runs between 80-90. Maybe I need a stronger BP med after starting on parnate?? Or should I just monitor it closer while beginning parnate. In your opinion, what is the best thing to do if I see my BP starting to go up or down? I have already informed my GP about parnate and had a full heart work-up about a month ago. Everything came back fine.
Do you find that people with generally high BP have as many problems with hypo-tension? Can I still run and weight train while taking parnate?
I realize that this is something that I will have to monitor closely, but am willing to try the parnate since all other ssri's have failed. (I seem to be very sensitive to them.)Have you or anyone else here on parnate ever gotten to the point of being stable on a regular basis? I know that the first couple of months can be unstable, but as far as being in remission, I would just like to know that with this med I might have a chance at feeling good for a long period of time.
Any advice would be greatly appreciated.
Thanks!!!
Courtney
Posted by CaptainAmerica1967 on January 13, 2009, at 20:32:11
In reply to Re: MAOI TX in Severe+Resistant Depression, posted by Cseagraves on January 13, 2009, at 16:39:32
Hi Courtney,
Yes, the general rule is that you need to be off any SSRI, SNRI for two weeks although the times I went onto-off MAOIs (Tofranil to Nardil...Effexor to Nardil..Nardil to Cymbalta...Cymbalta to Parnate), I never did a washout and started the next day without any problems. Tricyclics are safe with MAOIs too.
According to the psychiatist who is the "guru" on MAOIs I posted earlier, he transitions his patients to MAOI's (if they're on an ssri or snri) by putting them on either trazodone or remeron and building them up and has never had any problems.
I'd just moniter my BP when starting the Parnate if I had BP problems. It may go up or down temporarily, but will probably stabilize after a while. I cannot speak for others, but the MAOI's have generally braught my BP down, and I haven't had any ill effect on my exercising for both my cardiovascular and weight lifting training. When I used Nardil it did cause more hypotension that Parnate and after a heavy squat lift I may have become a little dizzy, but Parnate causes less of this.
I cannot answer for others about how they've responded as far as being stable and in remission. I can tell you my own experience though. I'm 41y/o and my depression started at the age of 15y/o. Out of the twenty-six years I've had treatment resistant depression and out of all the treatments I received (70 ECT, 50 some odd meds, other odd treatment attempts), I have been the most stable on MAOIs although I've had my trying times, but at least I was functionable. I guess I could say remission in a sense that my life was functionable, but the depression has never fully went into remission except two different summers when I exercised three times a day and felt so great that I thought the depression was gone for good until I stopped exercising three times a day and the depression returned.
Hope this helps,
Jeff
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