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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 20 of 20. This is the beginning of the thread.
Posted by Girlnterrupted78 on March 11, 2009, at 21:46:13
I will make this as brief as possible.
I have suffered from depression, social anxiety and anger problems ever since I was about 3-4 years old.
I am extremely sensitive to criticism and I am very uncomfortable in social situations. I have a lack of happiness where I can't smile unless I'm laughing at something funny, but for the most part it's VERY hard for me to smile. I also get angry very easily and my defense mechanisms are now taking over my whole life. So besides being anxious and depressed, I'm also sabotaging myself with all the (pathological?) mechanisms employed to deal with the distress of depression/anxiety.
I have tried several of AD's: Paxil, Zoloft, Celexa, Lexapro, Effexor, Nardil, Abilify, Lithium, Wellbutrin.
The single ONLY one that worked WONDERS was Celexa (and to some extent Adderall--but only for like a month.)
Celexa changed my life for a whole year. I was smiling literally every second, talking to everyone all the time, dating, meeting new people, etc. I was super creative and funny very naturally and spontaneously. I feel that was probably the "real" me, (when my personality was not clouded and flooded with depression and anxiety.) But Celexa pooped out after 1 year. Nothing has worked ever since.
Now my doctor doesn't know what to try next. I don't know either. Based on my chemistry, it seems like my problem is dopamine. But I tried Nardil precisely for that, and it didn't work. Yet adderall (a dopaminergic agent, I think) was great.
I feel like AD's worked for a small period of time, and somehow messed up my chemistry, which is now beyond treatment (that's my speculation, based on my failure to respond to any further treatment.) But I don't want to lose hope and I wonder if anyone here has any idea on what could I try next that might kickstart my production of dopamine (or serotonin, whichever is missing.)
Please give me any suggestions. My doctor is going to prescribe Prozac (since it's the only SSRI I never tried) but I'm not overly excited about it. Are there any successful treatments for social anxiety and depression, anger, sensitivity, etc? It just seems impossible to treat.
What else is there out there?
Any info would be greatly appreciated.
Posted by myco on March 11, 2009, at 22:20:01
In reply to What medication should I try after all has failed?, posted by Girlnterrupted78 on March 11, 2009, at 21:46:13
Hi,
Don't give up on Celexa yet...can you go back? Talk to your doctor about "augmenting" celexa...adding a small bit of another medication. Celexa being almost exclusively an SSRI, to my knowledge, can be augmented with other meds that play on dopamine and norepinephrine to give you added and different effects than celexa alone could ever do. People who suffer bad anxiety (myself included) find success with meds that play with dopamine to some extent. I would suggest something like amitriptyline (a tca) to start (take it at night - will also help your sleep)...or something similar. There are many augments to play with...and I bet you 10-1 that you will find an augment that brings back, at least some of, the effective you once found with celexa.
Don't give up...the fact that you had that one great med experience (something many of us never find) is an indication you are on the right path...don't ditch that med until youve "toyed" with it or adjusted it by adding trials of small doses of augments.
keep smilin,
myco---------------------------
>Celexa changed my life for a whole year. I was smiling literally every second, talking to everyone all the time, dating, meeting new people, etc. I was super creative and funny very naturally and spontaneously. I feel that was probably the "real" me, (when my personality was not clouded and flooded with depression and anxiety.) But Celexa pooped out after 1 year. Nothing has worked ever since.
Posted by elanor roosevelt on March 11, 2009, at 23:16:17
In reply to What medication should I try after all has failed?, posted by Girlnterrupted78 on March 11, 2009, at 21:46:13
I am so sorry to hear that the celexa stopped working for you. The same thing happened to me. A great time feeling "like me on a good day"
by far the best experience i have had with medsif you figure a way to make it work again
make sure i hear about it pleasehang in there
oh, did you try switching to lexapro? i got a bit more time that way
Posted by Phillipa on March 11, 2009, at 23:38:45
In reply to Re: What medication should I try after all has fai, posted by elanor roosevelt on March 11, 2009, at 23:16:17
I saw lexapro on the list. How long ago were you on it it could work now? Phillipa
Posted by desolationrower on March 12, 2009, at 10:41:54
In reply to What medication should I try after all has failed?, posted by Girlnterrupted78 on March 11, 2009, at 21:46:13
did you have anger problems as a kid? were you ever diagnosed with ADD? did the adderal lose benefit for mood symptoms only or everything? have you tried any anticonvulsants?
-d/r
Posted by polarbear206 on March 12, 2009, at 15:23:51
In reply to What medication should I try after all has failed?, posted by Girlnterrupted78 on March 11, 2009, at 21:46:13
With your history and the multiple AD failures, I'm surprised you only mention lithium. Perhaps you need to explore other mood stablizers to add on with your AD. Celexa with lamictal or depakote would be a start. Go to psycheducation.org
Posted by bleauberry on March 12, 2009, at 15:39:21
In reply to What medication should I try after all has failed?, posted by Girlnterrupted78 on March 11, 2009, at 21:46:13
Well, ask this question of 10 doctors and you'll get 10 different opinions.
I would say do things from other classes of meds that you have not done.
For example, if it is to be Prozac, then match it up with 5mg Zyprexa. Don't try to figure it out scientifically, ya know, the dopamine thing or whatever. That kind of armchair quarterbacking doesn't work, as you saw with celexa. There was no reason it should have worked, but it did. Just know Prozac+Zyprexa is a special combination.
Or return to Celexa and try adding Abilify to it first, zyprexa second if that fails, with risperdal on the back burner.
More common things would be to add lithium or buspar or ritalin.
Me personally, I've experienced and see some good things with SSRIs + antipsychotics. It is just a matter of finding the right two.
My two cents worth.
Posted by Zyprexa on March 12, 2009, at 18:00:50
In reply to What medication should I try after all has failed?, posted by Girlnterrupted78 on March 11, 2009, at 21:46:13
Have you tried uping the dose on celexa. Thats what I found worked. Also zyprexa is a great med to take with celexa. It will work on the dopamine. Its also good for your other simptoms.
If thats not good. They say adding abilify to an anti-depressant is good for making it work better. Abilify is also good on dopamine.
Posted by myco on March 12, 2009, at 19:07:10
In reply to What medication should I try after all has failed?, posted by Girlnterrupted78 on March 11, 2009, at 21:46:13
Youre getting good advice here from all. Definately consider celexa again...it was successful for you. That in itself is a good indication it can work again if you toy around with augments with your doctor. :o)
Wish I had a good response to an SSRI...they never worked for me
Posted by softheprairie on March 13, 2009, at 1:16:42
In reply to What medication should I try after all has failed?, posted by Girlnterrupted78 on March 11, 2009, at 21:46:13
Some here at psychobabble have talked about memantine (Namenda) being added to a stimulant to keep tolerance from developing (on the stimulant), although I'm not sure how established the evidence for that is. But, if what made the Adderall only help for ~a month was tolerance, maybe you could try Celexa + (Adderall OR Concerta) + memantine. (I think I preferred Concerta over generic mixed amphetamine salts.)
Perhaps also a mood stabilizer, as others mentioned.
Posted by Cseagraves on March 13, 2009, at 19:08:33
In reply to What medication should I try after all has failed?, posted by Girlnterrupted78 on March 11, 2009, at 21:46:13
Hi There!
Good advice here from everyone girlinterrupted. I swear I learn more from these people than you could ever find in any medical book.
I have taken pretty much the same meds as you except an maoi, which I tried for four days and it made me terribly sick. So I started wondering what exactly is going on chemically in my head also.
I have SAD, GAD, PTSD and agoraphobia. And thanks to a real mean father, I grew up with major anger issues also. Just know you are not alone.
Good to see what was posted here. I asked doctor today to go back and try zoloft again. I have never tried celexa, but I know that 8 years ago when I started taking Zoloft, it was primarily geared toward extreme anxiety, depression and phobias.
After a couple of years I came off. Then when I tried to go back on around this time last year, did not get the same effect. But I am wanting to give it another shot. Started the usual regimen of 25 mgs. yesterday and can already feel a lift. Maybe it will help this time.
I never knew you could combine a antipsych med with an ssri. THANKS GUYS!!! That makes me feel better knowing that if I can't get rid of the anxieties with zoloft alone, that I can add something to help. (I have tried Serorquel and hated it) What other antipsych med would be adivised with zoloft I wonder?
I am assuming that the psychmed would be a pretty low dose with an ssri? Does anyone know which one of the psychmeds is considered the mildest?
I hope that out of all of the information you find on here, you find something that works. Don't know if you tried CBT, but I started that last week also. People have been suggesting it for years, but I always thought I could handle this on my own.
Studies do show that CBT combined with meds show better results than doing either one alone. Might be worth a shot.
Keep smilin :-))))
Courtney
Posted by Jeroen on March 14, 2009, at 16:47:02
In reply to What medication should I try after all has failed?, posted by Girlnterrupted78 on March 11, 2009, at 21:46:13
hi, Try Seroquel 100 mg twice or 3 times a day start with 25 mg each day twice or 3 times daily
after 2 weeks if it works, you will hopefully feel better
it worked wonders for me for few months too
Posted by Girlnterrupted78 on March 15, 2009, at 21:39:46
In reply to Re: What medication should I try after all has failed? » Girlnterrupted78, posted by myco on March 11, 2009, at 22:20:01
"Don't give up on Celexa yet...can you go back? Talk to your doctor about "augmenting" celexa...adding a small bit of another medication."
Thanks for the info. I'm still on Celexa. I already tried augmenting with Lithium and with some thyroid med. They didn't work. The first time around Celexa relieved my symptoms at about a 90%. Now it barely does a 20%.
Also, after taking Nardil for 1 year, I returned to Celexa and now it gives me "bauxism" -- a term my psychiatrist gave me, which means I get terrible jaw tension all day and night time teeth grinding. I didn't have that at all during the first 5 years on Celexa. Now, just after Nardil, it is a MAJOR side effect and it's unbearable. I had to go down to about 10mgs a day, from originally being on 40mgs.
"I would suggest something like amitriptyline (a tca) to start (take it at night - will also help your sleep)...or something similar. There are many augments to play with...and I bet you 10-1 that you will find an augment that brings back, at least some of, the effective you once found with celexa."
I will mention this to my doctor next time I see him. The only problem might be the bauxism. I can only take 10mgs of Celexa. Might not be a therapeutic dose.
"Don't give up...the fact that you had that one great med experience (something many of us never find) is an indication you are on the right path..."
Thanks a lot.
Posted by Girlnterrupted78 on March 15, 2009, at 22:08:15
In reply to Re: What medication should I try after all has fai, posted by elanor roosevelt on March 11, 2009, at 23:16:17
"oh, did you try switching to lexapro? i got a bit more time that way"
Yeah, that was the biggest mistake ever. Lexapro was what made Celexa stop working. I went on Lexapro straight from Celexa and within days I was more depressed than ever and crying for no reason.
I had stopped Celexa in other occasions because I had ran out, and it never stopped working. I had been off it for 2+ weeks without a problem. But when I went on Lexapro, then it was truly the end of it. It never worked again. Whatever Lexapro did, it just ruined it.
Lexapro was a nightmare.
Thanks.
Posted by Girlnterrupted78 on March 15, 2009, at 22:13:57
In reply to Re: What medication should I try after all has fai, posted by Phillipa on March 11, 2009, at 23:38:45
"I saw lexapro on the list. How long ago were you on it it could work now? Phillipa"
For about 10 days. It was the worst nightmare. I went from feeling super happy to crying every second. I had to stop it because it was affecting my daily life (school and work).
Posted by Girlnterrupted78 on March 16, 2009, at 13:38:26
In reply to Re: What medication should I try after all has failed?, posted by desolationrower on March 12, 2009, at 10:41:54
"did you have anger problems as a kid?"
Yeah, always had them."were you ever diagnosed with ADD?"
Sort of. But only until college, where I had trouble concentrating and getting work done.
"did the adderal lose benefit for mood symptoms only or everything?"
For everything. It became useless in every way."have you tried any anticonvulsants?"
Only Clonazepam. I also built tolerance to it and eventually felt I'd had to up the dose. It doesn't help my social apathy, though, so it only solves 10% of the problem.Thanks
Posted by Girlnterrupted78 on March 16, 2009, at 13:40:49
In reply to Re: What medication should I try after all has failed?, posted by polarbear206 on March 12, 2009, at 15:23:51
"Celexa with lamictal or depakote would be a start. Go to psycheducation.org"
Thanks. I will suggest this to my doc. Most of my doctors seem very apathetic, don't want to try anything else. I go to clinics cause I can't afford private practice, so they just want to keep me on safe/easy meds, even if they don't work.
Posted by metric on March 16, 2009, at 17:29:27
In reply to What medication should I try after all has failed?, posted by Girlnterrupted78 on March 11, 2009, at 21:46:13
> The single ONLY one that worked WONDERS was Celexa (and to some extent Adderall--but only for like a month.)
>
> Celexa changed my life for a whole year. I was smiling literally every second, talking to everyone all the time, dating, meeting new people, etc. I was super creative and funny very naturally and spontaneously. I feel that was probably the "real" me, (when my personality was not clouded and flooded with depression and anxiety.) But Celexa pooped out after 1 year. Nothing has worked ever since.
>
> Now my doctor doesn't know what to try next. I don't know either. Based on my chemistry, it seems like my problem is dopamine. But I tried Nardil precisely for that, and it didn't work. Yet adderall (a dopaminergic agent, I think) was great.
>Hi Girlnterrupted,
IMO, all of the "antidepressants" suck and require some form of augmentation -- if they are to be used at all. Your lackluster response to traditional antidepressants is not surprising; whether they are more effective than placebo has been a matter of considerable debate in the medical scientific community.
You mentioned Adderall worked great for a while. Were you taking anything else with it? How much Adderall were you taking when it stopped working?
As I commented to someone else in another thread, I think dextroamphetamine (Dexedrine, DextroStat) is a better choice of stimulant than Adderall. Adderall is composed of a mixture of both dextro and racemic amphetamine salts. Since levo-amphetamine has more pressor and less central activity than its dextro counterpart, d-amphetamine has a more favorable ratio of CNS/ANS stimulation (i.e., pure d-amphetamine should cause less jitteriness per unit of mental stimulation than Adderall, and be less cardiotoxic). Doctors seem to prefer Adderall more for political reasons, but there is no rational basis for him/her to keep you from switching to d-amphetamine if so desire. DextroStat sounds less sinister than Dexedrine, so it might be expedient to mention the former if brand names are mentioned.
Some people find that low-dose selegiline can restore/maintain the effectiveness of CNS stimulants such as d-amphetamine or methylphenidate, but the combination should be approached very carefully (selegiline inhibits the metabolism of catecholamines). A low dose of mirtazapine (Remeron) at night can help with sleep and counter excessive stimulation. If this is attempted, I'd only add selegiline when/if the stimulant loses effectiveness.
You've tried Nardil. What about tranylcypromine (Parnate)? Have you tried them with stimulant augmentation?
Have you tried Modafinil?
Benzodiazepines: have you tried alprazolam (Xanax) and/or clonazepam (Klonopin). They sometimes work for depression as well as anxiety, but this seems to require considerably higher doses than most shrinks typically prescribe. There's some evidence that tolerance to the sedative effect of benzodiazepines develops to a disproportionately greater degree and/or rate than tolerance to the anxiolytic effect, which of course is a desirable scenario. Unfortunately, I can't comment on the strength of that evidence.
Are you taking an AD currently? SSRIs often cause terrible fatigue and emotional numbness (this usually develops over time and sometimes insidiously).
Posted by desolationrower on March 17, 2009, at 2:57:15
In reply to Re: What medication should I try after all has fai » Girlnterrupted78, posted by metric on March 16, 2009, at 17:29:27
well, you don't seem to have tried a tca; wellbutrin sort of enhances norepinepherine, but i don't think its really comparably. i'd give one a go.
There are some similarities of valproate to nardil (in how they raise gaba levels), so since nardil didn't seem to work (hopefully you got up to a high dose?), i might hold off on that, it has some side effects, especially for girls; it is quite good for irritability, and can help anxiety.
I think clonidine/guanfacine are good medicines; they have pretty mild side effects, are cheap, and as long as a doc is open to suggestions, they aren't too hard to get. they can help with adhd symptoms, and tend to be more calming.
topiramate also has some evidence for social anxiety and controlling irritability. it can make you stupid, but it won't make you fat.
I agree it is frustrating when things stop working. One of my theories is that underlying poor health makes it less likely ADs will work; vitamin d3 and magnesium/zinc come to mind b/c of their interaction with the dopaminergic and nmda systems, respectively. it could be i focus on my health because its easier than fixing my head.
one thing - bruxism afaik is associated with hypersensitivity to dopamine. i think it also is more common in stage 1&2 sleep, so maybe a sleep drug would help, one that increased deep sleep. there was a report of gabapentin used to treat it.
it is frustrating when doctors seem reluctant to treat your condition
-d/r
Posted by myco on March 17, 2009, at 18:43:39
In reply to Re: What medication should I try after all has fai, posted by desolationrower on March 17, 2009, at 2:57:15
-----------------------------
I think your theory is truth actually d/r...there seems to be support in the literature for it. One example I just came across is a study (have yet to go to the Univ to copy it) that indicates people who have high levels of cortisol in them prior to phenylzine treatment demonstrate a higher failure rate.
-----------
J Clin Psychiatry. 1987 Dec;48(12):480-2.Pretreatment dexamethasone suppression test as a predictor of response to phenelzine.
Janicak PG, Pandey GN, Sharma R, Boshes R, Bresnahan D, Davis JM.
Illinois State Psychiatric Institute, Chicago.
Twenty inpatients who met Research Diagnostic Criteria and DSM-III criteria for depression underwent a 2-week washout period before the administration of a pretreatment dexamethasone suppression test (DST); the patients then received the monoamine oxidase inhibitor (MAOI) phenelzine. The mean MAO inhibition level achieved during treatment was greater than 80%. On the basis of clinical global evaluation and changes in Hamilton Rating Scale for Depression scores, 7 of the 9 baseline DST suppressors were classified as responders, 1 as a partial responder, and 1 as a nonresponder; of the 11 baseline DST nonsuppressors, 3 were responders, 1 a partial responder, and 7 nonresponders. The Mann-Whitney U test yielded p less than .02, indicating that an abnormally high pretreatment level of cortisol in response to the DST appeared to be predictive of nonresponse to phenelzine.
-----------------------------
>One of my theories is that underlying poor health makes it less likely ADs will work; vitamin d3 and magnesium/zinc come to mind b/c of their interaction with the dopaminergic and nmda systems, respectively. it could be i focus on my health because its easier than fixing my head.
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