![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 15 of 15. This is the beginning of the thread.
Posted by glenni on May 25, 2009, at 22:00:37
I've been in a major refractory episode for over a year now. I've been on 60mg of Cymbalta for about 5 months with Zyprexa, Geodon, Neurontin, Adderall, Xanax, Klonopin, Seroquel, Oxycodone, Lithium with little improvement. Prior to that did a full trial of nortiptyline and effexor with no improvement. Over the years I've been on every ssri but lexapro. pdoc is recommending ECT over an MAOI. Any thoughts?
Posted by chumbawumba on May 25, 2009, at 22:42:27
In reply to Advice on next steps, posted by glenni on May 25, 2009, at 22:00:37
That seems like a lot of medication. I would think Klonopin and Xanax are redundant as are Zyprexa and Seroquel.
Seems like some medications in that combination are counteracting others. Adderall and the benzos for instance.
Have you tried psychotherapy?
Posted by greywolf on May 25, 2009, at 22:53:01
In reply to Advice on next steps, posted by glenni on May 25, 2009, at 22:00:37
You were on all those meds at the same time?
Before you go the ECT route, I highly recommend trying the MAOIs. Many people find them effective, and the dietary restrictions are easy to handle. I've tried them all, and I like Parnate the best.
Greywolf
Posted by floatingbridge on May 25, 2009, at 23:18:29
In reply to Re: Advice on next steps, posted by greywolf on May 25, 2009, at 22:53:01
> You were on all those meds at the same time?
>
> Before you go the ECT route, I highly recommend trying the MAOIs. Many people find them effective, and the dietary restrictions are easy to handle. I've tried them all, and I like Parnate the best.
>
> Greywolf
I second Greywolf.Candace
Posted by Phillipa on May 26, 2009, at 0:03:58
In reply to Re: Advice on next steps, posted by floatingbridge on May 25, 2009, at 23:18:29
Me too so many meds and redundant two benzos and two atypical antipsychotics. Phillipa
Posted by Neal on May 26, 2009, at 3:36:56
In reply to Re: Advice on next steps, posted by Phillipa on May 26, 2009, at 0:03:58
i don't think this individual was on all at the same time.
Ever tried Effexor plus Remeron?
Posted by bleauberry on May 26, 2009, at 5:36:51
In reply to Advice on next steps, posted by glenni on May 25, 2009, at 22:00:37
As an ECT survivor, I strongly emphatically (banging the fists on the table) recommend to stay far far away from that. Pretend it doesn't even exist. It is not an option. In literature it appears promising. In the real world, not. Of the half dozen people I went through ECT with, the efficacy rate was 0%. In cases where it does work, relapses are almost guaranteed (80+
%) and happen very quickly (within days or weeks, sometimes a few months). Memory loss is more severe than you are told. It is not temporary as you are told. Entire blocks of my life are gone, haven't returned 3 years post-ECT, congnitive function was damaged significantly, and the 3 month period leading up to ECT and the 3 month period following ECT do not exist. Zero memory.The only benefit I can say ECT has is that it erases so many memories that you kind of get a new start. Many of those bad times and bad memories are gone, along with any good ones. People here have noticed unusual perplexing new symptoms following ECT, such as super sensitivity to meds and the inability to tolerate meds.
Total cost for 12 treatments was $22,000. I had to pay $6,000 of that. Insurance got hit with the rest. If you are going to spend that much money, buying a new car is more likely to help your depression than ECT.
MAOIs have an extraordinary track record. Within a slightly modified diet (not nearly as strict as you are told), they are quite safe.
Go to psychotropical.com to read what Dr Gillman has to say about MAOIs. He has used them in over 1000 patients. Extremely good information to debunk any hesitations or misinformation your doctor may have pertaining to Parnate or Nardil. Print it and take it with you to your appointment.
Second to MAOIs he found the combinations of Zoloft+Nortriptyline to be very good, when either alone did not work.
Outside of that, at this stage of the game is becomes more and more important to reconsider the diagnosis. Is this unrecognized Lyme disease? Is this unrecognized yeast overgrowth? Is there a history of amalgam fillings in the teeth (mercury toxicity)? Is your 24 hour 4-sample cortisol curve in a normal range? Are thyroid freeT3 and T4 in optimal ranges?
I couldn't quite understand whether you are taking all the meds you listed at the same time, or whether you had tried them at various times? If they are all in your present cocktail, all I can say is that is way too much meds. Even in the STAR*D clinical study where they had a higher than 80% remission record, the most meds given at any time were 3, but ususally only 2. It is a matter of the right meds, not how many. If a med isn't producing, it should be dropped and relpaced, not piled onto with other meds. I see that here all the time, where people and their doctors pile one loser on top of another on top of another. Geez, no wonder they feel so bad. No wonder the meds won't work. How could anyone possibly feel improvement when they have so many worthless failures in their bloodstream. That one med not working might actually be preventing other good ones from working. Get the non-perfomers out of the picture.
Duloxetine by the way is, anecdotally, a rather poor antidepressant.
So what kind of med works when ECT doesn't? Well, I can think of three. Parnate. Nardil. Milnacipran. Yeah, Milnacipran got this ECT failure feeling surprising improvement rather quickly. It is a new med approved for Fibromyalgia in USA, but is an antidepressant with a solid track record in the rest of the world. It is called Savella in USA.
No ECT.
Yes MAOI.
Maybe Savella.
Maybe Zoloft+Nortriptyline.
Yes limit meds to 3, drop the underperformers.
Revisit the diagnosis, looking for causes of brain impact originating below the neck.
psychotropical.com
Posted by greywolf on May 26, 2009, at 5:54:07
In reply to Re: Advice on next steps, posted by bleauberry on May 26, 2009, at 5:36:51
I agree with bleauberry about ECT. It totally sucks. I had it a couple months ago, and I still can't tell you how long I was off work, basic events that happened during that time or within a few years prior. It's embarrassing to have to ask my family things I should know or to not know what company a long-term client is with when they call.
And, bottom line, it didn't help my depression one bit even though it costs a fortune.
If you want a non-med alternative, consider VNS.
But I would still go the MAOI route first.
Greywolf
Posted by Zana on May 26, 2009, at 8:56:40
In reply to Advice on next steps, posted by glenni on May 25, 2009, at 22:00:37
Everyone is different. I was in the process of getting ready to start ECT when I had been though Geodon, Seroquel and Lithium along with a bunch of other stuff including Neutrontin. Lithium turned me into a zombie. The minute I got off it I was better. Still depressed but better. Seroquel helped a little bit with my depression but made me feel weird, downed out not myself.
I agree that Geodon and Seroquel and Zyprexa are all redundant. I would try to get off the atypicals. I am now weaning off Seroquel at 50mgs every 3 weeks. All this med stuff takes so long.
I have been taking Remeron for a long time. Didn't seem to do anything but make me sleep which is wonderful. But after bombing out on every AD I tried Pristiq and bang! I suddenly, within days, felt a thousand percent better. I have since learned that Remeron and Pristiq are called "California Rocket Fuel."
I also started taking Provigil again. I had used it for years off and on but had been avoiding it because I was so agitated. Taking it again has helped my mood and energy a lot. I didn't do well on Adderall or any of the other amphetamines. Provigil is a horse of a different color and worth a look.
I too take klonopin. Klonopin and Xanax are also redundant. Take one or the other and I would recommend sticking with the Klonopin since it has a long half life and is less likely to provoke rebound anxiety- as long as you keep taking it. Neurontin can also down you out. Except for the
adderall, everything you are taking, including the oxycodone, is a downer.
I agree with others that you need to weed out some of the redundant meds and I think you need to get on something that is potentially stimulating.
What is your history with AD's and what other med regimes have you tried? And how would you characterize your depression? What symptoms are you trying to target?
How long have you been on this regime? Sounds like regimes I have been on: things don't get better, your doc just keeps adding things and next thing you know you are on a laundry list of meds and still not better.I avoided ECT for one reason. The doc I consulted at Mass General, who is considered a top shock doc, told me all about potential memory problems. When I asked him about problems stemming from the right hemisphere he responded, "If you are a dancer, you might remember your choreography but be unable to make your dance beautiful; if you were a musician, you might remember all of your score but be unable to make your instrument sing."
That did it for me.Therapy has been extremely helpful for me.
I would definitely get a psychopharm consult before proceeding to ECT. I think there is room for a lot of improvement with your meds.Zana
Posted by glennb on May 26, 2009, at 15:47:53
In reply to Advice on next steps, posted by glenni on May 25, 2009, at 22:00:37
thanks for all the thoughts. to clarify, I was on Cymbalta for the entire time..all of the other meds were at different times/different combinations, not all at once.
Posted by glennb on May 26, 2009, at 15:48:48
In reply to Re: Advice on next steps, posted by Neal on May 26, 2009, at 3:36:56
yes, thorough trial of effexor; tried to augment with remeron did nothing for me but further sedate me unfortunately.
Posted by glennb on May 26, 2009, at 16:56:54
In reply to Re: Advice on next steps, posted by chumbawumba on May 25, 2009, at 22:42:27
yes, therapy twice a week. has been the only thing that helps, but it's only partial improvement.
Posted by Phillipa on May 26, 2009, at 20:10:29
In reply to Re: Advice on next steps, posted by glennb on May 26, 2009, at 16:56:54
I'm sorry glad not on all the meds at the same time. Love Phillipa
Posted by sampieses on May 27, 2009, at 12:35:38
In reply to Advice on next steps, posted by glenni on May 25, 2009, at 22:00:37
31 years of Hell - and I can assure that SSRI's only constrain anxiety.That seems alright: but just move outside any of your comfort-zone perimeters?? They're sort of reliable, but cannot eradicate that chronic anxiety that, every now and then, just floors you with a vicious panic attack. I often have to wonder at the majority of doctors' - well-meaning enough - understanding of what it's like to be in this strange category of people, whose rational/irrational fears simply kill the spirit within us! No slur implied to those who've won the T-shirt.
Posted by desolationrower on May 29, 2009, at 1:27:44
In reply to Re: Advice on next steps, posted by sampieses on May 27, 2009, at 12:35:38
i'm not 100% against electroshock, but you should take an MAOI.
I'd also suggest xanax, as its less likely to cause depression than clonazapam. although if kpin is better for your anxiety, take that.
Also, if cympalta isn't helping, don't stay on it (future advice.)
=d/r
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.