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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 16 of 16. This is the beginning of the thread.
Posted by Ezrahite on September 7, 2009, at 19:38:46
I've been on generic tranylcypromine for about a month, I'm up to 40 mg/day. There may have been a brief period where there was some benefit, but that seems to have been from the stimulating side effect; for a while I was able to push myself into activity, especially when I was going up in dose. But the effects that are persistent are that I feel more depressed, angry, frustrated, hopeless, and now I can't even think as well - I already have a lot of trouble with that, and I can't deal with more.
I know that if there's a dose that would help me with TRD it's likely to be higher - 60-80 at least, possibly much higher. Unfortunately Parnate is raising my blood pressure consistently, and when I take three pills at a time, or doses too close to each other, it gets higher than I can accept long-term. My blood pressure medication doesn't feel like it's helping, and I don't like the idea of raising the dose anyway. I think I could get up to 60 mg, but doubt I could take it higher. The other limit is what my doctor is willing to do, even if I could go up over 100 safely I doubt she would agree. And with my treatment resistance and from what I've read, I would probably need to.
I only decided to try a psychiatrist again because I got my hopes up about Parnate - such a potent and thorough action on neurotransmitters must surely help if anything will. Now I'm not so sure that's the approach that I need. It's just that nothing much else ever helped either. Only twice did I get results beyond a day or two. When I was four, I was given imipramine, and my Mother says it really improved my mood and focus. Later in my twenties I tried that again for ADD, and desipramine, with no result. But I also tried dexedrine and that really seemed to work, at 20 mg/dose. But I didn't get the chance to continue that, and years later when I tried it again there were no results.
Other things I tried in my thirties: Effexor improved my mood, fatigue, maybe a few other things - but only for a day, and by the next week I couldn't even tell I was taking it. SSRIs didn't seem to do anything. Wellbutrin didn't work. I tried various supplements. Bitter melon definitely elevated my mood and relieved my fatigue, but only for a day, then came the awful crash; by the third day I could get no benefit from it at all. When I started on T4 and T3 for a slight thyroid deficiency, the first day again I had great relief, but the effect never reappeared. I never felt any better with thyroid replacement, only worse for a while if I discontinued it.
Anyway, back to Parnate. I feel like I may be giving up on it without giving it shot. I tend to go in with high hopes and then give up when things take too long. I get anxious about the passage of time. Maybe some of the worsening symptoms are from increased sleep difficulties, or some coincidental factor. Maybe augmentation would work, I had intended it; but the doctor said we had to get to the right dose of Parnate first, and I foresee that being a matter of going as high as I can tolerate and then parking there indefinitely until somehow the parnate starts working. From what I've read, it's good to start the augmentation at the same time as the Parnate, or even add the Parnate later (especially if used with a stimulant).
So the best I could come up with is switch to something else closer to what has worked in the past, and then if needed I can add an MAOI to augment that. That most likely means tricyclics, though I fear the side effects will not be as hard to reach as the desired effects. And I can't really accept more constipation, brain fog, or fatigue. What I'd really like to try is dexedrine spansules from Mallinckrodt, but I have little hope in getting anyone to work with stimulants.
When I first saw this doctor and mentioned MAOIs, she was kind of enthusiastic about Emsam, and still is if I mention selegiline. I can't afford Emsam, and it's not covered by my insurance. Maybe she has a point in a way though, it has (mediocre) stimulant metabolites. I think her concerns are dietary restrictions, plus not wanting to prescribe selegiline off-label. Maybe I should see if there's a way I can afford to give it a shot?
Okay, sorry for rambling... My choices seem to be to continue with Parnate for months and see if it can be made to work, or to drop parnate and try a tricyclic (but which one?), or if somehow it were possible try Emsam instead. Can anyone advise?
Posted by Phillipa on September 7, 2009, at 21:37:56
In reply to Should I switch from Parnate?, posted by Ezrahite on September 7, 2009, at 19:38:46
Well I can welcome you to babble. So many on MAO's now that you should hopefully get a lot of responses. Good luck. Phillipa
Posted by Girlnterrupted78 on September 8, 2009, at 4:02:57
In reply to Should I switch from Parnate?, posted by Ezrahite on September 7, 2009, at 19:38:46
>But the effects that are persistent are that I feel more depressed, angry, frustrated, hopeless, and now I can't even think as well - I already have a lot of trouble with that, and I can't deal with more.
Do you feel more depressed/angry & frustrated than before starting Parnate, or just the same? Does Parnate seem to be exacerbating your depression?
> I know that if there's a dose that would help me with TRD it's likely to be higher - 60-80 at least, possibly much higher. Unfortunately Parnate is raising my blood pressure consistently, and when I take three pills at a time, or doses too close to each other, it gets higher than I can accept long-term.
You should try to spread the doses, then. Are you getting any hypotension? Or you're just getting high blood pressure? I get tons of hypotension on Parnate, and have never gotten high blood pressure on it, and I'm on 40mgs. Try spreading the doses more, or a lot more, and see how that helps.
>I think I could get up to 60 mg, but doubt I could take it higher. The other limit is what my doctor is willing to do, even if I could go up over 100 safely I doubt she would agree. And with my treatment resistance and from what I've read, I would probably need to.
You should try to do this slowly while allowing your body to adapt. When I was on Nardil, I started with lots of side effects, and I eventually adapted to every one of them. They all went away within 2-3 months. Now I'm on Parnate, and the same thing is happening. And if your doctor refuses to treat your TRD by increasing the dose, then switch docs. You can't let one doctor decide your fate.
> I only decided to try a psychiatrist again because I got my hopes up about Parnate - such a potent and thorough action on neurotransmitters must surely help if anything will. Now I'm not so sure that's the approach that I need. It's just that nothing much else ever helped either. Only twice did I get results beyond a day or two.
I only ever had 1 AD work, while everything else failed. I also have TRD. Now I'm on Parnate and I'm giving it a FULL TRIAL. I'm on my 3rd week now. I noticed an improvement within the first 2 weeks. And I noticed another improvement when my doctor augmented with 5mg Adderall. And my doctor won't stop until I am on remission, so we will add anything we can to Parnate. He's not letting me go up above 40mgs yet because of my hypotension, but as soon as my body adapts to it, we will continue going up. And we will increase the Adderall and possibly add other augmenters if it ends up being necessary.
I think you should do the same. Give it a really fair trial before you give it up. Go slow. Spread doses. Allow your body to adapt. Augment with several medications.
Best of luck
Posted by bleauberry on September 8, 2009, at 13:06:35
In reply to Should I switch from Parnate?, posted by Ezrahite on September 7, 2009, at 19:38:46
I don't know. This is a tough call. Sometimes I feel confident giving suggestions. This time I think the best I can do is just offer some thoughts that went through my head.
The first was the word generic. That to me was the very first place to point a finger at a possible suspect. Obviously the generic is doing something as evidenced by the blood pressure. But is it doing the clinical equivalence of brand in terms of the brain? We don't know. All we know is there is a ton of anecdotal evidence of generics and brands not being of the same clinical value, not always, but often enough that it has to be a consideration when a generic med is not working. Has to be. No ifs ands or buts about it. It also makes the most sense in terms of weaning, withdrawal, new meds, etc. Makes sense to optimize the first med before moving on. To this point, that has not been done.
Adding a stimulant or a TCA to the Parnate was another thought. And of course, the brand versus generic thing might be a consideration with that as well.
Apart from those ideas, there is the SNRI/SSRI + Antipsychotic route, maybe with a stimulant. Or the SSRI/SNRI + TCA route.
Another completely different option, especially considering the frustrating history, is to recruit the help of an Integrative MD onto your team. Someone who knows how to look at a wide array of things your psychiatrist and family doc never will.
Just pure logic tells me that when a wide variety of potent psychiatric meds are not doing what they were intended to do, then it is really pretty simple...they are all missing the target. That doesn't really help to point out what mechanism you need to feel better, but it does at least tell you which mechanisms won't, and so no sense in continuing with those.
Maybe you are one of those people that just needs super high doses? Doesn't have to be Parnate. Whatever it is, really high doses, above the top limit.
Posted by Ezrahite on September 8, 2009, at 16:11:38
In reply to Re: Should I switch from Parnate? » Ezrahite, posted by Girlnterrupted78 on September 8, 2009, at 4:02:57
Thanks for the reply!
> Do you feel more depressed/angry & frustrated than before starting Parnate, or just the same?
Moreso than before. It's hard for me to compare mental states over time, but I did notice when I was on 20 mg that suddenly I was falling more easily into a bleak hopeless pit and struggling more to get out, and having a slow burning anger about everything and everyone. It's at 30 and 40 mg that I noticed the increasing difficulty with expressing myself or even finding something to say.
> You should try to spread the doses, then. Are you getting any hypotension? Or you're just getting high blood pressure?
I never have had any hypotension. Just the high blood pressure - it feels like my heart is beating harder and slower. On 30 mg it was 182/80. I can feel it in my head, sometimes in my whole body. When I was taking 30 mg once a day, or 20 mg doses less than eight hours apart, after a few days of that I had a dull achiness in my head like I'd sneezed too hard. It seems unhealthy.
I think I'm spreading doses as much as I can. I have always had trouble dealing with twice a day, let alone eight or ten. Also, other people have tried it, and had worse side effects.
> And if your doctor refuses to treat your TRD by increasing the dose, then switch docs. You can't let one doctor decide your fate.
I can't switch docs. It's gotten very difficult to get a University clinic psychiatrist, and that's all my insurance allows. Anyway, she's not a bad doctor, not many are willing to work with Parnate to start with.
> I only ever had 1 AD work, while everything else failed. I also have TRD. Now I'm on Parnate and I'm giving it a FULL TRIAL. I'm on my 3rd week now. I noticed an improvement within the first 2 weeks. And I noticed another improvement when my doctor augmented with 5mg Adderall. And my doctor won't stop until I am on remission, so we will add anything we can to Parnate.
I'm sorry if I seem down on Parnate. It works wonders for a lot of people. I know that it sometimes gets worse at a lower dose before getting better. But since I don't see problems getting better, only worse, I don't have much hope it will work at a dose I can take.
One reason I tried Parnate was thinking that I might be lacking in neurotransmitters, and Parnate is pretty much the ultimate in making more of them available. Now I doubt that's the case; and when I look at all the supplements I've taken to raise their levels, they never helped either.
Anyway my priorities have changed since I started taking Parnate. I need to be more able to participate and get things done - I can live with how I feel if I can do that.
I guess what I am looking for is other people's experiences that were similar to mine, and how they turned out in the long run. It would be stupid to jump ship if there were a decent chance of success. If not, now is especially not a good time to waste more time.
Posted by Ezrahite on September 8, 2009, at 18:06:07
In reply to Re: Should I switch from Parnate?, posted by bleauberry on September 8, 2009, at 13:06:35
> The first was the word generic. That to me was the very first place to point a finger at a possible suspect. Obviously the generic is doing something as evidenced by the blood pressure. But is it doing the clinical equivalence of brand in terms of the brain?
That's a very good point. Unfortunately for me, brand names are mostly not an option. Money is the issue. It's a vicious cycle: I need money or good insurance to get the best meds, I need to get better so I am capable of getting money and good insurance.
> Adding a stimulant or a TCA to the Parnate was another thought. And of course, the brand versus generic thing might be a consideration with that as well.
>
> Apart from those ideas, there is the SNRI/SSRI + Antipsychotic route, maybe with a stimulant. Or the SSRI/SNRI + TCA route.There are so many possibilities. One reason I start to panic if it looks like I might spend another year barking up the wrong tree. And yet I'm also anxious about ever quitting if somehow it might have turned out to be what would have worked in the end.
> Another completely different option, especially considering the frustrating history, is to recruit the help of an Integrative MD onto your team.
I don't know if my insurance would cover that, probably not. But over the years I've seen doctors and done my own research about all sorts of possibilities. Endocrine problems, chronic fatigue, diet, Lyme Disease. Nothing has got me anywhere yet.
> Just pure logic tells me that when a wide variety of potent psychiatric meds are not doing what they were intended to do, then it is really pretty simple...they are all missing the target.
I seem to have had some strange metabolic problem from birth, and my depression goes all the way back with that. I think it may be my underlying issue, but I don't know if anything has ever helped that either, unless the imipramine and dexedrine did. Losing weight might at least help - but that has been incredibly difficult.
> Maybe you are one of those people that just needs super high doses? Doesn't have to be Parnate. Whatever it is, really high doses, above the top limit.
There's a lot more information and personal experiences on the internet to draw on these days, and I notice that it's quite common for people to go way over what I was told was the limit. It puts my whole history into question. It would be typical if I've suffered all this time simply from being treated as an average and not an individual.
Posted by ColoradoSnowflake on September 8, 2009, at 23:59:15
In reply to Should I switch from Parnate?, posted by Ezrahite on September 7, 2009, at 19:38:46
Parnate didn't work for me until I had been on it for 3 months, got up to 60mg. and added Nortriptyline. That was "the bomb". Gayle
Posted by Ezrahite on September 9, 2009, at 11:50:44
In reply to Re: Should I switch from Parnate?, posted by ColoradoSnowflake on September 8, 2009, at 23:59:15
> Parnate didn't work for me until I had been on it for 3 months, got up to 60mg. and added Nortriptyline. That was "the bomb". Gayle
Interesting. How long were you at 60 mg? How fast did you titrate up? What effects are you getting? Mood, calmness, focus, drive?
Posted by Girlnterrupted78 on September 9, 2009, at 14:34:04
In reply to Re: Should I switch from Parnate?, posted by Ezrahite on September 8, 2009, at 16:11:38
> Moreso than before. It's hard for me to compare mental states over time, but I did notice when I was on 20 mg that suddenly I was falling more easily into a bleak hopeless pit and struggling more to get out, and having a slow burning anger about everything and everyone. It's at 30 and 40 mg that I noticed the increasing difficulty with expressing myself or even finding something to say.Well, I'm very sorry to hear this. Doesn't sound like a pleasant experience to go through. Today I saw my pdoc and asked him about this specifically. He responded that he's never seen someone get "worse" on Parnate. He's had people not respond, or respond just halfway, but has never seen someone get worse. Then his theory was that (he might be wrong about this, since we don't have your info) that you might have recently discontinued another med, which was helping to some extent, and now that it's washed out completely, it's causing your severe depression. Could this be the case?
> I never have had any hypotension. Just the high blood pressure - it feels like my heart is beating harder and slower. On 30 mg it was 182/80. I can feel it in my head, sometimes in my whole body. When I was taking 30 mg once a day, or 20 mg doses less than eight hours apart, after a few days of that I had a dull achiness in my head like I'd sneezed too hard. It seems unhealthy.
Yes, this doesn't seem right. These side effects you're describing are terrible and so different from everything me and others are getting. I get hypotension rather than hypertension, and shortness of breathe, in addition to seeping problems.
> I can't switch docs. It's gotten very difficult to get a University clinic psychiatrist, and that's all my insurance allows. Anyway, she's not a bad doctor, not many are willing to work with Parnate to start with.Would you mind telling me where you're located? Thanks. Maybe I could help in some way.
> I'm sorry if I seem down on Parnate. It works wonders for a lot of people. I know that it sometimes gets worse at a lower dose before getting better. But since I don't see problems getting better, only worse, I don't have much hope it will work at a dose I can take. One reason I tried Parnate was thinking that I might be lacking in neurotransmitters, and Parnate is pretty much the ultimate in making more of them available. Now I doubt that's the case; and when I look at all the supplements I've taken to raise their levels, they never helped either.
Anyway my priorities have changed since I started taking Parnate. I need to be more able to participate and get things done - I can live with how I feel if I can do that.
I guess what I am looking for is other people's experiences that were similar to mine, and how they turned out in the long run. It would be stupid to jump ship if there were a decent chance of success. If not, now is especially not a good time to waste more time.I had a similar experience to yours, but with Nardil. It did nothing for me. It made me slow-thinking, I'd forget words, I was bad socially, and I didn't feel any antidepressant effects. It also gave me an occipital headache when I reached 90mgs, and a blush when I was at 75mgs. I gained 25lbs in a year on Nardil.
The only reason I stayed on it for a whole year was because I wanted to give it a fair trial and at the time it seemed like my last resort.
I tried every dose, for enough periods of time, and I wanted to augment it. That's where things went wrong. My pdoc at the time refused to augment it, so I stayed even longer while looking for a new pdoc who would augment. But in the meantime my weight got to a point where I could not take it anymore, so I discontinued the med.But see, this is after a whole year trial, which is what I gave Nardil. And I still regret not having augmented it. Who knows what would have happened?
Best of luck and I hope it will give you some benefit.
Posted by Ezrahite on September 9, 2009, at 19:10:54
In reply to Re: Should I switch from Parnate? » Ezrahite, posted by Girlnterrupted78 on September 9, 2009, at 14:34:04
> Well, I'm very sorry to hear this. Doesn't sound like a pleasant experience to go through. Today I saw my pdoc and asked him about this specifically. He responded that he's never seen someone get "worse" on Parnate.
Keep in mind that it could be a secondary effect - from sleep disturbance, rebound to the stimulant effect, high blood pressure, etc. Or I'm just idiosyncratic - there's always someone who doesn't fit the pattern, and it's usually me. As for other medications, none this year. Not even a supplement any time recently.
> These side effects you're describing are terrible and so different from everything me and others are getting.
I don't mean to give the impression that I'm suffering terribly. It's not a really major change. It's just that when you barely have enough to make some progress, a little more difficulty can start you sliding back down the hill. And the blood pressure doesn't feel bad, of itself, it's just problematic for my health.
> Would you mind telling me where you're located? Thanks. Maybe I could help in some way.
Thanks for the offer, but as with the Parnate I hesitate to change doctors until I've given this one a fair trial. She's actually pretty above average so far to judge by my medical experience.
> I had a similar experience to yours, but with Nardil. It did nothing for me. It made me slow-thinking, I'd forget words, I was bad socially, and I didn't feel any antidepressant effects. It also gave me an occipital headache when I reached 90mgs, and a blush when I was at 75mgs. I gained 25lbs in a year on Nardil.
It's tough to have to endure weight gain just to feel better, let alone when the results are so negative. I've been afraid of that myself. I weighed myself today, thinking since I've been on my diet for a couple weeks now it wouldn't hurt to check. It turns out I've lost fifty pounds. The only explanation is the Parnate. Fifty pounds in two months.
Another thing is, the progress I've been making recently, though certainly it has to do with my evolving attitude and perspective, in retrospect the Parnate must have had something to do with that as well. Especially the period where I found myself really getting things done. It kept me focused enough to get a job. Unfortunately that focus has disappeared.
Those things make it seem like maybe there's a point to going on. I tried taking three pills at a time again yesterday; my blood pressure still went up, but it didn't last as long it seems.
Of course the good effects could be transient. The increased drive in particular looks like it's part of the stimulating effect that wears off. Dexedrine is probably out, but maybe I should sound out my psychiatrist about Vyvanse. It's not so cheap but I think you can get a month's worth free. If it helps I should be making some money by refill time.
> Best of luck and I hope it will give you some benefit.
Thanks. I think I'll try to push the augmentation more. Nortriptaline was probably going to be my next step, and I can't think of anything that would be objectionable about that.
Posted by Phillipa on September 9, 2009, at 19:31:59
In reply to Re: Should I switch from Parnate? » Girlnterrupted78, posted by Ezrahite on September 9, 2009, at 19:10:54
Does your doc know of the headache and blood pressure? No chance of spontaneous hypertensive crisis right? Phillipa
Posted by Ezrahite on September 9, 2009, at 21:22:38
In reply to Re: Should I switch from Parnate? » Ezrahite, posted by Phillipa on September 9, 2009, at 19:31:59
> Does your doc know of the headache and blood pressure? No chance of spontaneous hypertensive crisis right? Phillipa
She knows, I believe she's waiting to see if the hypertension fades. She did tell me to see my PCP, and suggested increasing my blood pressure medicine. But whether I take it or not doesn't seem to make a difference with the Parnate.
The headache didn't seem like a crisis, it was mild and took days to develop. I did have a sort of tyramine event once, after eating some funky chicken, where my whole body was pulsating, but no danger signs.
Posted by Maxime on September 10, 2009, at 9:40:49
In reply to Re: Should I switch from Parnate? » Girlnterrupted78, posted by Ezrahite on September 9, 2009, at 19:10:54
God, I hope Parnate helps me to lose weight. :)
Posted by TheRealGidget on March 4, 2010, at 22:32:32
In reply to Re: Should I switch from Parnate? » Girlnterrupted78, posted by Ezrahite on September 9, 2009, at 19:10:54
Any updates Ezrahite? I am on week 5 of Parnate and am experiencing the same thing regarding having horrible trouble trying to think of things to say. My thoughts just do not flow at all like they used to. It's compounding my depression and social anxiety rather than relieving it. I just want to make sure I give it a fair shot time-wise since so many people have such success.
Posted by Ezrahite on March 5, 2010, at 8:36:23
In reply to Re: Should I switch from Parnate?, posted by TheRealGidget on March 4, 2010, at 22:32:32
Okay, an update, though probably not too helpful.
As I recall, I had only negative effects at the start. I'm not sure how long that lasted, by two months I didn't think there was any effect at all, positive or negative. Maybe if I'd gone up from 40 mg but that was my doc's limit.
What I did find out, is that it changed the effect of caffeine on me. A long time ago, it stopped acting as a stimulant for me, and eventually it was clear that any boost from it was minimal, and it would leave me feeling drained and more depressed for a day or more. But now, on the parnate, one day I had to stay up, so I drank a bunch of coffee. And I found myself suddenly talking, very naturally, with people, like my haircutter, where normally I would find it awkward and not have much to say. I think I must have been more interesting as well. I didn't feel like I was high, or even buzzed, the difference was one I noticed mostly when I found myself interacting better and enjoying it more.
I think what was happening was that the Parnate causes dopamine and norepinephrine to stay in good supply, but doesn't necessarily make them more active in the synapses, while caffeine releases the neurotransmitters, but normally for me without the Parnate leaves me depleted.
Unfortunately caffeine is a messy way to add a stimulant action to Parnate. I think the fact that it activates cAMP was affecting me. I've been reading about executive functions and working memory in the prefrontal cortex, and the process that impairs them works through activation of cAMP. But whatever the reason, I do think it was gradually affecting my judgment and sense of propriety. Though in retrospect I already had major problems in the PFC, and the removal of barriers of fear and aversion just exposed them, my inexperience also being a factor. So probably caffeine would not be problematic for most people; but I don't recommend it. I notice now that there's a small warning label on the bottle about caffeine.
Anyway, after making some unfortunate misjudgments, I was too alarmed to continue and stopped taking the Parnate. I changed insurance at the start of the year, and have tried Remeron, which didn't help and I had to stop because of joint problems. I may try the Parnate again, I'd be interested to see if it could work with augmentation.
> Any updates Ezrahite? I am on week 5 of Parnate and am experiencing the same thing regarding having horrible trouble trying to think of things to say. My thoughts just do not flow at all like they used to. It's compounding my depression and social anxiety rather than relieving it. I just want to make sure I give it a fair shot time-wise since so many people have such success.
Posted by TheRealGidget on March 6, 2010, at 8:34:18
In reply to Re: Should I switch from Parnate? » TheRealGidget, posted by Ezrahite on March 5, 2010, at 8:36:23
Thanks for the update! I actually have had a few very nice days on Parnate, including yesterday, where I don't even think about thinking if it's working. I just feel super decent and more like "myself." I just need to start having more of those all in a row. :-)
I also had an unusually long wash-out period (Cymbalta), like 5 weeks, I think, because it took forever for the pharmacy to fill the prescription. It's the longest I've been without medicine since my early 20s when I was first diagnosed, and I do have to wonder if these "weird-can't-think-or-talk" Parnate days are due to having ZERO medicine in me, with not yet enough time for Parnate to build up.
Anyway, hanging tough for a full 8 weeks is my plan. Hope to have good things to report. :-)
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