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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 10 of 10. This is the beginning of the thread.
Posted by zana on September 14, 2009, at 15:52:04
I have a major depressive disorder which is being treated with a slew of meds. I have listed them before; here goes again:
Pristiq 100mgs- good response at first; less good now.
Wellbutrin 300mgs- helps with sexual side effects and energy but probably increases anxiety.
Remeron 45mgs- I sleep like a log but noticed no AD effect though it is thought to be a good combo with Pristiq.
Seroquel 150mgs- got me out of bed when I was at my worst but never made me feel good.
Rispedal 1mg- when I try to decrease it my thoughts darken.
Klonopin 3mgs- started when I was in an agitated depression.
Provigil 200mgs- improves my mood, gets me going.
Gabapentin 600mgs- takes the edge off the provigil.
I keep trying to decrease the doses of the seroquel and the rispedal. When I lower the seroquel 25mgs, I become weepy after about 5 days. When I lower the dose or respedal, my thoughts darken after about 5 days.
MY QUESTION IS: How do I know what is a withdrawal symptom and what is a re-emergence of my depression? Do I just tough it out and see if the weeping lessens over time? How long do I give it?
I really want to decrease the meds I am on but I'm stuck at this point.
Any help?
Thanks for reading the too long post.
Zana
Posted by cactus on September 14, 2009, at 16:21:31
In reply to Discontinuation: How do you know?, posted by zana on September 14, 2009, at 15:52:04
It's really hard to say zana, I personally get emotional sometimes when I lower my meds but it's usually accompanied with physical symptoms too. Sometimes mild and sometimes down right nasty. Now not everyone gets the physical symptoms and man are they lucky. I'd talk it through with your pdoc and hopefully other here will contribute. It always comes back to the good old saying that everyone reacts differently. To me personally, it does sound like rebound, not withdrawal, but you have a combo of some serious medication going on there.
Posted by SLS on September 14, 2009, at 16:45:24
In reply to Discontinuation: How do you know?, posted by zana on September 14, 2009, at 15:52:04
Hi Zana.
Your treatment regime looks like quite a mess, although I imagine there was logic involved with adding each drug.
How have you gone about tapering your medication?
I am not sure how to resolve the difference between withdrawal rebound and relapse as you describe your experiences at this point. (I am guessing that imaging studies could differentiate between them). The temporal relationship between discontinuation and the emergence of depressive symptoms might provide a clue. Obviously, the longer the depressive symptomatology persists, the more likely it is to be relapse, especially if other withdrawal effects have come and gone.
Maybe you should get rid of the Remeron first. That would leave Seroquel in place to continue to provide histamine H1 blockade and prevent rebound insomnia and anxiety. I would then attempt to discontinue the Risperdal. You then might want to bring nortriptyline in before getting rid of the Seroquel. This might replace the 5-HT2a antagonism of the Seroquel and the NE reuptake inhibition of the Seroquel metabolite to prevent relapse.
- Scott
Posted by SLS on September 14, 2009, at 17:16:01
In reply to Re: Discontinuation: How do you know? » zana, posted by SLS on September 14, 2009, at 16:45:24
> Maybe you should get rid of the Remeron first. That would leave Seroquel in place to continue to provide histamine H1 blockade and prevent rebound insomnia and anxiety. I would then attempt to discontinue the Risperdal. You then might want to bring nortriptyline in before getting rid of the Seroquel. This might replace the 5-HT2a antagonism of the Seroquel and the NE reuptake inhibition of the Seroquel metabolite to prevent relapse
Now that I think about it, I think it makes more sense to add the nortriptyline after you discontinue the Remeron and before you try to discontinue the Risperdal. Risperdal is a potent antagonist of 5-HT2a receptors, and it might be smart to have nortriptyline on board as a buffer.
- Scott
Posted by Phillipa on September 14, 2009, at 20:24:07
In reply to Re: Discontinuation: How do you know?, posted by SLS on September 14, 2009, at 17:16:01
Zana your docs recommendations right? Did different docs start this cocktail of meds? Hope you called the doc. Love Phillipa
Posted by bleauberry on September 14, 2009, at 20:48:51
In reply to Discontinuation: How do you know?, posted by zana on September 14, 2009, at 15:52:04
This case is a very unfortunate example of why I hate to see people get into large cocktails. It can be like getting into quicksand. It isn't so hard to get in, but real hard to get out.
I don't think it is a return of your original symptoms. As those doses come down, noradrenergic stimulation is coming down. Any number of unknown things are happening with dopamine. Not mention the dozens of other things we don't even have a good handle on yet...genes, enzymes, secondary messengers. The weepy part is where your brain is realizing something has changed. It needs to adjust but can't do it fast enough for you.
My best suggestion would be to reduce the doses in much smaller steps, then go back up a small step for a day, then back down, kind of in a see-saw pattern. Whatever dose-size you decreased was probably too much. Cut pills, slice slivers off them, customize capsules...tricks to get tiny custom dose changes.
Posted by yxibow on September 15, 2009, at 0:10:30
In reply to Discontinuation: How do you know?, posted by zana on September 14, 2009, at 15:52:04
> I have a major depressive disorder which is being treated with a slew of meds. I have listed them before; here goes again:
> Pristiq 100mgs- good response at first; less good now.
> Wellbutrin 300mgs- helps with sexual side effects and energy but probably increases anxiety.
> Remeron 45mgs- I sleep like a log but noticed no AD effect though it is thought to be a good combo with Pristiq.
> Seroquel 150mgs- got me out of bed when I was at my worst but never made me feel good.
> Rispedal 1mg- when I try to decrease it my thoughts darken.
> Klonopin 3mgs- started when I was in an agitated depression.
> Provigil 200mgs- improves my mood, gets me going.
> Gabapentin 600mgs- takes the edge off the provigil.
> I keep trying to decrease the doses of the seroquel and the rispedal. When I lower the seroquel 25mgs, I become weepy after about 5 days. When I lower the dose or respedal, my thoughts darken after about 5 days.
> MY QUESTION IS: How do I know what is a withdrawal symptom and what is a re-emergence of my depression? Do I just tough it out and see if the weeping lessens over time? How long do I give it?
> I really want to decrease the meds I am on but I'm stuck at this point.
> Any help?
> Thanks for reading the too long post.
> Zana
I know how it feels to want to decrease medications in polypharmacy. I wish I could decrease some of the 5 or 6 + medications on board.It sounds like a careful dance... because the Pristiq, the Remeron, the Seroquel, and the Risperdal all have to be monitored for serotonin syndrome interaction.
Having two stimulants on board (Wellbutrin and Provigil) sounds redundant but maybe there's a reason for it, I can't second guess.
But if you have to "take the edge" off of Provigil with gabapentin, what is the use of the dose of Provigil you're on? There's one that could be cut down since the Wellbutrin should already be stimulating.
I don't want to be crass or mean to say "tough it out"... nobody wants that situation. Sometimes side effects though are admittedly hard to tell from a complicated set of medications.It sounds more like anxiety-driven withdrawal from the Seroquel. The Risperdal I can't say -- it is more potent, if you do have any psychotic spectrum parts to your depression, it could be emergent symptoms, but I can't say at that dose.
I'm not sure why the combination of two antipsychotics on top of all the rest though.
Are you "playing" with the medications yourself or has your doctor given you instructions to try?
Maybe you should have a real strong discussion with your doctor about the load of medications, how they make you feel, make sure that both of you are on board about the amounts and what they're for and then try to reduce them.
-- best wishesJay
Posted by 49er on September 15, 2009, at 18:30:31
In reply to Discontinuation: How do you know?, posted by zana on September 14, 2009, at 15:52:04
> I have a major depressive disorder which is being treated with a slew of meds. I have listed them before; here goes again:
> Pristiq 100mgs- good response at first; less good now.
> Wellbutrin 300mgs- helps with sexual side effects and energy but probably increases anxiety.
> Remeron 45mgs- I sleep like a log but noticed no AD effect though it is thought to be a good combo with Pristiq.
> Seroquel 150mgs- got me out of bed when I was at my worst but never made me feel good.
> Rispedal 1mg- when I try to decrease it my thoughts darken.
> Klonopin 3mgs- started when I was in an agitated depression.
> Provigil 200mgs- improves my mood, gets me going.
> Gabapentin 600mgs- takes the edge off the provigil.
> I keep trying to decrease the doses of the seroquel and the rispedal. When I lower the seroquel 25mgs, I become weepy after about 5 days. When I lower the dose or respedal, my thoughts darken after about 5 days.
> MY QUESTION IS: How do I know what is a withdrawal symptom and what is a re-emergence of my depression? Do I just tough it out and see if the weeping lessens over time? How long do I give it?
> I really want to decrease the meds I am on but I'm stuck at this point.
> Any help?
> Thanks for reading the too long post.
> ZanaZana,
It definitely sounds like withdrawal if symptoms are occuring only after 5 days.
Pick whichever med you want to reduce first and taper by 10% of current dose every 3 to 6 weeks. With the antipsychotics, you might have to go more slowly but you could start with 10%,
I would only taper one med at a time and leave the sleep meds for last
49er
49er
Posted by zana on September 16, 2009, at 16:51:52
In reply to Re: Discontinuation: How do you know?, posted by 49er on September 15, 2009, at 18:30:31
Thank you everybody for the input. I have discussed this with my pdoc but he is pretty passive and kind of follows my lead. I mean if I tell him I want to try reducing the seroquel he is fine with that and gave me a script for 25mgs to work with. Same with respirdal. I thought it would be a good idea to start with the APs since I have no psychotic symptoms and since I think they are kind a flattening me out. He seems content with the status quo as it is keeping the worst of my depression at bay. I see him in 2 weeks. In the meantime I think I will try decreasing the seroquel again and see what happens. I feel pretty alone in this since he is so passive and it feels like he is not really invested in me. I have been to a bunch of pdocs in the last months and I really don't know if I have the energy to look for a new one. I did take down Andrew Nierenberg's number- thank you Scott. If I decide to see someone new, I think it would make a lot of sense to see him from what you say.
Sigh.
Zana
PS My therapis thinks I'll be able to get off all these meds. Is he crazy?
Posted by Phillipa on September 16, 2009, at 20:51:52
In reply to Re: Discontinuation: How do you know?, posted by zana on September 16, 2009, at 16:51:52
Seriously I sure hope not. Love Phillipa
This is the end of the thread.
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