![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 12 of 12. This is the beginning of the thread.
Posted by mtdewcmu on December 25, 2009, at 20:05:29
I need to run my situation by the regulars here and maybe get some advice or reassurance...
I am taking 20mg Prozac, 30mg Remeron, 150mg Wellbutrin, 75mg Zoloft, and 2mg Abilify. It seems like I am on a ton of meds, but sometimes I don't feel like I'm on anything. I've noticed lately that I get very depressed and dysphoric after the sun goes down, which happens about 5:00 here right now. I have a bunch of possibilities running through my head; like I've only been on Prozac for slightly more than 2 weeks, so maybe it needs more time; I decreased the Zoloft from 100mg a few days ago, so maybe I'm having a little bit of withdrawals or a let-down from that; I'm on either too much or too little Remeron, I can't figure out which; and I'm on either too much or too little Wellbutrin.
The reason I think I might be on too much Remeron/Wellbutrin, is because I feel like my sleep is not refreshing, which could be a result of excessive stimulation. On the other hand, my sleep may not be refreshing due to depression, which would argue for increasing the dose of those drugs. When I was on a higher dose of Wellbutrin, I felt great for a few days, but then I started to feel terrible and I was waking up after getting about 4 hours of sleep, which is not normal for me. It seemed like the WB+Remeron was preventing me from sleeping, and so I halved the dose of WB. (Could this be WB withdrawal?)
I've had this experience of feeling crappy when the sun goes down previously, pre-medication. So it would seem to be a symptom of my depression and not a side effect of any of the meds. Which argues for either increasing the dose of something, or waiting for the current meds to work. My dose of Remeron has been steady for well over a month now. I tried upping the Abilify for a while, but over the past week I have been trying to let it wash out of my system at the suggestion of my pdoc and because I am doubtful of its benefits.
I'm going to wrap this up, because this post is already pretty long -- and no-doubt confusing, like my med history. The reason I've been making so many changes in such a short period is that I have been running out of patience with this process. I started the process of changing meds way back in July, and I'm not 100% certain if I've made any progress at all. So I am trying all kinds of ideas in the hope that something will work. I just took a second 20mg Prozac this evening in the hopes that that would help smooth things out and perhaps make up for the decreasing levels of Zoloft.
OK, so, I think I've convinced myself that the nighttime dysphoria is actually my disease and not the meds. So I must need more meds or more time for them to work. I hope I haven't terribly confused you... any suggestions?
Posted by Phillipa on December 25, 2009, at 21:45:37
In reply to Nighttime dysphoria and already on meds..., posted by mtdewcmu on December 25, 2009, at 20:05:29
Does seem like a lot of meds. Lots of serotonin. No sleeping med? Geez I hope the experts can help later. Maybe some history would help like when it all started and first meds etc. You know what I mean. Love Phillipa
Posted by mtdewcmu on December 26, 2009, at 7:45:28
In reply to Re: Nighttime dysphoria and already on meds... » mtdewcmu, posted by Phillipa on December 25, 2009, at 21:45:37
> Does seem like a lot of meds. Lots of serotonin. No sleeping med? Geez I hope the experts can help later. Maybe some history would help like when it all started and first meds etc. You know what I mean. Love Phillipa
With as much medication as I'm on, you would think it would feel like a lot of meds. Instead I seem to be having more symptoms than side effects.
I accidentally took 300mg of Wellbutrin yesterday and I woke up at 4:00AM again. Guess there's a connection there.
Posted by bleauberry on December 26, 2009, at 20:24:10
In reply to Nighttime dysphoria and already on meds..., posted by mtdewcmu on December 25, 2009, at 20:05:29
I would consider replacing Remeron and Wellbutrin with first choice Nortriptyline, second choice Savella.
It sounds like a daily rhythm, timeclock, adrenaline, cortisol thing. Complicated. But norepinephrine reuptake inhibitors can balance that out and reset it over time. Remeron and Wellbutrin are, in my view, likely to be worsening it.
If you had your cortisol checked on the Adrenal Stress Index test, it would not surprise me if the 3rd saliva sample of the day (the one you take at the time the sun goes down) is way below where it should be. An NRI will help compensate for that in the short run and restore it to normal in the long run. As will specific attention to foods you choose to eat, but that's another story.
The only reason I happen to recognize what you are talking about is because I've had some experience with it myself.
What does your doctor say about all this? What is the reasoning behind combining those doses of Prozac and Zoloft? Is he aware of the danger in doing that?
Posted by mtdewcmu on December 26, 2009, at 21:58:37
In reply to Re: Nighttime dysphoria and already on meds..., posted by bleauberry on December 26, 2009, at 20:24:10
> I would consider replacing Remeron and Wellbutrin with first choice Nortriptyline, second choice Savella.
>
> It sounds like a daily rhythm, timeclock, adrenaline, cortisol thing. Complicated. But norepinephrine reuptake inhibitors can balance that out and reset it over time. Remeron and Wellbutrin are, in my view, likely to be worsening it.
>
> If you had your cortisol checked on the Adrenal Stress Index test, it would not surprise me if the 3rd saliva sample of the day (the one you take at the time the sun goes down) is way below where it should be. An NRI will help compensate for that in the short run and restore it to normal in the long run. As will specific attention to foods you choose to eat, but that's another story.
>
> The only reason I happen to recognize what you are talking about is because I've had some experience with it myself.
>
> What does your doctor say about all this? What is the reasoning behind combining those doses of Prozac and Zoloft? Is he aware of the danger in doing that?I did not think to mention it, or it didn't seem like as much of an issue at my last appointment. The reason I am taking both Prozac and Zoloft is because I am transitioning from Zoloft to Prozac, and the doctor recommended a cross-taper. It doesn't seem like much, as it has not been causing any typical SSRI side effects.
Well, today I took 45mg of Remeron, and I felt better for the first part of the day. Then I took an extra 20mg Prozac. So that makes 40 of Prozac per day. I actually feel some effects now!
I was thinking about nortriptyline, as I had an initially good experience with amitriptyline when I tried it years ago (for sleep, but it was too stimulating, so I tried taking in the morning). The problem with amitriptyline was that my heart rate went up to about 120 after a few days. Cardiac effects are associated with all tricyclics, so I am not sure if I could tolerate any of them. However, I have read that nortriptyline is somewhat better in this respect. Nortrip is something I'm holding in reserve in case a higher dose of Prozac and Remeron does not work.
Posted by Phillipa on December 26, 2009, at 23:35:08
In reply to Re: Nighttime dysphoria and already on meds..., posted by mtdewcmu on December 26, 2009, at 21:58:37
How you doing today just home??? Love Phillipa
Posted by mtdewcmu on December 27, 2009, at 5:38:39
In reply to Re: Nighttime dysphoria and already on meds... » mtdewcmu, posted by Phillipa on December 26, 2009, at 23:35:08
> How you doing today just home??? Love Phillipa
I woke up too early this morning, but it was my own fault. I'm hoping to go back to sleep.
Posted by bleauberry on December 27, 2009, at 6:46:31
In reply to Re: Nighttime dysphoria and already on meds..., posted by mtdewcmu on December 26, 2009, at 21:58:37
Well, I am relieved. You seem to have a smart plan and know what you are doing. You seem to be in more control of the situation than I was with mine several times. :-)
Back to the original symptoms, I suspect an adrenal exhaustion scenario. The largest dip of the 24 hour period probably occurs when you feel the sinking. If my hunch is correct, Remeron in particular is not doing you any favors, as it is putting additional stress on the already struggling adrenal glands. I know this particular topic pretty well and just thought it would be important to throw it out there in case someone else doesn't.
If my hunch were correct, a norepinephrine reuptake inhibitor holds a strong potential, through feedback loops and artificially boosting norepinephrine, to rebalance the entire network that is involved.
> > I would consider replacing Remeron and Wellbutrin with first choice Nortriptyline, second choice Savella.
> >
> > It sounds like a daily rhythm, timeclock, adrenaline, cortisol thing. Complicated. But norepinephrine reuptake inhibitors can balance that out and reset it over time. Remeron and Wellbutrin are, in my view, likely to be worsening it.
> >
> > If you had your cortisol checked on the Adrenal Stress Index test, it would not surprise me if the 3rd saliva sample of the day (the one you take at the time the sun goes down) is way below where it should be. An NRI will help compensate for that in the short run and restore it to normal in the long run. As will specific attention to foods you choose to eat, but that's another story.
> >
> > The only reason I happen to recognize what you are talking about is because I've had some experience with it myself.
> >
> > What does your doctor say about all this? What is the reasoning behind combining those doses of Prozac and Zoloft? Is he aware of the danger in doing that?
>
> I did not think to mention it, or it didn't seem like as much of an issue at my last appointment. The reason I am taking both Prozac and Zoloft is because I am transitioning from Zoloft to Prozac, and the doctor recommended a cross-taper. It doesn't seem like much, as it has not been causing any typical SSRI side effects.
>
> Well, today I took 45mg of Remeron, and I felt better for the first part of the day. Then I took an extra 20mg Prozac. So that makes 40 of Prozac per day. I actually feel some effects now!
>
> I was thinking about nortriptyline, as I had an initially good experience with amitriptyline when I tried it years ago (for sleep, but it was too stimulating, so I tried taking in the morning). The problem with amitriptyline was that my heart rate went up to about 120 after a few days. Cardiac effects are associated with all tricyclics, so I am not sure if I could tolerate any of them. However, I have read that nortriptyline is somewhat better in this respect. Nortrip is something I'm holding in reserve in case a higher dose of Prozac and Remeron does not work.
Posted by mtdewcmu on December 27, 2009, at 10:54:26
In reply to Re: Nighttime dysphoria and already on meds... » mtdewcmu, posted by bleauberry on December 27, 2009, at 6:46:31
> Well, I am relieved. You seem to have a smart plan and know what you are doing. You seem to be in more control of the situation than I was with mine several times. :-)
>Thanks. It does bother me that I'm still on 2 SSRIs. I am going down to 50mg of Zoloft this week.
> Back to the original symptoms, I suspect an adrenal exhaustion scenario. The largest dip of the 24 hour period probably occurs when you feel the sinking. If my hunch is correct, Remeron in particular is not doing you any favors, as it is putting additional stress on the already struggling adrenal glands. I know this particular topic pretty well and just thought it would be important to throw it out there in case someone else doesn't.
>I tried taking a low dose of Cortef each day a few years ago, and it didn't produce a noticeable benefit. I don't think it's an adrenal problem; I think it's entirely depression.
I think the sinking feeling when the sun goes down must be something akin to SAD.
Why would Remeron be worse than an NRI? Remeron blocks presynaptic alpha-2 receptors to achieve the same effect on norepinephrine.
> If my hunch were correct, a norepinephrine reuptake inhibitor holds a strong potential, through feedback loops and artificially boosting norepinephrine, to rebalance the entire network that is involved.
>
Posted by Roslynn on December 27, 2009, at 17:21:28
In reply to Nighttime dysphoria and already on meds..., posted by mtdewcmu on December 25, 2009, at 20:05:29
Hi mtdewcmu,
I don't have any suggestions regarding the meds, but I wanted to say that I too have experienced the sinking feeling when the sun sets in winter. It was a lot worse last winter for me. Mine was mixed with a bit of panic.
Are you able to get out a bit? What I found that helped me was being somewhere other than home when the sun set. Like, at a bookstore or coffee shop. I would make sure I was out, distracted by something, between the hours of say 4 and 7. Even if I was alone it helped to be around other people. Anyway, just a suggestion...and wanted to let you know you were not alone.
Posted by mtdewcmu on December 27, 2009, at 21:26:23
In reply to Re: Nighttime dysphoria and already on meds..., posted by Roslynn on December 27, 2009, at 17:21:28
> Hi mtdewcmu,
>
> I don't have any suggestions regarding the meds, but I wanted to say that I too have experienced the sinking feeling when the sun sets in winter. It was a lot worse last winter for me. Mine was mixed with a bit of panic.
> Are you able to get out a bit? What I found that helped me was being somewhere other than home when the sun set. Like, at a bookstore or coffee shop. I would make sure I was out, distracted by something, between the hours of say 4 and 7. Even if I was alone it helped to be around other people. Anyway, just a suggestion...and wanted to let you know you were not alone.I'm sorry to hear that you have suffered this problem, too. I started taking a second 20mg Prozac around midday, and so far it is helping to get me through the evening. Thanks for your support.
Posted by mtdewcmu on December 27, 2009, at 22:03:19
In reply to Re: Nighttime dysphoria and already on meds..., posted by Roslynn on December 27, 2009, at 17:21:28
I forgot to mention that I also bumped up the Remeron to 45mg. So now I am on
Remeron 45mg
Prozac 20mg b.i.d. (40mg total)
Wellbutrin 150mg (Budeprion XL)
A little bit of Zoloft and Abilify.At least I can feel it working now.
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.