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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 19 of 19. This is the beginning of the thread.
Posted by g_g_g_unit on February 16, 2012, at 21:40:17
So I took 250mg of Depakote last night in an attempt to ease my Parnate irritability.
Unfortunately, I found it activating - I went from feeling bleary-eyed and exhausted to being unable to fall asleep until 3am.
Is this a weird reaction? Should I try raising the dose?
Also, if I'm only taking the IR (no ER in Australia), would there likely be withdrawal during the day?
Posted by SLS on February 17, 2012, at 7:17:22
In reply to Depakote questions, posted by g_g_g_unit on February 16, 2012, at 21:40:17
> So I took 250mg of Depakote last night in an attempt to ease my Parnate irritability.
>
> Unfortunately, I found it activating - I went from feeling bleary-eyed and exhausted to being unable to fall asleep until 3am.That's interesting. That might not be such a bad thing.
Questions: Was your mind more active than usual? Were your thoughts more positive, or were they more depressive? Was your level of anxiety higher or lower?
> Is this a weird reaction?
I'm sure God wouldn't think so. However, us humans don't know any better than to call it a paradoxical reaction. I have not heard of it before. But then again, I am in no position to observe hundreds of people on valproate.
> Should I try raising the dose?
Based upon my experience with valproate, I would probably opt to raise the dosage to between 500 - 1000 mg/day. You should dose twice a day. The half-life of valproate is somewhat short (9 - 16 hours). Your taking valproate is only an experiment of a doctor. If going higher in dosage makes things worse, then perhaps it will be time to end the experiment. However, if you do discontinue it, and you need an augmenter in your antidepressant therapy at some point in the future, valproate might be an interersting choice. It depends on whether it is energizing in a good way or a bad way.
Let us know how it goes.
- Scott
Posted by ed_uk2010 on February 17, 2012, at 14:32:37
In reply to Depakote questions, posted by g_g_g_unit on February 16, 2012, at 21:40:17
>I went from feeling bleary-eyed and exhausted to being unable to fall asleep until 3am.
>
> Is this a weird reaction?Not that weird. Insomnia has been reported in clinical trials of valproate. I've heard that it occurs most often in children, but also in adults in some cases, especially at high doses.
>Also, if I'm only taking the IR (no ER in Australia), would there likely be withdrawal during the day?
Most valproate tablets are enteric-coated (gastro-resistant). This does delay the release of valproate to some extent. There are also some sustained-release formulations eg. Epilim Chrono in the UK.
Posted by SLS on February 17, 2012, at 15:13:23
In reply to Re: Depakote questions » g_g_g_unit, posted by ed_uk2010 on February 17, 2012, at 14:32:37
> >I went from feeling bleary-eyed and exhausted to being unable to fall asleep until 3am.
> >
> > Is this a weird reaction?
>
> Not that weird. Insomnia has been reported in clinical trials of valproate. I've heard that it occurs most often in children, but also in adults in some cases, especially at high doses.For those people who experience insomnia on valproate, is daytime sedation still a problem?
Do you know what the mechanism is behind the production of insomnia by valproate? Could it be some sort of physiological disinhibition?
- Scott
Posted by linkadge on February 17, 2012, at 20:21:34
In reply to Re: Depakote questions » ed_uk2010, posted by SLS on February 17, 2012, at 15:13:23
Valproate mixes with antidepressants like cologne mixes with B.O.
I've never had sucess with valproate plus and AD. The combination just made me more disinhibited. Valproate alone wasn't bad though.
Linkadge
Posted by g_g_g_unit on February 17, 2012, at 20:30:08
In reply to Re: Depakote questions, posted by SLS on February 17, 2012, at 7:17:22
> > So I took 250mg of Depakote last night in an attempt to ease my Parnate irritability.
> >
> > Unfortunately, I found it activating - I went from feeling bleary-eyed and exhausted to being unable to fall asleep until 3am.
>
> That's interesting. That might not be such a bad thing.How so?
>
> Questions: Was your mind more active than usual? Were your thoughts more positive, or were they more depressive? Was your level of anxiety higher or lower?Yes, my mind was more active I believe. My anxiety was lower. My thoughts may have been more depressive, though there's also some life circumstance stuff going on at the moment.
I found the combination of anxiolysis, increased energy, increased mental activity yet with paradoxical decrease in alertness and attention to be frustrating.
>
> > Is this a weird reaction?
>
> I'm sure God wouldn't think so. However, us humans don't know any better than to call it a paradoxical reaction. I have not heard of it before. But then again, I am in no position to observe hundreds of people on valproate.
>
> > Should I try raising the dose?
>
> Based upon my experience with valproate, I would probably opt to raise the dosage to between 500 - 1000 mg/day. You should dose twice a day. The half-life of valproate is somewhat short (9 - 16 hours). Your taking valproate is only an experiment of a doctor. If going higher in dosage makes things worse, then perhaps it will be time to end the experiment. However, if you do discontinue it, and you need an augmenter in your antidepressant therapy at some point in the future, valproate might be an interersting choice. It depends on whether it is energizing in a good way or a bad way.
>
> Let us know how it goes.
>I've been finding that I'm calmer and my mood is more flat/even in the mornings. This offsets the irritability of the Parnate to some extent, but it also leaves me feeling dopey and bored, which results in agitation.
Posted by SLS on February 17, 2012, at 21:31:06
In reply to Re: Depakote questions » SLS, posted by g_g_g_unit on February 17, 2012, at 20:30:08
> I've been finding that I'm calmer and my mood is more flat/even in the mornings. This offsets the irritability of the Parnate to some extent, but it also leaves me feeling dopey and bored, which results in agitation.
That doesn't sound so good.
Were there any other drugs considered to treat your irritability? I had thought to mention propranolol, but I don't know enough about its usage in a situation like yours.
Which anti-anxiety drugs do you want to avoid?
I doubt that you want to allow for mission-creep and start using anxiolytics for an extended period of time to treat a side effect that is thought to be only temporary. If your doctor likes the idea of using an anticonvulsant to treat irritability, Trileptal and Neurontin would make rational alternatives.
What is your current dosage of Parnate?
- Scott
Posted by SLS on February 17, 2012, at 21:37:41
In reply to Re: Depakote questions, posted by linkadge on February 17, 2012, at 20:21:34
> Valproate mixes with antidepressants like cologne mixes with B.O.
My olfactory bulb is writhing in agony at the mere thought.
> I've never had sucess with valproate plus and AD.
I was never able to make it "stick". My depression would improve only transiently upon the initiation of valproate treatment and immediately after subsequent dosage adjustments. Perhaps that was a bipolar thing.
> The combination just made me more disinhibited.
How do you experience disinhibition?
- Scott
Posted by g_g_g_unit on February 18, 2012, at 1:38:29
In reply to Re: Depakote questions » g_g_g_unit, posted by SLS on February 17, 2012, at 21:31:06
> > I've been finding that I'm calmer and my mood is more flat/even in the mornings. This offsets the irritability of the Parnate to some extent, but it also leaves me feeling dopey and bored, which results in agitation.
>
> That doesn't sound so good.Hi Scott.
I tend to get quite agitated and frustrated whenever I'm sedated because it interferes with my ability to concentrate. So it's hard to know whether this is a direct effect of the Depakote, or simply a personal reaction to the state it induces in me.
Last night I was up until 4am after dosing at 10pm. I was reading through my journal from the last time I trialed Depakote and it seemed like if I took 500mg at night, I'd fall asleep 2 hours later, so I may increase the dose. The only frustrating thing is it induces acute cognitive impairment in me, so it's hard to know what to do during those 2 hours before I fall sleep.
Does the apathy/mental dulling ever pass on AC's, or is it a case of what you see is what you get?
>
> Were there any other drugs considered to treat your irritability? I had thought to mention propranolol, but I don't know enough about its usage in a situation like yours.I periodically speak to Dr Gillman to update him on my treatment and propranolol was his recommendation as well. I guess great minds must think alike =)
>
> Which anti-anxiety drugs do you want to avoid?None. It's a matter of what my psychiatrist is willing to prescribe.
>
> I doubt that you want to allow for mission-creep and start using anxiolytics for an extended period of time to treat a side effect that is thought to be only temporary. If your doctor likes the idea of using an anticonvulsant to treat irritability, Trileptal and Neurontin would make rational alternatives.
>
> What is your current dosage of Parnate?
>Only 10mg.
Posted by linkadge on February 18, 2012, at 6:03:46
In reply to Re: Depakote questions » linkadge, posted by SLS on February 17, 2012, at 21:37:41
>How do you experience disinhibition
It just seemed to cause more impulsiveness, more moving around physically, more likely to make stupid uncalculated statements.
Posted by SLS on February 18, 2012, at 7:00:36
In reply to Re: Depakote questions » SLS, posted by g_g_g_unit on February 18, 2012, at 1:38:29
Hi GGG.
> Does the apathy/mental dulling ever pass on AC's, or is it a case of what you see is what you get?
I found that much of the cognitive "brain-fog" stuff disappeared early during my first trial of Depakote. I am guessing that it took about a week for this to happen. With a drug like Tegretol, the sedation tends to persist. Of course, two people can react differently to the same drug. If the brain-fog and cognitive dulling does not disappear within two weeks, I would begin to think about finding an alternative treatment. Depakote can produce mild to moderate depression as a side effect.
> > Were there any other drugs considered to treat your irritability? I had thought to mention propranolol, but I don't know enough about its usage in a situation like yours.
>
> I periodically speak to Dr Gillman to update him on my treatment and propranolol was his recommendation as well. I guess great minds must think alike =)> > Which anti-anxiety drugs do you want to avoid?
> None. It's a matter of what my psychiatrist is willing to prescribe.
This is a good thing. I would try the propranalol first followed by a benzodiazepine if necessary, knowing that it will be used for a short period of time. I would recommend something with a long half-life like Klonopin, but that drug can produce depression. I happen to like Ativan. It feels very "clean" to me. I experience no cognitive dulling or hangover effect. I am somewhat afraid of Xanax. Some people come to like its euphoriant effects too much. Not everyone experiences this, though.
> > What is your current dosage of Parnate?
> Only 10mg.Gosh. I would begin to entertain the possibility that Parnate is the wrong drug for you. Damn. Did Dr. Gillman say that he has seen this before with Parnate, and that it resolves with time? I definitely experience stimulant-like effects when I first start taking Parnate. They seem to disappear between one and two weeks. However I start at 30 mg and move up to 40 mg by the end of the first week.
You know that someone is bound to mention Nardil or Marplan as a replacement for Parnate. Oops. I guess I just did. :-)
What are the things about Nardil that might dissuade you from trying it?
Nardil effectively treats:
- unipolar depression (especially for the atypical subtype)
- bipolar depression
- social phobia / social anxiety
- GAD
- OCDI admire your fortitude and willingness to tolerate adverse effects in an effort to give a treatment a chance to work.
- Scott
Posted by g_g_g_unit on February 18, 2012, at 7:21:15
In reply to Re: Depakote questions » g_g_g_unit, posted by SLS on February 18, 2012, at 7:00:36
> Hi GGG.
>
> > Does the apathy/mental dulling ever pass on AC's, or is it a case of what you see is what you get?
>
> I found that much of the cognitive "brain-fog" stuff disappeared early during my first trial of Depakote. I am guessing that it took about a week for this to happen. With a drug like Tegretol, the sedation tends to persist. Of course, two people can react differently to the same drug. If the brain-fog and cognitive dulling does not disappear within two weeks, I would begin to think about finding an alternative treatment. Depakote can produce mild to moderate depression as a side effect.Thanks. I'll keep that in mind.
>
> > > Were there any other drugs considered to treat your irritability? I had thought to mention propranolol, but I don't know enough about its usage in a situation like yours.
> >
> > I periodically speak to Dr Gillman to update him on my treatment and propranolol was his recommendation as well. I guess great minds must think alike =)
>
> > > Which anti-anxiety drugs do you want to avoid?
>
> > None. It's a matter of what my psychiatrist is willing to prescribe.
>
> This is a good thing. I would try the propranalol first followed by a benzodiazepine if necessary, knowing that it will be used for a short period of time. I would recommend something with a long half-life like Klonopin, but that drug can produce depression. I happen to like Ativan. It feels very "clean" to me. I experience no cognitive dulling or hangover effect. I am somewhat afraid of Xanax. Some people come to like its euphoriant effects too much. Not everyone experiences this, though.My psychiatrist definitely has certain preferences when it comes to prescribing. He has no issues with Xanax, though prefers to avoid Ativan, as he says tolerance builds relatively quickly. He's also a fan of Valium, though seemed reluctant when I mentioned Klonopin.
>
> > > What is your current dosage of Parnate?
>
> > Only 10mg.
>
> Gosh. I would begin to entertain the possibility that Parnate is the wrong drug for you. Damn. Did Dr. Gillman say that he has seen this before with Parnate, and that it resolves with time? I definitely experience stimulant-like effects when I first start taking Parnate. They seem to disappear between one and two weeks. However I start at 30 mg and move up to 40 mg by the end of the first week.Is your concern based on the fact that the stimulation hasn't disappeared?
I've been on Parnate (albeit beginning at 20mg) for 12 days total and still notice mild euphoria and stimulation with each dose. However, I do tend to be excessively sensitive to medication and can barely tolerate starting doses of Dexedrine. Do you think the fact that you start at 30mg might mean you develop a tolerance faster?
It was my hope that the stimulant effect might continue to some degree, since I'd like the drug to improve my attention. Dr. Gillman believed that a higher dose would potentially offset any irritability and anxiety. I'd like to reach at least 30-40mg before I give up.
>
> You know that someone is bound to mention Nardil or Marplan as a replacement for Parnate. Oops. I guess I just did. :-)
>
> What are the things about Nardil that might dissuade you from trying it?I don't believe it would be as effective (if at all?) for ADHD.
>
> Nardil effectively treats:
>
> - unipolar depression (especially for the atypical subtype)
> - bipolar depression
> - social phobia / social anxiety
> - GAD
> - OCD
>
> I admire your fortitude and willingness to tolerate adverse effects in an effort to give a treatment a chance to work.Thanks =) I figured 12 days was far too early to bail on a trail. If anything though I'm highly antsy and impatient when it comes to treatment.
Posted by SLS on February 18, 2012, at 7:56:44
In reply to Re: Depakote questions » SLS, posted by g_g_g_unit on February 18, 2012, at 7:21:15
Hi.
I agree that it would be optimal for you to continue your trial of Parnate.
> Dr. Gillman believed that a higher dose would potentially offset any irritability and anxiety.
I believe I saw a poster write that somewhere.
:-)
Just to give you some perspective, Parnate generally requires a minimum dosage of 40 mg to treat depression. I don't know about ADD. I don't reap the benefits of Parnate until I reach a dosage of 80 mg. From what I can see, the true therapeutic dosage range for Parnate is 40 - 80 mg. A special high-dose treatment used for stubborn TRD cases uses dosages of 120 mg and higher. For many people, Parnate has a more acceptable side effect profile than Nardil.
In its clinical history, Parnate has been tried in treating conditions as diverse as ADD, OCD, and borderline personality disorder. It is even sometimes effective in treating social anxiety disorder.
Keep the faith.
- Scott
Posted by ed_uk2010 on February 18, 2012, at 13:21:23
In reply to Re: Depakote questions » ed_uk2010, posted by SLS on February 17, 2012, at 15:13:23
>Do you know what the mechanism is behind the production of insomnia by valproate? Could it be some sort of physiological disinhibition?
I'm not sure of the mechanism, but it does seem to be a problem.
http://www.ncbi.nlm.nih.gov/pubmed/22315172
'VPA....can increase awakening and arousal. VPA can increase wake time after sleep onset.'
Posted by ed_uk2010 on February 18, 2012, at 13:54:24
In reply to Re: Depakote questions, posted by linkadge on February 17, 2012, at 20:21:34
>Valproate mixes with antidepressants like cologne mixes with B.O
I just laughed out loud. I love your sense of humour!
Posted by g_g_g_unit on February 20, 2012, at 1:35:37
In reply to Re: Depakote questions » g_g_g_unit, posted by SLS on February 18, 2012, at 7:56:44
> Just to give you some perspective, Parnate generally requires a minimum dosage of 40 mg to treat depression. I don't know about ADD. I don't reap the benefits of Parnate until I reach a dosage of 80 mg. From what I can see, the true therapeutic dosage range for Parnate is 40 - 80 mg.
Just to update you:
I noticed that after my second 5mg dose this afternoon, I felt unusually calm, focused and emotionally even.
I wonder if some tolerance is developing to the more abrasive side of the stimulation, or if this is an effect of the Depakote. Overall, I'm less angry and irritable, I would say, but I also feel very grey, sad and depressed, particularly when a dose wears off.
Since Depakote isn't helping my sleep at this point, I might give it another week or so before trying something else.
Posted by SLS on February 20, 2012, at 6:51:39
In reply to Re: Depakote questions » SLS, posted by g_g_g_unit on February 20, 2012, at 1:35:37
> > Just to give you some perspective, Parnate generally requires a minimum dosage of 40 mg to treat depression. I don't know about ADD. I don't reap the benefits of Parnate until I reach a dosage of 80 mg. From what I can see, the true therapeutic dosage range for Parnate is 40 - 80 mg.
> Just to update you:
>
> I noticed that after my second 5mg dose this afternoon, I felt unusually calm, focused and emotionally even.This great news!
> I wonder if some tolerance is developing to the more abrasive side of the stimulation, or if this is an effect of the Depakote. Overall, I'm less angry and irritable, I would say, but I also feel very grey, sad and depressed, particularly when a dose wears off.
This is to be expected, of course. Hopefully, we will see a more consistent improvement once you get up into the therapeutic dosage range for Parnate. The subjective stimulant effect might disappear completely. However, insomnia might worsen.
> Since Depakote isn't helping my sleep at this point, I might give it another week or so before trying something else.Unless you think that there is a chance that you are bipolar, it probably makes sense to discontinue the Depakote if it is not helping you sleep. However, I do recall your describing an improvement in energy when you first started taking it. I would keep that in mind as you progress through your drug trials. That being said, I would suggest that Depakote might be making you feel "very grey, sad and depressed" if this is not your usual presentation.
I am optimistic for you.
- Scott
Posted by g_g_g_unit on February 20, 2012, at 7:10:07
In reply to Re: Depakote questions » g_g_g_unit, posted by SLS on February 20, 2012, at 6:51:39
> > Just to update you:
> >
> > I noticed that after my second 5mg dose this afternoon, I felt unusually calm, focused and emotionally even.
>
> This great news!Thanks Scott. I know it seems a little silly, given it's such a tiny dose, but I am pretty sensitive. Hopefully the effect continues.
>
> > I wonder if some tolerance is developing to the more abrasive side of the stimulation, or if this is an effect of the Depakote. Overall, I'm less angry and irritable, I would say, but I also feel very grey, sad and depressed, particularly when a dose wears off.
>
> This is to be expected, of course. Hopefully, we will see a more consistent improvement once you get up into the therapeutic dosage range for Parnate. The subjective stimulant effect might disappear completely. However, insomnia might worsen.
>
> > Since Depakote isn't helping my sleep at this point, I might give it another week or so before trying something else.
>
> Unless you think that there is a chance that you are bipolar, it probably makes sense to discontinue the Depakote if it is not helping you sleep. However, I do recall your describing an improvement in energy when you first started taking it. I would keep that in mind as you progress through your drug trials. That being said, I would suggest that Depakote might be making you feel "very grey, sad and depressed" if this is not your usual presentation.
>
> I am optimistic for you.I'm not sure if I am Bipolar or not. I do notice that my mood swings a bit on the Parnate, but I figured that's related to the stimulant effect. The Depakote has quelled the rage somewhat, but replaced it with a certain sadness. I also noticed a little greyness on the Parnate too, perhaps, which tends to happen with stimulants (unrelated to it's anti-depressant effects, I hope), so either the Depakote is not helping or exacerbating it.
I think even if I was Bipolar though the sleep thing would be a deal-breaker. It is a little energizing, but it produces too much acute cognitive impairment for me to want to take it during the day, unless it was a temporary thing.
I'm going to e-mail my psychiatrist to look into Prazosin based on your recommendation.
Anyway, I'm rather touched that you've been keeping track of my reactions etc. Thanks for your input! I find your responses very comforting at the least.
Posted by SLS on February 20, 2012, at 8:28:07
In reply to Re: Depakote questions » SLS, posted by g_g_g_unit on February 20, 2012, at 7:10:07
> I think even if I was Bipolar though the sleep thing would be a deal-breaker.
Please don't let insomnia be a deal-breaker until you have tried to treat it aggressively. If Parnate works, you might have to take 3 drugs to treat the insomnia. In my way of thinking, it is well worth it.
In 1987, a doctor placed me on a combination of Parnate and desipramine. I didn't sleep for 2 weeks before he decided to intervene. I ended up taking a combination of Halcion and Ativan. It worked like a charm, and I slept very well. I went on to respond to this antidepressant combination. They were the best months of my life. It was well worth taking two benzodiazepines in order to live those months in remission. I relapsed only because this doctor had me discontinue the two antidepressants for fear of an escalating drug-induced mania. If Depakote were around back then, I could have stayed on the drugs and abolish the mania. But then, you would never know me. :-)
- Scott
This is the end of the thread.
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