![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 30 to 54 of 54. Go back in thread:
Posted by Zyprexa on April 26, 2012, at 18:14:18
In reply to i cant even smile., posted by b2chica on April 25, 2012, at 14:50:32
I suggest going up on perphenazine. Back on it and up the dose. 4-8mg /2-3 times a day. I think it may help with weight. Becuase it makes you tired and you sleep off the weight. It does also help with anxiety. I'm pretty sure of that now.
Why did you go off the perphenazine?
Posted by SLS on April 27, 2012, at 7:05:44
In reply to Re: i cant even smile. » SLS, posted by Alexei on April 26, 2012, at 13:50:32
> Thank you for this. The only concern would be postural hypotension.... since both drugs can cause it.
It helps to hydrate with a fluid that contains electrolytes like Gatorade. For me, the hypotension was worst at the beginning of treatment and mitigated over time. It was well worth the wait.
> Would it be possible to remain on vyvanse?
I don't know about Vyvanse, but I have tried Dexedrine along with Parnate and desipramine. There were no adverse effects.
http://www.dr-bob.org/tips/split/MAOIs-in-high-doses-and-wi.html
"Combined MAOI, TCA, and direct stimulant therapy of treatment-resistant depression"
http://www.ncbi.nlm.nih.gov/pubmed/3997787
I wish I could find the full text.
http://www.dr-bob.org/tips/split/TCAs-+-MAOIs.html
> What would make desipramine the preferred TCA?I was making reference to using desipramine when weight-gain is a concern. For me, nortriptyline produces a better antidepressant response than desipramine. However, the first time I entered a period of extended remission, it was the result of treatment using a Parnate + desipramine combination.
> I know it is one of the most potent NRI's. Could low dose seroquel be used for insomnia?
I can't think of any reason why not.
http://www.theannals.com/content/40/3/567.full
Interestingly, high dosages of Seroquel result in a certain amount of NE reuptake inhibition via an active metabolite.
- Scott
Posted by Alexei on April 27, 2012, at 8:13:07
In reply to Re: i cant even smile. » Alexei, posted by SLS on April 27, 2012, at 7:05:44
> Interestingly, high dosages of Seroquel result in a certain amount of NE reuptake inhibition via an active metabolite.
>
> - Scott
How high a dose are you thinking? 200-300mg?
Thank you for all the links. I'm finding seroquel is a drug that covers a lot of ground.... Insomnia, anxiety, controlling OCD and mania.
And it works well as an antidepressant.... as good as abilify, IMHO.
Posted by bleauberry on April 27, 2012, at 17:47:06
In reply to i cant even smile., posted by b2chica on April 25, 2012, at 14:50:32
> i make vailed attempts at passersby but my mouth cant even make a smile without getting shaky like i haven't used those muscles in a year.
Yeah, dang, I've been through stages where it was that bad too. Horrible. Part of mine was a zyprexa related cycling thing. I felt best in evening a couple hours after dose, a bizarre waking anxiety that would go away in a couple hours, and a dreary day until the next dose. Weird. I'm convinced it is actually adrenal issues treatable with herbs and diet, and that somehow zyprexa exaggerates that particular chemistry. Because my daily patterns on zyprexa were exactly what I saw on my 4 sample 24 hour cortisol test. In other words while zyprexa is really good at treating anxiety in general, it is not good for treating that kind of anxiety and in fact maybe makes it worse.
>
> since starting back on zyprexa ive had about equal time good and bad, with feeling worst about 11-5 or 7 at night. best in the morning.
>> i started menses today and i think it has dropped me Terribly low.
> cant concentrate at work and i'm under deadline that i feel is piling up by the second.
> my memory s#cks.
> feeling gray and tingly in my mind.Cortisol is only one of several major hormones and I know how it felt, feels, so sure I am on board with the idea that hormones can whack mood all over the map. I think that's where the adaptogen herbs can do a good job. Rhodiola rosea, eleuthero, ashwaghanda, probably the three best in my opinion. In my experience with them, rhodiola has the most prominent and rapid antidepressant and antianxiety action. All of them really take months up to a year to do their stuff but they also have immediate effects and in that regard I think rhodiola is my first pick.
>
> i'm sure its due to menses, however i also stopped taking my perphenazine. Even though it was so little should i have continued to take it? was it somehow helping with depression too? i was placed on it for anxiety thats why low dose (2mg am and 4mg pm).If I'm not mistaken, perphenazine at very low doses is sort of similar to amisulpride at low doses...dopamine stimulation being more prominent than dopamine blunting, though both are happening. And so, like amisulpride, it has potential in depression and anxiety. Regardless, yeah, the recent stoppage of it would probably cause some moderate to severe discomfort for a few days to a couple weeks maybe as the body adjusts to not having that molecule.
>
> i just want to curl up in bed and stare at the wall. i might call in sick tomorrow... i dont know that i'm any good here.
>
> any suggestions.I know it sucks, believe me I know, but no matter how in the dumps you are tomorrow...and maybe you won't be...go to work. One minute at a time. Really hard and the clock seems to go too slow so it helps me to get as immersed into something as I can and just focus on that and block out everything else. Anyway, I see depression as a tool of the demons and I'm not going to let them win a battle without a fight.
> PS i am NOT upping zyprexa to 10. i've already gained 15lbs but now able to control appetite better and i can get up to exercise. if i go to 10 my appetite increases AND i wont beable to wake up in the morning.
> so please dont suggest that....please.
>Over the 8 years I was on zyprexa I refused to go any higher. Most of the time 5mg was good. A couple times I tried higher doses at 7.5 and 10 but those doses didn't agree with me. People do fine or really good with 10mg, but I'm not one of them. I knew the longterm risks and consequences of antipsychotics and I was very aware of it and I also knew that complications were correlated with the size of the dose and the length of time. I couldn't really control the length of time since I din't have a crystal ball to predict future, but I figured it would be a while, years maybe, so the part I could control was the dose which stayed at 5mg. But that's just my story shared for comparison that's all.
It seems like depression has its grasp stronger than other symptoms, is that right? If so then the only course of action is to focus immediately on ways to enhance/support mood specifically, starting with and hopefully being fine with a few easy health food store items. Maybe medication is perceived as an immediate choice then my opinion would be to go for the norepinephrine+serotonin balanced approaches. That's because I think they work faster than other meds when they work, they work more often, and the response is more robust and long lasting. Such as combos of zoloft or prozac with nortriptyline or desipramine; savella by itself or combined with any other common antidepressant; clomipramine. Maybe the simple addition of prozac. I know first hand because it worked well for years for me, there is a special synergy between prozac and zyprexa. It's different than either med alone and the end result is more than the parts combined. Anyway, good potential with that combination and well researched.
Hang in there. I'm not having a bad day today but when I do have bad days you described them very well so just wanted you to know someone else can relate.
Posted by SLS on April 27, 2012, at 23:09:33
In reply to Re: i cant even smile. » SLS, posted by Alexei on April 27, 2012, at 8:13:07
> > Interestingly, high dosages of Seroquel result in a certain amount of NE reuptake inhibition via an active metabolite.
> How high a dose are you thinking? 200-300mg?More like 400 mg. However, Seroquel begins to show antidepressant properties at dosages as low as 150 mg. It is difficult to ascribe its antidepressant effect solely to NE reuptake inhibition.
http://thelastpsychiatrist.com/2010/02/how_seroquel_xr_works_part_1.html
- Scott
Posted by Alexei on April 28, 2012, at 6:40:58
In reply to Re: i cant even smile. » Alexei, posted by SLS on April 27, 2012, at 23:09:33
> More like 400 mg. However, Seroquel begins to show antidepressant properties at dosages as low as 150 mg. It is difficult to ascribe its antidepressant effect solely to NE reuptake inhibition.
>
> http://thelastpsychiatrist.com/2010/02/how_seroquel_xr_works_part_1.html
>
>
> - ScottThank you. The Last Psychiatrist is a great site. Do you have any experience with seroquel? I would think it makes no sense to take abilify and seroquel at the same time... sort of redundant.... plus more of the AAP side effects.
(From bleauberry) .... "Such as combos of zoloft or prozac with nortriptyline or desipramine; savella by itself or combined with any other common antidepressant; clomipramine."
I've come to think these combos are more effective than the newer, more marketed snri's such as effexor and cymbalta.
Posted by papillon2 on April 28, 2012, at 7:36:27
In reply to Re: i cant even smile. » SLS, posted by Alexei on April 28, 2012, at 6:40:58
b2, how are you?
Papillon
Posted by bleauberry on April 28, 2012, at 8:37:40
In reply to Re: i cant even smile. » SLS, posted by Alexei on April 28, 2012, at 6:40:58
>
> (From bleauberry) .... "Such as combos of zoloft or prozac with nortriptyline or desipramine; savella by itself or combined with any other common antidepressant; clomipramine."
>
> I've come to think these combos are more effective than the newer, more marketed snri's such as effexor and cymbalta.
>
>Yeah, me too. That is partially based on just what my eyes have casually anecdotally observed over the years, and on experiences of others such as Dr Gillman for one example.
One reason the existing SNRIs don't measure up, imo, is because they really aren't SNRIs. It's more of a marketing ploy than an accurate name. Cymbalta ratio of serotonin to norepinephrine is 9:1....not much NE there. I think prozac actually increases NE in the brain more than the snris do and it isn't even a snri. Effexor is 30:1. Savella is the closest to a true SNRI at a ratio of 2:3.
With any med however, the ratio is fixed. That's where combos come in handy.
Posted by europerep on April 28, 2012, at 11:13:14
In reply to Re: i cant even smile. » Alexei, posted by bleauberry on April 28, 2012, at 8:37:40
> With any med however, the ratio is fixed.
That's not true actually. At low doses, venlafaxine has less NE reuptake inhibition than fluoxetine, but venlafaxine becomes a SNRI at doses of 300mg and upwards.
Posted by SLS on April 28, 2012, at 12:08:33
In reply to Re: i cant even smile. » bleauberry, posted by europerep on April 28, 2012, at 11:13:14
> > With any med however, the ratio is fixed.
>
> That's not true actually. At low doses, venlafaxine has less NE reuptake inhibition than fluoxetine, but venlafaxine becomes a SNRI at doses of 300mg and upwards.You are probably right. This must be what happens when one continues to raise the dosage beyond the point where the SERT binding sites have become saturated with the drug.
Who really knows all the ways in which venlafaxine differs from drugs like sertraline and nortriptyline. The bottom line is to observe what works in real life. Effexor works. My impression is that Savella is not as effective as Effexor in terms of the percentage of people achieving remission. To my knowledge, there is only one study comparing the efficacies of Effexor and Savella. The two drugs were reported to be equally effective at a dosage of 200 mg. Knowing the dosage is important because Effexor becomes fully effective at dosages of 300 mg and higher, while there is no evidence that milnacipran is any more effective at dosages above 200 mg. The manufacturer of Savella lists 200 mg as the maximum dosage while that of Effexor lists the maximum of this drug at 375 mg. It was never a fair fight. It can be inferred from this study that Effexor is more effective than Savella as the rate of response increases substantially when dosages of Effexor are brought up to 300 mg or more, but not when dosages of Savella are increased.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2854083/
- Scott
Posted by europerep on April 28, 2012, at 13:57:56
In reply to Re: i cant even smile., posted by SLS on April 28, 2012, at 12:08:33
Interesting link there!
I find it interesting not only because of the actual findings, but also because I didn't know milnacipran was available in France. You really never know what the French are up to next. On the one hand, they still prescribe the old MAOI iproniazid, on the other hand they introduce new drugs like milnacipran before they are available elsewhere.
So anyhow, thanks for the link.
Posted by bleauberry on April 29, 2012, at 15:10:20
In reply to Re: i cant even smile. » bleauberry, posted by europerep on April 28, 2012, at 11:13:14
That is correct and thank you for pointing out the error. Zoloft has some dopamine impact at very high doses, you mentioned effexor, and such. I guess what I should have said is the meds are basically fixed ratios with some mild to modest variation dependent upon the size of the dose. While effexor impacts NE heavier above 300mg roughly, that impact is still very small compared to its impact on serotonin.
> > With any med however, the ratio is fixed.
>
> That's not true actually. At low doses, venlafaxine has less NE reuptake inhibition than fluoxetine, but venlafaxine becomes a SNRI at doses of 300mg and upwards.
>
>
Posted by SLS on April 29, 2012, at 18:52:08
In reply to Re: i cant even smile., posted by bleauberry on April 29, 2012, at 15:10:20
> That is correct and thank you for pointing out the error. Zoloft has some dopamine impact at very high doses, you mentioned effexor, and such. I guess what I should have said is the meds are basically fixed ratios with some mild to modest variation dependent upon the size of the dose. While effexor impacts NE heavier above 300mg roughly, that impact is still very small compared to its impact on serotonin.
>
> > > With any med however, the ratio is fixed.
> >The binding affinities might be fixed, but not the absolute occupancy. If you were to bring the dosage of Effexor high enough, the ratio of occupancy might approach 1:1.
- Scott
Posted by Dinah on April 30, 2012, at 8:55:22
In reply to Re: i cant even smile., posted by ron1953 on April 26, 2012, at 11:41:48
> It's sad enough having professionals who play doctor and prescribe medications (often with dubious results) in a trial-and-error fashion, but sadder still that there are folks on the internet who are so delusional and/or arrogant as to think they have expertise in the same foggy area. If someone on this site doesn't trust their doctor, perhaps they should question the entire paradigm instead of taking advice from a stranger in the cloud.
That's a scary prospect. It was people at Babble along with my observations that correctly concluded that my mother was having TIA's while the doctors were clueless as to what could be causing her problems. Including the doctors in whose offices she was having TIA's. Including the *neurologist* in the emergency room while she was having a moderate stroke. I was calling around her doctor's offices telling them this is what I thought was wrong. I told the doctor in the emergency room who was sure she was having a seizure that the one I saw sure looked like a TIA.
It might not have made a difference to her care as it turned out. But if I'd have seen one and *not* put my trust in the almighty doctors but instead sought out answers from strangers in the cloud, my mother might not be left with neurolgical problems from a stroke. She trusted the doctors. See where it got her. They couldn't even diagnose a horse, much less a zebra.
I've found out more information from the internet on hoarding and emetophobia than I ever have from any doctor I've ever seen.
It's *our* health. We have the right and the responsibility to seek out any knowledge we can. We and our loved ones are the ones who live with it, and we're the ones who care.
It's also our responsibility not to blindly follow the advice of strangers in the cloud just as much as it is to not blindly follow the advice of the high and mighty doctors. Information is information. It's our right and responsibility to use information wisely.
Ought doctors know best? Probably so. Do they? Probably not. And how would we know unless we seek information and advice from those who have been where we've been.
No one on Babble can prescribe. It's physically impossible. I haven't seen anyone here suggesting that people order medications illegally and follow internet advice instead of consulting with their doctors. And if anyone did, I would strongly suspect that a large number of posters would provide contrary advice.
What people do is, in the light of their personal experience and observations, offer suggestions. And thank God they do. Perhaps my insistence that my mother was having strokes and not seizures made the ER doctor run those tests a bit faster than he otherwise would. I know the doctors I contacted by phone decided to move up her tests because of my calls, had she not had a stroke on the Monday after.
Thank you Solstice, Scott, Phillipa, and Sigi. Because you cared and were willing to speak up, you were of immense help to me and to my mother.
B2, don't give up. I got worse on the wrong medicines, but infinitely better on the right ones and appropriate therapy. Don't let anyone tell you it's helpless. And please don't ever stop listening to friends in the cloud.
I haven't had the energy to keep up at Babble lately, but I hope you're feeling better.
Posted by ron1953 on April 30, 2012, at 10:08:00
In reply to Re: i cant even smile., posted by Dinah on April 30, 2012, at 8:55:22
Just to be clear, I was referring specifically about taking medication advice. Yes, no one is actually prescribing, but it's not at all uncommon for long-term psych patients to have a stockpile of medications on hand, remnants of previous failed trials. So, there is a possibility, even likelihood that somebody might actually try one of these posted suggestions, without consulting elsewhere, which I think can be pretty hazardous.
The missing caveat is "This advice is being given by a layperson who has no training or clinical experience in regard to the administration of prescription medications".
I'm all for self-empowerment about our health, and I agree that the internet can provide a wealth of information. However, it can also be, and often is, an excellent source of utter nonsense disguised as useful advice.
Posted by Phil on April 30, 2012, at 12:28:36
In reply to Re: i cant even smile. » Dinah, posted by ron1953 on April 30, 2012, at 10:08:00
This has been the byline at babble since the beginning.
"Don't necessarily believe everything you hear. Your mileage may vary."
I think if everyone is concerned they should try to find dr bob. But if I remember correctly this place has always been about the blind leading the blind.
People could just as easily stop meds after reading the blitz of anti-med, brain damage posts that seem to be taking over here. I don't understand why people would stay on a med board if they don't like meds anymore.
Or they could google psych meds and only get 300 anti-psychiatry sites and think, wow, what do I do now? Maybe I should just not take it and just hope I don't have another psychotic mania and attempt suicide again. I mean I don't want brain damage.
Babble, more or less, used to be a safe place to ask questions but I'll say right now, I'll never come here for med advice again for fear of getting pounced on, directly or indirectly, from anti-med folks.
I would just encourage people to run everything they read here by their doc.
Posted by ron1953 on April 30, 2012, at 12:53:14
In reply to Re: i cant even smile. » ron1953, posted by Phil on April 30, 2012, at 12:28:36
I'm aware of the PB disclaimer, but over the years, I've seen one self-appointed guru or another who appears to garner a following of believers who seek, and presumably take, his/her advice. Seems dangerous to me, so sometimes I point that out. Sharing personal experiences with meds is one thing; giving out specific advice is another. These are people we're talking about, not cars or washing machines.
Either extreme (pro-med vs anti-med) is not a good thing, IMO. I pretty much ignore posts to either extreme and/or posters who seem to have a narrow agenda. Hopefully, sharing my experience before meds, during meds, and after meds, will be useful to some folks, as I'm sure that many who are in the "during" phase will end up going full circle, as I have.
Posted by Phil on April 30, 2012, at 13:16:41
In reply to Re: i cant even smile. » Phil, posted by ron1953 on April 30, 2012, at 12:53:14
I could be one of those.
I haven't been around enough I guess. If I had a following here I think I would tell each one that this is just my opinion so talk to your doc.
Posted by Phillipa on April 30, 2012, at 20:06:43
In reply to Re: i cant even smile., posted by Dinah on April 30, 2012, at 8:55:22
Dinah so your Mom did have a stroke? I'm very sorry. I just knew by your description what was going on. Remember I did Nurse and learned to recognize the symtoms. So glad you did bet the docs to finally listen. No wonder we are usually advised to get a second opinion preferably at a doctor or facility that is not affilitated with first. So no collaborating for lack of a better work. Phillipa
Posted by Dinah on April 30, 2012, at 20:10:02
In reply to Re: i cant even smile. » Dinah, posted by Phillipa on April 30, 2012, at 20:06:43
With that level of care, a fourth or fifth opinion is probably a good idea.
I never did like the hospital in question. But I'm not sure if it's different anywhere else. How often do doctors really listen anymore?
Posted by Phillipa on April 30, 2012, at 20:59:29
In reply to Re: i cant even smile. » Phillipa, posted by Dinah on April 30, 2012, at 20:10:02
Dinah sometimes you have to ask for a patient advocate and if needed threaten to sue. I know didn't used to be this way. I don't trust any hospital never again will I go into a hospital willingly. You have the right to request any doctor you wish. Can ask for a transfer to another hospital also. How's your Mom? I'm so sorry she had a stroke. Will the impairments improve with time? More reason for you to continue good care for your diabetes as I'm sure you know risk factor for all sorts of illnesses. You are a good advocate to have in one's court. Love Phillipa
Posted by Dinah on April 30, 2012, at 22:20:53
In reply to Re: i cant even smile. » Dinah, posted by Phillipa on April 30, 2012, at 20:59:29
Not really. I'm more bunny than lion.
Short term I can be assertive. But long term I can't.
Posted by bleauberry on May 1, 2012, at 7:37:32
In reply to Re: i cant even smile., posted by SLS on April 29, 2012, at 18:52:08
Maybe. Maybe not. I have never seen anything in writing that would suggest that but ok. You know your stuff so I will take that as fully trustable at face value. Maybe lower doses of a TCA+SSRI combo might be more attractive than a monster dose of effexor.
> > That is correct and thank you for pointing out the error. Zoloft has some dopamine impact at very high doses, you mentioned effexor, and such. I guess what I should have said is the meds are basically fixed ratios with some mild to modest variation dependent upon the size of the dose. While effexor impacts NE heavier above 300mg roughly, that impact is still very small compared to its impact on serotonin.
> >
> > > > With any med however, the ratio is fixed.
> > >
>
> The binding affinities might be fixed, but not the absolute occupancy. If you were to bring the dosage of Effexor high enough, the ratio of occupancy might approach 1:1.
>
>
> - Scott
Posted by SLS on May 1, 2012, at 9:47:05
In reply to Re: i cant even smile., posted by bleauberry on May 1, 2012, at 7:37:32
"Maximal SERT inhibition at week 8 for paroxetine and venlafaxine was 90% (SD 7) and 85% (SD 10), respectively. Maximal NET inhibition for paroxetine and venlafaxine at week 8 was 36% (SD 19) and 60% (SD 13), respectively."
http://www.ncbi.nlm.nih.gov/pubmed/18418363
SERT = 85%
NET = 60%1.4:1 is certainly more balanced than 30:1. This occurred at dosages of 375 mg.
- Scott
Posted by SLS on May 1, 2012, at 13:29:00
In reply to Re: i cant even smile., posted by bleauberry on May 1, 2012, at 7:37:32
> You know your stuff so I will take that as fully trustable at face value.
I forgot to mention that you should never do that again. I am quite fallible.
:-)
- Scott
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.