![[dr. bob]](/dr-bob-sm.gif)
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 Louisiana Sportsman on June 28, 2014, at 18:43:48
Hey, everybody! I've missed contributing, but I felt that a mental health rehabilitation treatment center "vacation" was necessary.
I decided that something had to be done to ameliorate my symptoms, and I wanted to work with a top-notch treatment team.
I am blessed to be able to take off work like this and have my insurance cover nearly $25,000 lol, it was a great experience! Never felt better in my life. I am going to advocate psychotherapy more often.
Regiment Completely Discontinued with no psych meds for 9 days. This is what I was on before:
Latuda 60mg. QHS CF
Brintellix 20mg. QD
Topamax XR [Trokendi XR] (topiramate) 100mg. BID
Klonopin (clonazepam) 0.5mg. TID
Desoxyn (methamphetamine) 30mg.
Nuvigil 250mg.Six is generally my "sweet spot" that I try not to go over. But I did lol.
My new seven, all prescribed by PDOCs within a 37 day span of time. with mg. amounts:
Latuda 60mg.
Topiramate (Topamax) 100mg.
Nuvigil 250mg.
Bupropion (Wellbutrin) SR 450mg.
Sertraline (Zoloft) 50mg.
Mirtazapine (Remeron) 15mg.
Gabapentin (Neurontin) 2,400mg.I also received an exhaustive investigation of conclusive diagnosis as follows:
Dx. Axis I: Bipolar Depression marked with neurotic anxiety and comormid ADHD. Axis II: Schizoid Personality Disorder with covert features.
This is the best regiment I've been on and it's relatively cheap compared to some combos in the past since everything is a generic $10 except for the $60 for Latuda and Nuvigil. Doctor visit is $50 with insurance so $220/month is what I think about because I could finance a car so besides this stuff being a hobby the time is money lol.
Anxiety, which can spark sadness, is the main issue, but I don't want to take benzos or really a gabapentinoid since I'm liable to abuse the script. I told myself I'd never get gabapentin again, but the treatment center managed giving it out. I think I'm gonna try to stick with it. I think if does wonders for mood. Gabitril is on my mind. What else?
ADHD is still a factor too, but the 450mg. SR bupropion dose and the Nuvigil honestly helps, but not like the Desoxyn. I really don't want an amp, methyl, atomoxie, or a hypertension medicine.
Opinions? Ideas? Thoughts? Suggestions of what augment or adjust? Any input is welcome!
Posted by Phillipa on June 28, 2014, at 22:45:56
In reply to Update: treatment 37 days; regimen now thoughts?, posted by Louisiana Sportsman on June 28, 2014, at 18:43:48
Good to hear from you. Sounds like you have had a productive time with a lot of changes. Since you say you feel better than ever why would you want to change a thing? I see you stopped the Brintellix. So the older meds better. And saves you a lot of money also. Phillipa
Posted by Louisiana Sportsman on June 28, 2014, at 23:50:39
In reply to Re: Update: treatment 37 days; regimen now thoughts? » Louisiana Sportsman, posted by Phillipa on June 28, 2014, at 22:45:56
Glad to see one of my favorite posters is still around. :)
Phillipa, my drug addiction is psychiatric meds; I'm always trying to get it perfect and try out exotic frontiers, if that makes sense. I would type more, but I'm on the ipad lol.
--
I'm looking at Gabitril for anxiety what else? Mirapex ER and Namenda XR look promising cognitively for ADHD and might be a good augment. Suggestions?
Posted by SLS on June 29, 2014, at 7:23:04
In reply to Update: treatment 37 days; regimen now thoughts?, posted by Louisiana Sportsman on June 28, 2014, at 18:43:48
Guanfacine for the ADHD?
I am extremely happy and encouraged by your success. Keep going!
- Scott
Posted by Louisiana Sportsman on June 30, 2014, at 9:46:23
In reply to Re: Update: treatment 37 days; regimen now thoughts? » Louisiana Sportsman, posted by SLS on June 29, 2014, at 7:23:04
> Guanfacine for the ADHD?
>
> I am extremely happy and encouraged by your success. Keep going!
>
>
> - ScottHey, bud! Long time; no see. How's it going with your regimen? I can analyze it if you'd like.
I plan on turning this current regimen of this:
Lurasidone (Latuda) 40mg.
Armodafinil (Nuvigil) 250mg.
Topiramate (Topamax) 100mg.
Bupropion (Wellbutrin) SR 450mg.
Mirtazapine (Remeron) 15mg.
Sertraline (Zoloft) 50mg.
Gabapentin (Neurontin) 2,400mg.Into this:
Increase dosages where necessitated:
Lurasidone (Latuda) 60mg.
Armodafinil (Nuvigil) 250mg.
Topiramate XR (Trokendi XR) 150mg. from 100mg.
Bupropion (Wellbutrin) SR 450mg.
Mirtazapine (Remeron) 30mg. from 15mg.
Gabapentin (Neurontin) 3,200mg. from 2,400mg.
DC Sertraline
Augment one of the following for ADHD/anxiety/residual depression;
Memantine (Namenda XR) 7-28mg.
Keppra
Riluzole
Gabitril
Mirapex
AmantadineObviously, I'm leaning toward memantine, but what about the other selections?
Scott, I've tried Intuniv and preferred it to clonidine; however, it is not the right med for me appreciate the suggestion tho!
Anyone have thoughts? Comments?
Posted by SLS on June 30, 2014, at 10:44:36
In reply to Re: Update: treatment 37 days; regimen now thoughts?, posted by Louisiana Sportsman on June 30, 2014, at 9:46:23
> Hey, bud! Long time; no see. How's it going with your regimen? I can analyze it if you'd like.
I have had a hellish few months. I had to discontinue minocycline due to the emergence of hyperpigmentation. I elected to discontinue Abilify due to amotivation and metabolic concerns. I switched from nortriptyline to desipramine due to a lack of drive that feels like laziness along with a subdued personality. Weight gain was also an issue. My doctor wanted me to titrate desipramine gradually, as he is perhaps overly cautious about combining it with Parnate, even though we had tried that once before. It has been painful and frustrating. I am currently taking 200 mg/day. I think that I am starting to feel better.
> I plan on turning this current regimen of this:
>
>
> Lurasidone (Latuda) 40mg.
> Armodafinil (Nuvigil) 250mg.
> Topiramate (Topamax) 100mg.
> Bupropion (Wellbutrin) SR 450mg.
> Mirtazapine (Remeron) 15mg.
> Sertraline (Zoloft) 50mg.
> Gabapentin (Neurontin) 2,400mg.
>
> Into this:
>
> Increase dosages where necessitated:
> Lurasidone (Latuda) 60mg.Good.
> Armodafinil (Nuvigil) 250mg.
Good for ADHD, but not for bipolar depression according to recent studies.
> Topiramate XR (Trokendi XR) 150mg. from 100mg.
I found topiramate equally helpful at 100 mg/day as I did at 200 mg/day. The inhibition of carbonic anhydrase and the risk of metabolic acidosis and kidney stones is dosage dependent.
> Bupropion (Wellbutrin) SR 450mg.
> Mirtazapine (Remeron) 30mg. from 15mg.For depression, it is my impression that the most effective dosages of mirtazapine lie between 45 - 90 mg/day.
> Gabapentin (Neurontin) 3,200mg. from 2,400mg.
> DC SertralineIf you end up needing a SRI to combine with Wellbutrin, I would recommend trying Pristiq (desvenlafaxine) first.
> Augment one of the following for ADHD/anxiety/residual depression;
> Memantine (Namenda XR) 7-28mg.
> KeppraProbably underutilized, especially for rapid cyclicity.
> Riluzole
For me, it was an expensive placebo. I believe that someone here on PB is having great success with it.
> Gabitril
This is sometimes used for anxiety and insomnia, but its effects can be quite variable between individuals. Some people become nervous and agitated. Paradoxically, it can also cause seizures.
> Mirapex
Some people report that Mirapex helps with depression. However, I see more reports of disappointment. I wouldn't dissuade you from trying it, though. Just be aware that some people experience sleep-attacks.
> Amantadine
Interesting choice for ADHD.
-----------------------------------------
My current treatment regime for bipolar depression:
Parnate 100 mg/day
desipramine 200 mg/day
Lamictal 200 mg/day
lithium 450 mg/day
prazosin 30 mg/day
- Scott
Posted by Louisiana Sportsman on June 30, 2014, at 14:33:29
In reply to Re: Update: treatment 37 days; regimen now thoughts? » Louisiana Sportsman, posted by SLS on June 30, 2014, at 10:44:36
Armodafinil is indeed good for ADHD. I don't believe the PDOC will triple my dosage of mirtazapine without doubling it first but 45mg. is preferable. I've tried Pristiq and it's tied with sertraline and a lot harder to get off of; definitely see the pharmacological reasoning behind the combination with bupropion. I appreciate the analysis of the medications I made a list of, very interesting!
Scott,
I'm sorry to hear that things aren't shaping out the way they should for ya since I've been absent. I was hoping that at least you'd be doing well. It really helped me that I got to adjust/augment medication so often. I had about six sessions.
I discontinued aripiprazole for the same reasons, but as we discussed Latuda worked for me. I'm sorry it didn't work for you. What about Fanapt? Seems a bit side effect heavy...
>
> My current treatment regime for bipolar depression:
>
> Parnate 100 mg/day
> desipramine 200 mg/day
> Lamictal 200 mg/day
> lithium 450 mg/day
> prazosin 30 mg/day
>
>
> - ScottWill you increase the desipramine to 300mg.? That's about as high as I'd dose it with Parnate.
Your lithium dosage is a bit low; I doubt it's even within the therapeutic blood serum level. Consider raising it?
If you raise the lithium, perhaps you could lower the lamotrigine to 100mg.? It seems to have more of antidepressant effect at lower doses. Might help with cognition and overall sense of being to lower it too. You'll feel better, I didn't realize how strong it was until I went off of it.
You know how the prazosin is working for your symptoms. How is that?
Posted by SLS on June 30, 2014, at 17:40:07
In reply to Re: Update: treatment 37 days; regimen now thoughts?, posted by Louisiana Sportsman on June 30, 2014, at 14:33:29
> > My current treatment regime for bipolar depression:
> >
> > Parnate 100 mg/day
> > desipramine 200 mg/day
> > Lamictal 200 mg/day
> > lithium 450 mg/day
> > prazosin 30 mg/day> Will you increase the desipramine to 300mg.?
That's the plan. :-)
> That's about as high as I'd dose it with Parnate.
I am a rapid metabolizer of tricyclics. Still, 300 m/day is as high as I am willing to go with desipramine.
> Your lithium dosage is a bit low; I doubt it's even within the therapeutic blood serum level. Consider raising it?
For me, dosages of 300 - 450 mg/day produce a mild antidepressant effect. Higher dosages produce no further improvements, while cognitive effects become pronounced. Lithium is a poor anti-manic for me when mania is precipitated by antidepressants. I continue to take lithium in the hope that it will help to prevent Alzheimers Dementia.
> If you raise the lithium, perhaps you could lower the lamotrigine to 100mg.? It seems to have more of antidepressant effect at lower doses. Might help with cognition and overall sense of being to lower it too. You'll feel better, I didn't realize how strong it was until I went off of it.
That's a good idea. It was my intention to reduce the dosage of Lamictal to 150 mg/day, but I wanted to wait until the other treatment changes settle in.
> You know how the prazosin is working for your symptoms. How is that?
I tried to reduce the dosage of prazosin a number of months ago. I deteriorated quite a bit. I don't think anyone knows exactly how it works, but I came upon a few things that lead me to believe that NE alpha-1b receptors are involved.
Thanks for all of your help. I hope your changes in treatment produce meaningful results.
- Scott
Posted by Louisiana Sportsman on June 30, 2014, at 20:41:49
In reply to Update: treatment 37 days; regimen now thoughts?, posted by Louisiana Sportsman on June 28, 2014, at 18:43:48
The last time my PDOC saw me, she had me on this regimen:
Latuda 60mg. QHS CF
Brintellix 20mg. QD
Topamax XR [Trokendi XR] (topiramate) 100mg. BID
Klonopin (clonazepam) 0.5mg. TID
Desoxyn (methamphetamine) 30mg.
Nuvigil 250mg.The docs in rehab put me on:
Latuda 60mg.
Topiramate (Topamax) 100mg.
Nuvigil 250mg.
Bupropion (Wellbutrin) SR 450mg.
Sertraline (Zoloft) 50mg.
Mirtazapine (Remeron) 15mg.
Gabapentin (Neurontin) 2,400mg.My PDOC changed it to:
Latuda 60mg.
Topiramate (Topamax) 150mg.
Nuvigil 250mg.
Bupropion (Wellbutrin) SR 450mg.
Mirtazapine (Remeron) 45mg.
Gabapentin (Neurontin) 3,200mg.Dropped Zoloft. Upped Remeron to effective AD dosage to compensate. Upped gabapentin and topiramate. I know I said my PDOC probably wouldn't triple Remeron, but I never give her enough credit. Amazing doctor, really. Did what I asked.
I didn't bother her with bringing up a new med today since it was a FaceTime session on our iPhone 5s'. I get an office visit Wednesday.
Posted by Louisiana Sportsman on July 5, 2014, at 10:21:22
In reply to Result of PDOC Session, posted by Louisiana Sportsman on June 30, 2014, at 20:41:49
I received a call on the 2nd before I filled my medication from my PDOC.
She: "Have you filled your medications yet?"
Me: "Nope."
She: "Why didn't you remind me to change your Topamax to Trokendi XR and your Wellbutrin to Aplenzjn?"
Me: "I thought you were going for stability. Also, I never knew you were truly a fan of these medications. I figured you saw them as ripoffs; besides, they're more expensive, so I'm saving money. I was just using your judgement for once instead relying on my own ideas."
She: "Well, this isn't rehab anymore. With me, you're going to get the top of the line treatment, whatever it takes, whatever you need. I think they're justified, and you have good insurance and such."
Me: "Alright, call in Aplenzin and Trokendi."
She: "One more thing. I've found that Lyrica works better than gabapentin for anxiety. I've been writing it for many of my patients now. I know you've struggled with Lyrica addiction in the past, but you've just completed a rehab; do you think you could dose it correctly this time around?
Me: *long pause* "Yes. I think I can. Pregabalin is hands down the best medication for my brain chemistry mood stabilization and anxiety relief in one package."
She: "You're nearly maxed out on the gabapentin, so I think 150 TID would be good."My regimen after the discussion, and I plan to stick with it awhile:
Latuda (lurasidone) 40mg.
Trokendi XR (topiramate extended release)
Aplenzin (bupropion hydrobromide) 522mg.
Nuvigil (armodafinil) 250mg.
Lyrica (pregabalin) 150mg. TID [450mg.]
Remeron (mirtazapine) 45mg.
Zoloft (sertraline) 50mg.I get my medication at CVS Pharmacy, for giggles, and to see how much my insurance company hates me, I took the estimated cash price, using goodrx.com, without coupon, for a month supply of each medication totaled together: $3,588
Don't believe me? Add it up yourself lol, the monthly price without insurance of each medicine added together is $3,588; multiplied by 12: that's $43,056 a year! I'm sure they don't even pay half that tho, and it's just a front, but that's like me working from now to say the beginning of September just to pay for all of my medicine if I didn't have insurance! Ridiculous prices. O_o
Anyways, I just thought I'd update if anyone cared out there. Please feel free to comment about anything! I don't bite.
This is the end of the thread.
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