Psycho-Babble Medication Thread 1075968

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Re: Starting Parnate after 15 yrs treatment-resistance

Posted by ed_uk2010 on February 4, 2015, at 4:29:13

In reply to Starting Parnate after 15 yrs treatment-resistance, posted by Robert_Burton_1621 on February 4, 2015, at 2:55:13

Hello,

Welcome to p-babble and do keep us up-to-date with your Parnate experience.

>the small but hardly negligible number of treatment-refactory patients

Psychiatry might like society to think that the number/proportion of treatment-refractory patients is small, but in reality it is (unfortunately) huge.

There is plenty of information about tranylcypromine here, so I hope you get some helpful replies.

 

Re: Starting Parnate after 15 yrs treatment-resistance Robert_Burton_1621

Posted by baseball55 on February 4, 2015, at 19:57:18

In reply to Starting Parnate after 15 yrs treatment-resistance, posted by Robert_Burton_1621 on February 4, 2015, at 2:55:13

> I would be interested to hear from anyone who's taking or has taken the drug about your experience of its efficacy, side-effects, as well as onset (and duration of sustained) therapeutic action.
>
10mg is a low dose. 30 mg is the usual starting dose.
I took parnate when almost catatonic from depression and was up and about - not all better, but functioning for the first time in months - within 48 hours. It never really got completely rid of my depression, but I never again fell into that vegetative state while on parnate. It started not holding me after about 3 years. But intensive work with a DBT/CBT therapist kept me stable and, after 4 years, I stopped the parnate.

Side effects. For me, the only really noticeable and problematic side effects were postural hypotension and insomnia. My p-doc prescribed ativan (lorazapem) for sleep, which really worked, so that helped the insomnia. Tapering off lorazapem though caused rebound insomnia for a while. Nothing's perfect.

As for the postural hypotension, I just had to take care. When getting out of bed, I sat up for several seconds, stood up and held onto the dresser for several seconds. It wasn't hard to remember to do this, because in the first few weeks, I fell a few times. So I became very careful. This problem went away over several months, but it never went away completely. I had hip surgery a couple of years into parnate and was surprised to discover, when the visiting nurse checked my BP, that it plunged when I stood up. I don't know. Maybe my body just adjusted itself to this. I no longer got dizzy.

Don't worry overmuch about the food interactions. People get neurotic about this, but it's not such a big deal

Good luck!

 

Re: Starting Parnate after 15 yrs treatment-resistance

Posted by Robert_Burton_1621 on February 5, 2015, at 3:02:15

In reply to Starting Parnate after 15 yrs treatment-resistance, posted by Robert_Burton_1621 on February 4, 2015, at 2:55:13

> I have learnt a lot about MAOIs from the learned, analytical, engaging, and very generous Dr P.K. Gilman, whose site psychotropical.com is a rich resource which contains, for free, very well-reasoned and accessibly-articulated information on pharmacology.
>

Erratum: the name of the gentleman is Dr. Gillman, not *Gilman.

 

Re: Starting Parnate after 15 yrs treatment-resistance

Posted by Robert_Burton_1621 on February 5, 2015, at 4:01:30

In reply to Re: Starting Parnate after 15 yrs treatment-resistance, posted by ed_uk2010 on February 4, 2015, at 4:29:13

> Welcome to p-babble and do keep us up-to-date with your Parnate experience.
>

Thanks, indeed. Very early stages now, but would definitely like to post periodically on how I'm faring on it.

> Psychiatry might like society to think that the number/proportion of treatment-refractory patients is small, but in reality it is (unfortunately) huge.
>

I had not thought of putting the issue this way. Your observation identifies, perceptively, a plausible cause of the general lack of awareness of the actual extent of treatment-resistance. It does not appear to be much acknowledged outside of specialist studies. Outfits here, in Australia, like Beyond Blue, while they do some good work, also peddle to the public, quite misleadingly (in my view), the idea that "depression" is a more or less easily treatable condition. Such an assertion relies, of course, on an equivocation as to the precise meaning which is intended by use of the term "depression". My suspicion is that its usage in this way evacuates it of much clinically significant content; which therefore makes it unsurprising that - if "depression" is defined to include sub-clinical syndromes - it is transformed into an essentially transient condition which is claimed to be easily treatable according to the recognised modalities of conventional (which is not synonymous with scientifically-informed and critical) psychiatry.

I have become rather sceptical of the merits of mental health lobby groups like Beyond Blue. Their work tends rather to confirm the paradoxical truth of Byron's dictum that "this is the patent age of new inventions / For killing bodies, and for saving souls, / All propagated with the best intentions."

That description is of course a bit hyperbolic; but I am persuaded by personal experience that the high-minded intentions of mental health lobby groups can, on occassion, result in real damage to the interests of patients for whom the "new inventions" simply do not work. An example might make this a little clearer.

The disability offices of universities, mostly under the influence of the essentially upbeat message of organisations like Beyond Blue, have in recent years undertaken "awareness campaigns" about the supposed life-time incidence of "depressive" illnesses. The intent is to assist students who are suffering and cannot always comply with conditions on their candidature. But such "campaigns" seem always to go along with the assumption, often expressed without any qualification, that no-one should be hesitant to disclose his or her "depression" because treatment is essentially straightforward and in the majority of cases successful. The consequence, frequently, is this: departments become over-burdened by claims for consideration by students with "depression". Academics, who are not in any case well known for their empathy, become sceptical about the grounds of these proliferating claims. To accept them unsceptically would necessitate accepting the implied premise that the prevalence of clinically-serious depressive conditions has sky-rocketed in a matter of years, a premise that warrants explicit epidemiological justification, not mere unreflective assent. The result of such scepticism is two-fold: first, it leads academics to attribute the rise in claims not to genuine medical conditions but to student laziness, incapacity for tertiary study, preciousness, malingering, etc.; secondly, the fate of that small number of students who are, according to a rational and robust clinical definition, suffering terribly, is assimilated to that of everyone else, and the failure of their treatment to reflect the rosy prognostications of the "awareness" industry is attributed to their own failure to seek adequate treatment, a cruel and paradoxical conclusion that all too often has the effect of ruining the futures of these students.

Anyway, that's one (rather long!) example of the real-life implications of psychiatry's omission to acknowledge the extent of treatment-resistance.

> There is plenty of information about tranylcypromine here, so I hope you get some helpful replies.

So I have discovered! It is encouraging and I will make a point of looking through the archives.

 

Re: Starting Parnate after 15 yrs treatment-resistance

Posted by Robert_Burton_1621 on February 5, 2015, at 4:53:28

In reply to Re: Starting Parnate after 15 yrs treatment-resistance Robert_Burton_1621, posted by baseball55 on February 4, 2015, at 19:57:18

> 10mg is a low dose. 30 mg is the usual starting dose.

Thanks for this advice. I am working up to 40mg over two weeks. From what I infer from my doctor's prescriptions, the tapered increase is recommended so as to decrease the risk of sudden hypotension, dizziness, etc. That makes sense to me.

> I took parnate when almost catatonic from depression and was up and about - not all better, but functioning for the first time in months - within 48 hours. It never really got completely rid of my depression, but I never again fell into that vegetative state while on parnate.

That is an astonishing account, thank you. My symptoms have also been, consistently, neuro-vegetative and, to use your words, "almost catatonic". This is just my second day on 10mg, but even though the parnate has induced a pretty smashing fatigue, I can nonetheless get up - or rather, I nonetheless *want* to get up - and be relatively active. Last night my sleep appeared to me to be distinctly "shallow"; I'm not sure why, but I got the sense (i.e., it was apparent to me while I was sleeping) that I didn't really *fall* to sleep. Yet I was able to get up and function okay today.

> Side effects. For me, the only really noticeable and problematic side effects were postural hypotension and insomnia. My p-doc prescribed ativan (lorazapem) for sleep, which really worked, so that helped the insomnia.
>

Thanks for this bit of information, too! I certainly found it difficult to get to sleep. I have some mirtazapine from a previous trial, and had thought of taking a small dose (7.5mg) to help me nod off (with the assistance of its massively potent H1 receptor antagonism). I know it can't induce serotonin toxicity, but I thought it most prudent just to ride the insomnia through rather than experiement independently.

> Don't worry overmuch about the food interactions. People get neurotic about this, but it's not such a big deal
>

Yes, from the latest studies that I've read (in particular: Gillman (2011) J Clin Psycho Pharm 31.1) the food interactions have been exaggerated. It is best to err on the side of caution, I think, though; I have been advised to test my tolerance by introducing tentatively only small amounts of excluded foods.

> Good luck!

Thanks so much. I wish you the best, too.

 

Re: Starting Parnate after 15 yrs treatment-resistance

Posted by Robert_Burton_1621 on February 5, 2015, at 6:59:23

In reply to Re: Starting Parnate after 15 yrs treatment-resistance, posted by Robert_Burton_1621 on February 5, 2015, at 4:01:30


> I have become rather sceptical of the merits of mental health lobby groups like Beyond Blue.
>

In contrast to BB, Professor Gordon Parker's Black Dog Institute, on the other hand, is (from my knowledge of it) a model of sober, accurate, scientifically rigorous, and extremely helpful advocacy in the service of mental health awareness: http://www.blackdoginstitute.org.au/

 

Re: Starting Parnate after 15 yrs treatment-resistance baseball55

Posted by ed_uk2010 on February 5, 2015, at 7:03:53

In reply to Re: Starting Parnate after 15 yrs treatment-resistance Robert_Burton_1621, posted by baseball55 on February 4, 2015, at 19:57:18

>....was surprised to discover, when the visiting nurse checked my BP, that it plunged when I stood up. I don't know. Maybe my body just adjusted itself to this. I no longer got dizzy.

Definitely, the body does adjust. The postural drop still occurs, but the brain adjusts so that it still functions normally in spite of the sudden drop. As a result you no longer get as dizzy. The phenomenon occurs in others forms of postural (orthostatic) hypotension too. After the condition has been present for a long time, it's often possible to patients with autonomic nervous system dysfunction to tolerate surprisingly large BP drops without symptoms.

 

Re: Starting Parnate after 15 yrs treatment-resistance

Posted by ed_uk2010 on February 5, 2015, at 7:12:32

In reply to Re: Starting Parnate after 15 yrs treatment-resistance, posted by Robert_Burton_1621 on February 5, 2015, at 6:59:23

I suppose... psychiatry promotes the idea that 'now we have modern medications, depression can be treated easily'. In reality, I'm unsure that the proportion of patients who can be treated effectively has increased that much over the last few decades. The number of pts having to discontinue due to adverse effects may have decreased due to a greater number of tolerable options, so that could have led to an increase in response rates. A large number of those who respond do not achieve remission, however. And this is important.

In some conditions such as bipolar disorder and particularly schizophrenia, some degree of treatment resistance is the norm, not the exception. A partial response to treatment is indeed the most common outcome.

 

Re: Starting Parnate after 15 yrs treatment-resistance

Posted by rjlockhart37 on February 5, 2015, at 15:07:02

In reply to Starting Parnate after 15 yrs treatment-resistance, posted by Robert_Burton_1621 on February 4, 2015, at 2:55:13

Parnate has always been known for treatment resistant success over other antidepressants, it is VARY effective in any type of depression, just side effects are a bit more.....

you may want to ask about adding a stimulant, parnate acts mildly like a stimulant (from what i've read in posts here) which maybe could be totally something else in other people.....

there's also Nardil and Marplan if parnate doenst do the trick.....

try to get the dose up maybe see if it works, adding a low dose stimulant too....

r

 

Re: Starting Parnate after 15 yrs treatment-resistance

Posted by europerep on February 5, 2015, at 16:10:51

In reply to Re: Starting Parnate after 15 yrs treatment-resistance, posted by Robert_Burton_1621 on February 5, 2015, at 4:53:28

Hello there!

> Psychiatry might like society to think that the number/proportion of treatment-refractory patients is small, but in reality it is (unfortunately) huge. (Ed)

I was thinking the same thing when I read Robert's post. A review article I read about two or three years ago by a European study group for treatment-resistant depression put the number at 30-45%. Of course, those are the patients corresponding to the clinical definition of it, i.e. a failure to respond to two adequate trials of antidepressants. That definition probably has some clinical value, but it's really not representative of the whole subgroup of treatment-resistant patients.


> I had not thought of putting the issue this way. Your observation identifies, perceptively, a plausible cause of the general lack of awareness of the actual extent of treatment-resistance. (...) My suspicion is that its usage in this way evacuates it of much clinically significant content; (...) (Robert)

I think I agree, if I understand you correctly that is ;-)... In my eyes, part of the problem is actually generated by people who mean well. One attempt to fight stigmatization of mental illness, or depression in this particular case, is to go with the "one in three individuals experiences a depressive episode at some point in their lives." What this does, I think, is that people go like "ah, right, back when Jenny's parents divorced she was really down for a few months, sometimes she wouldn't even show up in class, but then after a while it got better and now she's fine again." Jenny is of course just a random example I'm making up.

But this makes people think that that is what depression is, and if you're still stuck in it after a year, it's because "you're not trying hard enough" or "you're focusing too much on the problem" or "you need to change your mindset" or whatever.

In a way, people who know a little bit about depression are more problematic than people who just know nothing, because the former really think they understand depression even though they have no idea how broad the spectrum of depression is, and how dark one end of that spectrum is.

Anyway, regarding tranylcypromine. Over here, the generally recommended procedure is to start at 10mg/d, stay on it for a week, and then continue raising the dose by 10mg/d each week until positive effects appear. I think starting at 30mg/d or rapidly raising the dose should probably be limited to urgent cases.

The food restrictions are indeed not as bad as many people think. I too exposed myself to gradually increasing amounts of foods of that middle category that's allowed within limits, and that worked fine. Of course, those foods that are still completely forbidden must really be avoided, but I'm sure you know all that...

As far as side effects are concerned, I struggled with pretty bad insomnia too. I eventually started using zolpidem, but quickly 10mg weren't enough anymore, and I sometimes went up to 30 or 40mg per night, which I think is really not a good idea. What did help was exercising though. I'm not sure how I would have dealt with the insomnia had I had to stay on tranylcypromine long term. But I eventually tapered off again because it actually made my depression even worse. A doctor with much experience with MAOIs said that this happens very rarely though.

That's all I can think of right now. I wish you good luck with trial, there are people for whom it works really really well!

ER

 

Re: Starting Parnate after 15 yrs treatment-resistance

Posted by ed_uk2010 on February 5, 2015, at 17:20:38

In reply to Re: Starting Parnate after 15 yrs treatment-resistance, posted by rjlockhart37 on February 5, 2015, at 15:07:02

>you may want to ask about adding a stimulant, parnate acts mildly like a stimulant (from what i've read in posts here) which maybe could be totally something else in other people.....

Adding stimulants to MAOIs is something which would need to be done with great care, in specific circumstances only. It would never be done during the early stages of treatment in someone who hasn't taken an MAOI before.

 

Re: Starting Parnate after 15 yrs treatment-resistance

Posted by baseball55 on February 5, 2015, at 19:06:58

In reply to Re: Starting Parnate after 15 yrs treatment-resistance, posted by ed_uk2010 on February 5, 2015, at 7:12:32

I frequently see things in various media saying that "depression is highly treatable." Also that depression is very common - one in three people will suffer at some point in their life. The story seems to be that it's okay to be depressed and not something you need to hide because lots of people get depressed. And if you feel blue, you shouldn't suffer in silence but should pack yourself right off to the doctor who can prescribe meds that will make you better.

I wonder how much of this is propaganda (especially from the drug companies) and how much is because, as depression loses its stigma, more people decide they have it and seek treatment. At least half the people I know take AD's. And most of them have never seemed to me to be the least bit depressed. At least not depressed like I've been depressed. Is that because their meds work, so I've only seen them well? Or because they weren't really clinically depressed but just feeling kind of blah and stressed out by things going on in their lives?

I should also mention that (while I know that psychiatrists have their own problems) virtually everyone I know on ADs - and I'm talking at least 20 people - get them from PCPs and have never seen a psychiatrist. They go in for a check-up, say I've been feeling kind of depressed lately, get a scrip for prozac or wellbutrin, get better over time, then continue taking the med for years.

I know that studies find response rates fairly low for true MDD. But if you look at all the people who are taking ADs and ask them how they feel, I imagine a good proportion of them will say, much better thank you.

 

Re: Starting Parnate after 15 yrs treatment-resistance ed_uk2010

Posted by rjlockhart37 on February 6, 2015, at 10:46:16

In reply to Re: Starting Parnate after 15 yrs treatment-resistance, posted by ed_uk2010 on February 5, 2015, at 17:20:38

yea...amphetamine, it would effect the effect too much....but there always is just hving coffee to wake up in the morning, i don't think coffee is going to be a counteract with parnate, but yea amphetamine really could jack up MAOI action too much

 

Re: Starting Parnate after 15 yrs treatment-resistance rjlockhart37

Posted by ed_uk2010 on February 6, 2015, at 11:00:07

In reply to Re: Starting Parnate after 15 yrs treatment-resistance ed_uk2010, posted by rjlockhart37 on February 6, 2015, at 10:46:16

Hi RJ,

Most people on MAOIs appear to tolerate small amounts of caffeine. Due to the high frequency of sleep disruption on MAOIs, I would suggest consuming no caffeine after mid-afternoon.

It might be best to spread out one's caffeine intake across a few cups of tea or small cups of coffee. Large Starbucks (and other coffee shop) coffees often contain a huge amount of caffeine, which might be a bad idea!

 

Re: Starting Parnate after 15 yrs treatment-resistance

Posted by Robert_Burton_1621 on February 9, 2015, at 7:13:26

In reply to Re: Starting Parnate after 15 yrs treatment-resistance, posted by ed_uk2010 on February 5, 2015, at 17:20:38

RJ: >you may want to ask about adding a stimulant>

> Adding stimulants to MAOIs is something which would need to be done with great care, in specific circumstances only. It would never be done during the early stages of treatment in someone who hasn't taken an MAOI before.>

Thanks for both of these comments. In Australia, the addition of stimulants to parnate is proscribed, as far as I am aware.

 

Re: Starting Parnate after 15 yrs treatment-resistance

Posted by Robert_Burton_1621 on February 9, 2015, at 7:51:17

In reply to Re: Starting Parnate after 15 yrs treatment-resistance, posted by ed_uk2010 on February 5, 2015, at 7:12:32

> I suppose... psychiatry promotes the idea that 'now we have modern medications, depression can be treated easily'. In reality, I'm unsure that the proportion of patients who can be treated effectively has increased that much over the last few decades. The number of pts having to discontinue due to adverse effects may have decreased due to a greater number of tolerable options, so that could have led to an increase in response rates. A large number of those who respond do not achieve remission, however. And this is important.
>
> In some conditions such as bipolar disorder and particularly schizophrenia, some degree of treatment resistance is the norm, not the exception. A partial response to treatment is indeed the most common outcome.

Very good points, especially the one about the criterion for "remission". A couple of additional ones:

(1) It is difficult not to suspect that the loosening or extension of authoritative criteria (i.e. under the DSM) as to what amounts to clinically-relevant "depression" has not influenced, and distorted, the outcome of studies whose results appear on their face to support the proposition that "depression" is in the majority of cases successfully, and relatively straighforwardly, treatable. But what kind of "depression" did participants in such trials suffer from? Were sub-clinical syndromes included and categorised as "depression" as a result of expanded definitional parameters?

(2) The tendency to assume, and on the basis of such an assumption to promote the idea, that new medications invariably indicate an advance in the treatment of psychiatric illnesses is perhaps a function of two (not necessarily mutually supportive) imperatives: (a) to emphasise the character of psychiatry as a legitimate science which progresses cumulatively; and (b) to justify the financial investments made into research whose purpose is ostensibly to formulate more efficacious drugs, especially by commercial interests. In regard to (b), it is an irony that the porportion of dollars invested in narrowly targeted research projects (often structured by limited goals determined by perceived market priorities) does not always match the intrinsic importance and potential benefit of the clinical results actually achieved. Serendipity still sometimes rules. These observations do not argue against investment in research: they simply counsel scepticism in the face of puffery which leads us illicitly to infer that more investment inevitably means better and more effective treatments.

 

Re: Starting Parnate after 15 yrs treatment-resistance

Posted by Robert_Burton_1621 on February 9, 2015, at 8:00:35

In reply to Re: Starting Parnate after 15 yrs treatment-resistance, posted by rjlockhart37 on February 5, 2015, at 15:07:02

> Parnate has always been known for treatment resistant success over other antidepressants, it is VARY effective in any type of depression, just side effects are a bit more.....>

> there's also Nardil and Marplan if parnate doenst do the trick.....>

> try to get the dose up maybe see if it works,>

Thanks for this reassuring info. Parnate's effectiveness in "treatment-resistant" cases is one reason why I've pursued it. The often-cited Star*D trials which examined sequenced medication alternatives to treat chronic (or persistent) depressions reached the contrary conclusion: but this putatively authoratative contrariety is, it seems,owing substantially, perhaps exclusively, to flawed method: the median dose of parnate in the study was only 39mg, I think.

My psychiatrist's preference is Nardil, as it happens. I thought it most prudent to try Parnate first, given it is reputed to have less side-effects than phenelzine. This is the course suggested by Dr Gillman on his site, too, and it seems logical to me.

 

Re: Starting Parnate after 15 yrs treatment-resistance

Posted by Robert_Burton_1621 on February 9, 2015, at 8:22:12

In reply to Re: Starting Parnate after 15 yrs treatment-resistance, posted by europerep on February 5, 2015, at 16:10:51

> In a way, people who know a little bit about depression are more problematic than people who just know nothing, because the former really think they understand depression even though they have no idea how broad the spectrum of depression is, and how dark one end of that spectrum is.
>

Very well put! I agree absolutely.

> Of course, those foods that are still completely forbidden must really be avoided, but I'm sure you know all that...>

Thanks for the cautionary reminder. I had expressed myself ambiguously in the earlier post. The only foods I've been advised it's okay to introduce myself to slowly are those in the "be careful with" column.

> As far as side effects are concerned, I struggled with pretty bad insomnia too. I eventually started using zolpidem, but quickly 10mg weren't enough anymore, and I sometimes went up to 30 or 40mg per night, which I think is really not a good idea. What did help was exercising though.>

This is very interesting. When did you exercise so as to feel the benefits of it while you were battling the insomnia?

The insomnia and daytime sleepiness is a problem. I am on 30mg now. But it is only my first week. And I have learnt some interesting things about sleep, depression, and anti-depressants which help me to put my frustration with the insomnia into perspective. I'll list them below, but just in my words and according to my understanding of the science. I am no pharmacologist. If anyone spots a howler, please do point it out!

(1) REM sleep involves a (total?) suspension in the neurotransmission of certain monoamines (serotonin, noradrenaline);

(2) depressed patients are known to have excessive REM sleep: latency is reduced and duration is extended;

(3) apparently the excessive REM phases of sleep contribute to the consolidation of emotions of "negative valence", thereby reinforcing depressive traits like rumination and prolonging depressive episodes;

(3) sleep-deprivation has been found to relieve depressive symptoms, if only temporarily;

(4) most anti-depressants reduce REM sleep, but MAOIs do so very significantly, at first.

My tentative conclusions are:

(1) the sleep-disregulation which parnate induces is a function of its supression of REM sleep;

(2) this supression of REM sleep may be precisely what someone suffering from depression needs, at least in the initial stages of drug treatment;

(3) the insomnia is actually evidence that the drug is working as an anti-depressant.

Does the above strike people as plausible?

> That's all I can think of right now. I wish you good luck with trial, there are people for whom it works really really well!
>

Thanks, ER. I am certainly staying hopeful.

 

Re: Starting Parnate after 15 yrs treatment-resistance Robert_Burton_1621

Posted by ed_uk2010 on February 9, 2015, at 13:02:56

In reply to Re: Starting Parnate after 15 yrs treatment-resistance, posted by Robert_Burton_1621 on February 9, 2015, at 8:22:12

>the insomnia is actually evidence that the drug is working as an anti-depressant.

I think the insomnia is undoubtedly evidence that the drug is producing its usual effects. Whether this is 'what your brain needs' - time will tell. I hope so.

 

Re: Starting Parnate after 15 yrs treatment-resistance baseball55

Posted by Robert_Burton_1621 on February 10, 2015, at 22:27:28

In reply to Re: Starting Parnate after 15 yrs treatment-resistance, posted by baseball55 on February 5, 2015, at 19:06:58

> I frequently see things in various media saying that "depression is highly treatable." Also that depression is very common - one in three people will suffer at some point in their life. The story seems to be that it's okay to be depressed and not something you need to hide because lots of people get depressed. And if you feel blue, you shouldn't suffer in silence but should pack yourself right off to the doctor who can prescribe meds that will make you better.
>
> I wonder how much of this is propaganda (especially from the drug companies) and how much is because, as depression loses its stigma, more people decide they have it and seek treatment. At least half the people I know take AD's. And most of them have never seemed to me to be the least bit depressed. At least not depressed like I've been depressed. Is that because their meds work, so I've only seen them well? Or because they weren't really clinically depressed but just feeling kind of blah and stressed out by things going on in their lives?
>
> I should also mention that (while I know that psychiatrists have their own problems) virtually everyone I know on ADs - and I'm talking at least 20 people - get them from PCPs and have never seen a psychiatrist. They go in for a check-up, say I've been feeling kind of depressed lately, get a scrip for prozac or wellbutrin, get better over time, then continue taking the med for years.
>
> I know that studies find response rates fairly low for true MDD. But if you look at all the people who are taking ADs and ask them how they feel, I imagine a good proportion of them will say, much better thank you.

Everything you say strikes me as very plausible, baseball.

As it happens, I came across an article in the Guardian today by Professor Peter Gotzsche.

http://www.theguardian.com/commentisfree/2014/apr/30/psychiatric-drugs-harm-than-good-ssri-antidepressants-benzodiazepines

In that article he states that "many of these drugs" (by which he means, I infer from the context, the SSRIs) "benefit only one out of ten people with severe depression".

It is unclear whether his observations on anti-depressant efficacy (or inefficacy) are restricted to the SSRIs etc. They are the only class of drugs he mentions explicitly. The sub-editors have had a hand, I'd surmise, in writing the headline ("Psychiatric drugs are doing us more harm than good"); more catchy and sensationalist than the more accurate "SSRIs....".

I'm not familiar with the background of Gotzsche's research, but what he states in the article is not inconsistent with the proposition that the practice of psychiatry is affected by a paradox of over-diagnosis and undertreatment.

See,e.g., Leon, "Paradoxes of US Psychopharmacology Practice in 2013: Undertreatment of Severe Mental Illness and Overtreatment of Minor Psychiatric Problems" J Clinical PsychoPharm 34(2014)545-548.

The Guardian has published a critical response to Gotzsche:

http://www.theguardian.com/commentisfree/2015/feb/11/are-antidepressants-outright-bad-for-you-it-depends

The writer (who is not a psychiatrist) makes some valid points, but falters, I think, on the assumption that "anti-depressants" should be treated as a homogenous class. Perhaps the beginning of wisdom in this area is to be scientifically scrupulous about distinguishing what class of anti-depressant is likely to be beneficial for a sub-type of serious depressive condition. Gordon Parker has been working on such topics in depressive nosology and pharmacology for years.

It's interesting to note that the writer's perspective, as a GP, gives some support to the hypothesis made earlier in this thread that responsibility for "over-diagnosis and undertreatment" lies with primary care medicine, not with psychiatry.

I'm not sure about that myself. But the anecdote the writer ends with - deciding against prescription of an anti-depressant to a patient who was reacting in distress at her diagnosis of breast cancer - is perhaps revealing in its implied premise that such a decision was really about a genuinely hard case.

 

Re: Starting Parnate after 15 yrs treatment-resistance (nm) ed_uk2010

Posted by Robert_Burton_1621 on February 11, 2015, at 21:13:42

In reply to Re: Starting Parnate after 15 yrs treatment-resistance, posted by ed_uk2010 on February 4, 2015, at 4:29:13

 

Re: Starting Parnate after 15 yrs treatment-resistance Robert_Burton_1621

Posted by Robert_Burton_1621 on February 11, 2015, at 21:19:58

In reply to Re: Starting Parnate after 15 yrs treatment-resistance (nm) ed_uk2010, posted by Robert_Burton_1621 on February 11, 2015, at 21:13:42

I have just posted an update after being on parnate for a week, but I'm not sure where my post has ended up?

 

Re: Starting Parnate - Update ed_uk2010

Posted by Robert_Burton_1621 on February 11, 2015, at 22:39:17

In reply to Re: Starting Parnate after 15 yrs treatment-resistance, posted by ed_uk2010 on February 4, 2015, at 4:29:13

> Welcome to p-babble and do keep us up-to-date with your Parnate experience>

I'll give this another go.

I'm at the one-week point now, and have worked up to 40mg of parnate daily, all taken in one dose in the morning (or late morning).

For what they're worth, here are my observations of the drug's effects on me thus far:

1. Efficacy

Anti-depressant effects are mild, but it is, of course, early days. Then again, I suppose it depends what indicators of anti-depressant action you take as being central. I have experienced no "turning on of the lights" effect. But one very noticeable change has been my capacity to adhere to appointments I've committed myself to. I have not cancelled one appointment since being on parnate, even in the midst of pretty significant tiredness. This is in quite striking contrast to my state over Dec-Jan, directly before starting, when I cancelled 90% of appointments and suffered a not insignificant loss of income as a result.

My cognition and capacity for concetration has also moderately improved.

Some people speak of a stimulating (or, in its negative aspect, an agitating) effect over the two or so hours subsequent to taking their dose. I have not experienced this. The feeling I experience is like that which tends to accompany occassions of pleasurable anticipation, and it starts in the gut. The analogy that occured to me is the pleasant mixture of excitement and suspense that you tend to feel while waiting for news (e.g.) about a positive opportunity, prize, etc, which you believe you have good chances, respectively, of benefiting from or winning. The difference is that whereas experience of such a feeling in those circumstances tends to be transient or episodic, this parnate feeling is prolonged.

This feeling tends not to be stimulating but moderately anxiolytic. It is welcome.

2. Side-Effects

No orthostatic hypotension to speak of.

Insomnia and sleep disregulation are the only troubling side-effects, but they are getting more tolerable.

I experienced what I identified to be a mild tyramine-induced episode of hypertension one hour after consuming an Indian takeaway. Perhaps the food had been heated, stored, then reheated a few times, and had been stewing in the bain-marie for some time. I can't point to any obvious ingredient as being responsible (mushrooms, peas?), though perhaps the sauces had something in them. The main symptom was a hot and throbbing sensation in the back of my neck. It resolved after a couple of hours and did not affect my activities.

I have a constant, moderately painful tension-type headache which has settled in my forehead and across my eyes, but this may be a function of my insomnia.

All in all, my experience thus far has definitely been more positive than negative, though I hope for improvements in the weeks to come.

 

Re: Starting Parnate - Update

Posted by ed_uk2010 on February 12, 2015, at 12:43:47

In reply to Re: Starting Parnate - Update ed_uk2010, posted by Robert_Burton_1621 on February 11, 2015, at 22:39:17

You see it says 'nm' after my posting name above? nm means no message. You accidentally ticked the box saying 'no message, just post above subject'. You'll see that message when posting next time. Don't click on it!

 

Re: Starting Parnate - Update Robert_Burton_1621

Posted by ed_uk2010 on February 12, 2015, at 13:09:44

In reply to Re: Starting Parnate - Update ed_uk2010, posted by Robert_Burton_1621 on February 11, 2015, at 22:39:17

Hello and thanks for re-posting,

>Anti-depressant effects are mild, but it is, of course, early days.

I think it is very encouraging that you're feeling improvements already. Do you plan to stay at your current dose for a few weeks? It might be a good idea. You've already experienced benefits (early on) as well as insomnia (+tiredness). Parnate is clearly 'doing something' and you might not need any more than 40mg.

>But one very noticeable change has been my capacity to adhere to appointments I've committed myself to.

A very positive change.

>The feeling I experience is like that which tends to accompany occassions of pleasurable anticipation, and it starts in the gut. The analogy that occured to me is the pleasant mixture of excitement and suspense that you tend to feel while waiting for news (e.g.) about a positive opportunity, prize, etc, which you believe you have good chances, respectively, of benefiting from or winning.

It sounds like a sort of acute sensation of hopefulness. Almost like the opposite of the feelings of dread so common during depression.

>No orthostatic hypotension to speak of.

That may occur later, in a couple of weeks, but hopefully not.

>an Indian takeaway. Perhaps the food had been heated, stored, then reheated a few times, and had been stewing in the bain-marie for some time. I can't point to any obvious ingredient as being responsible (mushrooms, peas?), though perhaps the sauces had something in them.

The majority of vegetables contain very little tyramine, even when not fresh. Tyramine is produced during the degradation of protein-rich foods, from the amino acid tyrosine. Few vegetables contain enough tyrosine to convert to tyramine when spoiled.

Was there any meat or fish in the takeaway? If not, it was probably something in the sauce.

Takeaways are difficult due to problems knowing what you're actually eating. Sauces containing soy sauce, various soybean products, yeast extracts and meat extracts may be a problem. A large proportion of flavour enhancers, stock cubes and flavour cubes used in sauces contain one or more of the above ingredients. Takeaways often use a lot of flavour enhancers!

>I have a constant, moderately painful tension-type headache which has settled in my forehead and across my eyes, but this may be a function of my insomnia.

Do you have a BP monitor? Be careful what you take for the headache. A lot of over-the-counter medicines are not advisable. Plain single-ingredient paracetamol (acetaminophen) tablets have no interaction with MAOIs.

Good luck for the next few weeks!


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