Psycho-Babble Medication Thread 1075968

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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!

 

Re: Starting Parnate - Update » ed_uk2010

Posted by Robert_Burton_1621 on February 13, 2015, at 9:25:21

In reply to Re: Starting Parnate - Update » Robert_Burton_1621, posted by ed_uk2010 on February 12, 2015, at 13:09:44

> 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.>

I really appreciate your comprehensive feedback, Ed.

I may have progressed to 40mg too quickly, as mid-yesterday and today I've been feeling extremely weak. My limbs feel (paradoxically) both weightless and very heavy. It takes a conscious effort to stand up, hop up, walk, etc.

I've checked my BP and it was 127/71, so that is not the cause. It may be the cumulative effect of the insomnia hitting me. I've now got some temazepam from my specialist to help counter the insomnia. First time taking a drug from the benzo class.

I've also lost pretty much all of my appetite. Having eaten only some almonds, blueberries, and toast over the last two days wouldn't be helping my blood sugar. Perhaps that's why I'm feeling physically weak.

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

Yes, thank you. Today, though, because of my extreme weakness, I had no choice but to cancel.

> >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.
>

That is a good description, though I should emphasise that it feels, at this stage, exclusively physiological rather than affective/personal, as it were. I hope, though, that the physiological functions as the precursor of the personal, in time.

> >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!
>

This is very helpful, thank you. There was meat: lamb and chicken. And it's lack of freshness may have been disguised by the sauces. I can't know. But I will take it as a cautionary experience.

> >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.
>

I have a history of terrible migraine, so this tension-headache is, in comparision, tolerable. Yes, thanks, I have been advised about OTC analgesics. And I will be purchasing a BP monitor next week, just saved up, since they are a bit pricey.

Incidentally, would it be possible to take sandomigran [pizotifen] (which, in the past, solved my chronic transformed-migrainous state overnight)with parnate? It's a serotonin antagonist, so I'm assuming yes. I know triptans would be out of the question.

> Good luck for the next few weeks!>

Thank you indeed. I will be persevering!

 

Sleep, FOOD, fluids and hypotension. » Robert_Burton_1621

Posted by ed_uk2010 on February 13, 2015, at 11:33:58

In reply to Re: Starting Parnate - Update » ed_uk2010, posted by Robert_Burton_1621 on February 13, 2015, at 9:25:21

Hello.

>I've been feeling extremely weak. My limbs feel (paradoxically) both weightless and very heavy. It takes a conscious effort to stand up, hop up, walk, etc.
>
> I've checked my BP and it was 127/71, so that is not the cause.

MAOIs don't usually cause much in the way of sitting or lying (supine) hypotension. The major effect is to impair normal postural autonomic nervous system reflexes. The ability to maintain BP at a relatively constant level on changing position, particularly standing up for a sitting or lying position, is impaired (orthostasis - postural hypotension).

To detect postural hypotension with a home BP monitor, measure your BP after sitting quietly for 5 minutes or more. Use a BP monitor with a properly fitting upper arm cuff. Take a couple of measurements to ensure consistency eg. one in each arm. The cuff/arm should be at approx. heart (nipple) level! Then.... standing up abruptly and wait about 3 minutes. At this point, measure BP again with the arm/cuff at heart level. Examine the difference, looking for a substantial drop on standing.

Postural hypotension does not necessarily develop immediately after starting an MAOI, it can take a couple of weeks to set in. Although it may not disappear over time ie. a drop may still occur, the body can often adjust so that symptoms no longer occur. It seems the brain can adjust so that normal function still occurs at lower perfusion pressures.

Most people have a high salt intake anyway so there's rarely any need to increase.... but certainly, do not attempt a low salt diet while titrating the MAOI. Inadequate fluid and salt intake aggravates the postural BP drop. As well as eating adequately, you need to maintain a decent fluid intake. Becoming dehydrated whilst on an MAOI is likely to cause substantial weakness and postural hypotension.

>It may be the cumulative effect of the insomnia hitting me. I've now got some temazepam from my specialist to help counter the insomnia. First time taking a drug from the benzo class.

Temazepam is often helpful for short-term or 'as needed' use. How much are you taking, 10-20mg?

If you don't respond well to temazepam, you could still consider zolpidem 5-10mg or zopiclone 3.75-7.5mg, or perhaps cyproheptadine as mentioned below.

>I've also lost pretty much all of my appetite. Having eaten only some almonds, blueberries, and toast over the last two days wouldn't be helping my blood sugar. Perhaps that's why I'm feeling physically weak.

I think that will have made a huge difference. In fact, it could be the main problem. Do you live alone? Anyone who can help you out?

You need some calories even if you're not hungry. Maybe go for something starchy and filling (but easy) like a baked potato with baked beans, or pasta with tomato sauce (and no cheese in the sauce!)... or how about wholemeal bread and cooked chicken pieces as a sandwich with a bit of tomato, rocket salad and mayo? Fruit is good but it's definitely not going to give you enough calories to feel well considering how little you've eaten lately. Would be better to have an egg sandwich!

>I should emphasise that it feels, at this stage, exclusively physiological rather than affective/personal, as it were.

To be fair, it's only been a week, so a full response would be rare at this stage. It's good that you are sticking with it. If you think taking 40mg at once might be making you feel strange, you could try 20mg when you get up and 20mg a few hours later.

>There was meat: lamb and chicken. And it's lack of freshness may have been disguised by the sauces. I can't know. But I will take it as a cautionary experience.

Considering you still have a headache and feel weak, maybe just make some really basic high energy meals to safely boost you calorie intake until you feel better. Seriously, who knows what they stick in takeaway food.

>Incidentally, would it be possible to take sandomigran [pizotifen] (which, in the past, solved my chronic transformed-migrainous state overnight)with parnate? It's a serotonin antagonist, so I'm assuming yes. I know triptans would be out of the question.

Interesting, phenelazine (Nardil) has been used as a migraine prophylactic, although it takes several weeks to work. I don't know what effect Parnate has on migraine.

Pizotifen is a serotonin antagonist yes, at 5-HT2a and 2c. It is related to the tricyclic antidepressants and I'm not sure how thoroughly its reuptake inhibitor potency has been studied... probably not much! I do not believe it's a serotonin reuptake inhibitor but the pharmacology of many old drugs is not well known.

An alternative possibility is the closely related serotonin antagonist and antihistamine drug cyproheptadine (Periactin). It is structurally similar to pizotifen and has also been used for migraine prophylaxis. In addition, cyproheptadine has been used to treat serotonin syndrome. Cyproheptadine is generally rather sedating at first, so might be of benefit for insomnia when taken as a single dose in the evening eg. 4mg. Rarely, depression has been reported as a side effect, but I have heard other people say it helped their depression. Anyway, you could ask you doctor about it. Cyproheptadine improves sleep, stimulates appetite and reduces headaches. Daytime doses are likely to make you sleepy if you're not used to it.

I think it would be best to wait a few weeks in order to determine whether any additional drugs are needed for headache prophylaxis. In the mean time, you could take paracetamol or ibuprofen (or naproxen) for relief. NSAIDs often help headaches more than paracetamol but side effects are more common and they do have a variety of contra-indications. If you need an NSAID for more than a few days in a row, a PPI such as lansoprazole or omeprazole is recommended for gastro-protection.

And yeah, the triptans are metabolised by MAO so it's not recommended to take them with MAOIs. Side effects have been reported.

Good luck!

 

Re: Sleep, FOOD, fluids and hypotension. » ed_uk2010

Posted by Robert_Burton_1621 on February 14, 2015, at 7:33:20

In reply to Sleep, FOOD, fluids and hypotension. » Robert_Burton_1621, posted by ed_uk2010 on February 13, 2015, at 11:33:58

> To detect postural hypotension with a home BP monitor, .....>

This is extremely practically helpful. I was told to measure my orthstatic BP, but not told how to do so optimally (or even adequately).

I appreciate your advice on hydration and calorie intake. I agree (from what you've explained) that my lack of calories over the last three days is likely to be the main problem.

In regards to fluids - and dehydration - for the sake of full-disclosure, and at the risk of embarassment, I am having difficulty with alcohol. This has been a long-standing issue. I only drink at night, probably 7 standard drinks. I suppose Oprah would assess me as "self-medicating". And she'd be right. I am only drinking white wine since the move to parnate. But I don't want to, and I know that it is just another confounding factor. To be honest, I was secretely hoping that, being on parnate, I would not be able to tolerate *any* alcohol: that would have been an absolute barrier. I am going to stop it all from tomorrow.

As a side note, the astonishing thing about Effexor when it worked was that it not eradicated any *desire* for alcohol; i.e., it just didn't help me in avoiding the temptation, but totally eliminated the temptation itself. It do so within a week and I was alcohol free for close to six months.

I do live alone and alas there's no one I can call on to give me a hand. Or rather, there's no-one whom I would be *willing* to ask (a qualification which points perhaps to a pride or shame on my part). Outside of medical or uni officers (to whom I was required to disclose it), I have told no family and only one friend of my condition. As for the later, though he has known me for 20 years, he affected disbelief. He had a brief episode of depression himself years ago and recovered immediately on fluoxetine. I suspect he assumes that his experience of recovery would be replicable if I were genuine. It's because of the likelihood of reactions like this that I am very reluctant to disclose the severity of my depression or even that I am affected by it.

Be that as it may, what I think I will do is prepare some meals in advance and freeze them, so I can eat even if I am feeling weak.

I was interested in your stress on high-calorie meals. Was this made for the purpose of negating quickly my minimum-calorie consumption over the last three days, or because there's something about Parnate which makes a (within reason) high-calorie diet beneficial or important?

> Temazepam is often helpful for short-term or 'as needed' use. How much are you taking, 10-20mg?>

That's right, I've been told to take one or two tablets, up to 20mg. I took one and it had no effect, and two had a small effect though it was already 5am then and I suspect I may have fallen asleep soon thereafter anyway!

I've had some itching from the temazepam, I assume - scalp, eyes, ears, lips, tongue. It's not unbearable, but it is annoying.

Thanks for the list of alternatives. Would you consider doxepin potentially useful? We can't get trazadone here in Australia.

Mirtazapine (small dose) knocked me out in 15 minutes when i was taking it at night with Effexor. Is taking that out of the question?

Sorry - I'm imposing on you with all of these questions!


> Pizotifen is a serotonin antagonist yes, at 5-HT2a and 2c. It is related to the tricyclic antidepressants and I'm not sure how thoroughly its reuptake inhibitor potency has been studied... probably not much! I do not believe it's a serotonin reuptake inhibitor but the pharmacology of many old drugs is not well known.>

I see; that's instructive. The odd thing is that, i know pizotifen is prescribed as a prophylactic, but when I took it it actually "cured" the transformed-migrainous state I was in for many weeks - overnight.

I have just learnt from your comment that it's possible for something to be a serotonin antagonist and yet have serotonin reuptake inhibition as well. My "common-sense" would have concluded these properties were mutually exclusive. I do have a lot to learn.

> I think it would be best to wait a few weeks in order to determine whether any additional drugs are needed for headache prophylaxis.>

I agree.

> Good luck!

Thanks, again!


 

Re: Starting Parnate - Update » Robert_Burton_1621

Posted by SLS on February 14, 2015, at 7:49:01

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

I'm currently taking 120 mg/day of Parnate along with nortriptyline and a few other wonder drugs (I wonder why they aren't working). I increased the dosage of Parnate from the 100 mg/day I had been taking. For the first 2 days, I experienced more mental energy, but no antidepressant effect. Last night, I was not feeling well enough to go out, so I question how much benefit I am currently gleaning.

Parnate 120 mg/day
nortriptyline 100 mg/day
Lamictal 300 mg/day
lithium 450 mg/day
Abilify 10 mg/day
prazosin 30 mg/day

Degree of improvement: 35-40%


- Scott

 

Re: Starting Parnate - Update » SLS

Posted by Robert_Burton_1621 on February 14, 2015, at 8:23:21

In reply to Re: Starting Parnate - Update » Robert_Burton_1621, posted by SLS on February 14, 2015, at 7:49:01

I like your mordant whimsy about "wonder" drugs, Scott!

> I'm currently taking 120 mg/day of Parnate along with nortriptyline and a few other wonder drugs (I wonder why they aren't working). I increased the dosage of Parnate from the 100 mg/day I had been taking. For the first 2 days, I experienced more mental energy, but no antidepressant effect. Last night, I was not feeling well enough to go out, so I question how much benefit I am currently gleaning.
>
> Parnate 120 mg/day
> nortriptyline 100 mg/day
> Lamictal 300 mg/day
> lithium 450 mg/day
> Abilify 10 mg/day
> prazosin 30 mg/day
>
> Degree of improvement: 35-40%
>

To someone, like myself, who is equipped with very little psychopharmaceutical knowledge (and none that he could explain from first principles), this regime strikes me as such an aggressive one that I am sorry to hear that the degree of improvement thus far has only been modest. The disjunction between the personal effort required in medication compliance across 7 separate drugs and the degree of clinical benefits you've so far reaped must generate considerable frustration.

The combination and augmentation therapy you're on is so specialised I wouldn't know where to being to comment constructively. And it is proverbially reckoned most prudent for one to remain silent and only be thought a fool, than to open one's mouth and remove all doubt. But just FYI, have you come across this paper?

http://www.ncbi.nlm.nih.gov/pubmed/24972362

The addition of dextroamphetatime to the high-dose (120mg) parnate you are taking induced "remission" (definition?) in patients when parante alone did not.

And there is this case study on the use of N-Acetylcysteine as an augmenting agent to parnate:

http://www.researchgate.net/publication/253647461_N-Acetylcysteine_Augmentation_to_Tranylcypromine_in_Treatment-Resistant_Major_Depression

(read and download paper on the right of screen)

These suggestions are no doubt ridiculously ingenue. I hope they're not presumptuously so, though.

 

Re: Sleep, FOOD, fluids and hypotension. » Robert_Burton_1621

Posted by ed_uk2010 on February 14, 2015, at 10:25:13

In reply to Re: Sleep, FOOD, fluids and hypotension. » ed_uk2010, posted by Robert_Burton_1621 on February 14, 2015, at 7:33:20

Hi,

>I am only drinking white wine since the move to parnate. But I don't want to, and I know that it is just another confounding factor.

Perhaps it will help you to resist if you bear in mind that white wine does sometimes contain tyramine, so it's best to avoid drinking a lot. The tyramine content may vary between batches. A small amount of white white is likely to be safe, but may not provide the 'self medication' effect which makes you drink it in the first place. Large amounts are obviously best avoided. So maybe just avoid it? Easier said than done, but I think you can do it.

>Be that as it may, what I think I will do is prepare some meals in advance and freeze them, so I can eat even if I am feeling weak.

Some bulk preparation sounds like a good idea.

>Was this made for the purpose of negating quickly my minimum-calorie consumption over the last three days

Yes, exactly. You hadn't had enough calories to feel well.

>there's something about Parnate which makes a (within reason) high-calorie diet beneficial or important?

No, not at all.

>I've had some itching from the temazepam, I assume - scalp, eyes, ears, lips, tongue. It's not unbearable, but it is annoying.

I'd request something else. Temazepam is anxiolytic, but obviously wasn't sedating enough for you, and the itching is not a good sign. I would consider zopidem, zopiclone... or perhaps cyproheptadine, if available.

>Thanks for the list of alternatives. Would you consider doxepin potentially useful?

Possibly. Doxepin is a very potent antihistamine, a serotonin 5-HT2 receptor antagonist and a weak serotonin reuptake inhibitor. Because there isn't much experience combining it with MAOIs, I would suggest something lacking the SRI effect first. Doxepin is also very long-acting to use as a sleep aid.

>Mirtazapine (small dose) knocked me out in 15 minutes when i was taking it at night with Effexor. Is taking that out of the question?

No, it's not out of the question at all, but I don't know whether your doc would agree to it. He might feel worried simply by the fact it's another antidepressant. Although drugs with moderate or strong SRI effects are the major concern by far, doctors who do not use MAOIs regularly may not be too comfortable prescribing any other antidepressants at the same time. I think it depends a lot on the psychiatrist. I do suspect cyproheptadine would help. It shares a strong sedative antihistamine effect and 5-HT receptor blocking property with mirtazapine.

>Sorry - I'm imposing on you with all of these questions!

No problem!

>i know pizotifen is prescribed as a prophylactic, but when I took it it actually "cured" the transformed-migrainous state I was in for many weeks - overnight.

In that case, I wouldn't be surprised if the closely related serotonin antagonist cyproheptadine might do the same. Cyproheptadine is shorter-acting than pizotifen and possibly more sedating; I would suggest it might be more suitable as a sleep aid. If used for migraine, cypro is taken during the day as well as at night, but the first few doses should be given at night.

I feel like I'm selling cypro! This is uncommon - it just seems to fit your symptoms and med history particularly well!

>I have just learnt from your comment that it's possible for something to be a serotonin antagonist and yet have serotonin reuptake inhibition as well.

A lot of antidepressants have both properties, amitriptyline is a good example.

>I do have a lot to learn.

I don't know about that, but... I wrote you a post at the top of the page in the Effexor + Remeron vs Parnate thread. I called it 'pharmacology'. It might be of some use.

Take care.

 

Re: Starting Parnate - Update » Robert_Burton_1621

Posted by SLS on February 14, 2015, at 18:04:00

In reply to Re: Starting Parnate - Update » SLS, posted by Robert_Burton_1621 on February 14, 2015, at 8:23:21

Thanks Robert!

I will think seriously about adding NAC.


- Scott


> I like your mordant whimsy about "wonder" drugs, Scott!
>
> > I'm currently taking 120 mg/day of Parnate along with nortriptyline and a few other wonder drugs (I wonder why they aren't working). I increased the dosage of Parnate from the 100 mg/day I had been taking. For the first 2 days, I experienced more mental energy, but no antidepressant effect. Last night, I was not feeling well enough to go out, so I question how much benefit I am currently gleaning.
> >
> > Parnate 120 mg/day
> > nortriptyline 100 mg/day
> > Lamictal 300 mg/day
> > lithium 450 mg/day
> > Abilify 10 mg/day
> > prazosin 30 mg/day
> >
> > Degree of improvement: 35-40%
> >
>
> To someone, like myself, who is equipped with very little psychopharmaceutical knowledge (and none that he could explain from first principles), this regime strikes me as such an aggressive one that I am sorry to hear that the degree of improvement thus far has only been modest. The disjunction between the personal effort required in medication compliance across 7 separate drugs and the degree of clinical benefits you've so far reaped must generate considerable frustration.
>
> The combination and augmentation therapy you're on is so specialised I wouldn't know where to being to comment constructively. And it is proverbially reckoned most prudent for one to remain silent and only be thought a fool, than to open one's mouth and remove all doubt. But just FYI, have you come across this paper?
>
> http://www.ncbi.nlm.nih.gov/pubmed/24972362
>
> The addition of dextroamphetatime to the high-dose (120mg) parnate you are taking induced "remission" (definition?) in patients when parante alone did not.
>
> And there is this case study on the use of N-Acetylcysteine as an augmenting agent to parnate:
>
> http://www.researchgate.net/publication/253647461_N-Acetylcysteine_Augmentation_to_Tranylcypromine_in_Treatment-Resistant_Major_Depression
>
> (read and download paper on the right of screen)
>
> These suggestions are no doubt ridiculously ingenue. I hope they're not presumptuously so, though.
>

 

Re: Itching: Temazepam, Parnate or Amitriptyline? » ed_uk2010

Posted by Robert_Burton_1621 on February 15, 2015, at 5:26:27

In reply to Re: Sleep, FOOD, fluids and hypotension. » Robert_Burton_1621, posted by ed_uk2010 on February 14, 2015, at 10:25:13


> So maybe just avoid it? Easier said than done, but I think you can do it.>

Thanks, Ed. No time like the present, so I've stopped today.

> I'd request something else. Temazepam is anxiolytic, but obviously wasn't sedating enough for you, and the itching is not a good sign. I would consider zopidem, zopiclone... or perhaps cyproheptadine, if available.
>

I will definitely pursue this as far as hypnotic effect goes.

I am still itching after stopping temazepam a day and-a-half ago.

It's just occured to me that the itching may not be a reaction to it at all. I have been experiencing this symptom on and off for the last 18 months, ever since I withdrew from a high dose of amitriptyline. What's been happening is that every two or three weeks i get itching symptoms, slight at first but then within four day unbearable. This persisted while i was on Effexor and I took 5mg - 10mg of amitriptyline and the problem was solved for a couple of weeks. I didn't need to do this while on mirtazapine, nor when I was on nortriptyline. *But*, what strikes me as not coincidental, is that I stopped nortriptyline 10 days ago now: and the itching has come back.

Because I am taking nothing with H1 antagonism, I guess that's why the itching isn't being suppressed?

As I said, this has been a totally consistent pattern for the last 18 months - 2 years.

Are such symptoms heard of when people withdraw from amitriptyline, and is it not uncommon for them to persist so long?

I've stopped the temazepam: how long should I wait to be able to exclude it as a possible cause of the itching?

And the only other possible cause is parnate itself. But I haven't read anything about itching except as a case of severe allergic reaction and I don't seem to have the accompanying signs for that to be plausible.

Given the above, I think - instead of taking a small dose of amitriptyline every two weeks - your suggestion to use Cyproheptadine with its strong anithistamine sedative effect may be a way of killing two birds with one stone. (Well, three, actually, given its use in headache management, too)


> >Sorry - I'm imposing on you with all of these questions!
>
> No problem!
>

It's very generous of you - this stage of the parnate process would be so much more difficult were it not for this forum and the pretty amazing feedback I get from members like you.

>I wrote you a post at the top of the page in the Effexor + Remeron vs Parnate thread. I called it 'pharmacology'. It might be of some use.
>

Yes, noticed that right away. I have printed it out and read it once. But I need to take time and read it with full attention. It's the best outline (for someone like me) I've come across!

Would you recommend a basic, reliable, introductory textbook on psychopharmacology? Something a little more rigorous that (e.g.) "Prozac for Dummies" but not forbiddingly specialised.

 

Re: Itching: Temazepam, Parnate or Amitriptyline? » Robert_Burton_1621

Posted by ed_uk2010 on February 15, 2015, at 13:26:09

In reply to Re: Itching: Temazepam, Parnate or Amitriptyline? » ed_uk2010, posted by Robert_Burton_1621 on February 15, 2015, at 5:26:27

>I am still itching after stopping temazepam a day and-a-half ago.

Itching really isn't a common side effect of benzos at all. Given your history, I think you can almost rule it out as the likely cause if you're still itching today... unless you came out in a rash after you took it.

>Because I am taking nothing with H1 antagonism, I guess that's why the itching isn't being suppressed?

It could be. Some antihistamines are safe with MAOIs and others are not (in no case does the risk of side effects appear to have anything to do with histamine itself). I suggest you try cetirizine 10mg/day, if you haven't already. It's non-prescription in most countries and produces very potent H1 antagonism in the skin. Do not buy chlorphenamine/chlorpheniramine, it's a weak SRI. Cetirizine rarely cause side effects, about 1 in 10 people experience drowsiness and very uncommonly an upset stomach.

>Are such symptoms heard of when people withdraw from amitriptyline, and is it not uncommon for them to persist so long?

I've heard of problems when stopping other antihistamine ADs such as mirtazapine. Do you have any allergies or skin problems? If so, amitriptyline may have been suppressing a reaction to something in the environment.

>I've stopped the temazepam

Yeah, there's no point taking it unless it really helps. You can get something else now.

>And the only other possible cause is parnate itself.

It doesn't really correlate.

>Cyproheptadine. (Well, three, actually, given its use in headache management, too).

Four now!

Itching, insomnia, headache and maybe appetite.

You could buy some cetirizine 10mg tablets while you wait to see your doctor. Cyproheptadine is non-prescription in some countries but not others, and may not be kept in stock or routinely sold.

>Would you recommend a basic, reliable, introductory textbook on psychopharmacology? Something a little more rigorous that (e.g.) "Prozac for Dummies" but not forbiddingly specialised.

I must admit I tend to use quite a lot of different sources rather than one, and don't have a favourite book.

Take care.

 

Re: Itching: Temazepam, Parnate or Amitriptyline? » ed_uk2010

Posted by Robert_Burton_1621 on February 17, 2015, at 8:44:03

In reply to Re: Itching: Temazepam, Parnate or Amitriptyline? » Robert_Burton_1621, posted by ed_uk2010 on February 15, 2015, at 13:26:09

> Itching really isn't a common side effect of benzos at all. Given your history, I think you can almost rule it out as the likely cause if you're still itching today... unless you came out in a rash after you took it.
>

No rash. I think you're bang-on. It's not the benzo.

> Some antihistamines are safe with MAOIs and others are not (in no case does the risk of side effects appear to have anything to do with histamine itself). I suggest you try cetirizine 10mg/day, if you haven't already. It's non-prescription in most countries and produces very potent H1 antagonism in the skin. Do not buy chlorphenamine/chlorpheniramine, it's a weak SRI>

Thanks, Ed, that's important advice. I bought some Zyrtec (cetirizine) today

> I've heard of problems when stopping other antihistamine ADs such as mirtazapine. Do you have any allergies or skin problems? If so, amitriptyline may have been suppressing a reaction to something in the environment.
>

No pre-existing allergies or skin problems at all. No other sensitivities. No change in environmental circustances for 12 years. So my tentative conclusion is the ferocious pruritis is not an allergic reaction which the endep was surpressing. It seems that my H1 receptors are going haywire and are hyper-sensitive after having been anatgonised by the endep at high doses. I've tried to find information on this but so far nothing has come up.

> >And the only other possible cause is parnate itself.
>
> It doesn't really correlate.

That is a relief to hear!


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