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Dr. Bob is Robert Hsiung, MD,
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Posted by SLS on June 11, 2015, at 13:57:11
In reply to Re: Medications that don't touch the 5HT1 receptor?, posted by tiopenster on June 11, 2015, at 12:21:01
> Thanks for your input. I should state that my problem was anxiety, not depression. I only experience depression as a withdrawal side effect. When I would rapid cycle, it would be worse anxiety, normal, mania (rarely), and some times depression. Anxiety was always the core.
Thanks for the clarification.
I guess we'll need to rethink this a bit.
Anxiety can be a prominent symptom of a mixed-state bipolar disorder (or even unipolar disorder), especially earlier in life. Anxiety was a bigger problem for me than depression prior to my first severe depressive episode at age 17. Also, bipolar disorder and anxiety disorders can occur comorbidly. This might be a better explanation in your case.
How old are you now? How old were you when symptoms first appeared? Bipolar disorder usually appears earlier in life than unipolar depression.
Is your anxiety constant (like GAD), or is it more of a social anxiety?
I'm not trying to force a bipolar diagnosis down your throat. I am hoping to offer information that might make things easier for you to receive effective treatment. For instance, it might be interesting to discuss with your doctor combining Lamictal, Trileptal, and Paxil. Lamictal will help with bipolar depression. Trileptal will help stabilize you and prevent mania. Paxil will help with generalized anxiety disorder (GAD) and add enhanced antidpressant effects. Effexor can be substituted for Paxil, as it is also good for GAD, but Paxil is the best. If you get stuck, you can try discontinuing Paxil and Effexor and add an MAO inhibitor. Nardil is usually chosen when anxiety is prominent. Someone I know suffered from GAD, bipolar disorder, and a touch of panic disorder. Nardil monotherapy worked to bring her into remission of all symptoms. She would have been better off if she took a mood stabilizer at the same time, though, as the Nardil produced hypomania.
- Scott
Posted by phidippus on June 11, 2015, at 14:22:44
In reply to Re: Medications that don't touch the 5HT1 receptor?, posted by tiopenster on June 11, 2015, at 12:21:01
Anxiety can be a major component of mania-it is sometimes the only presentation mania.
Have you ever tried a mood stabilizer?
How exactly do you react to 5ht1a agonists?
Eric
Posted by tiopenster on June 11, 2015, at 15:11:08
In reply to Re: Medications that don't touch the 5HT1 receptor? » tiopenster, posted by phidippus on June 11, 2015, at 14:22:44
I've been on
neurontin (not effective),
depakote (not effective),
lamictal (somewhat effective),
lithium (not effective),
topamax (made me feel depressed)
lyrica (very effective, but poops out after a week)abilify (not effective),
seroquel (akastisia),
geodon (effective, then dropped in effectiveness)
risperdal (not effective)
zyprexa (very effective at over 10mg, but made me gain 45 lbs and very very tired)SSRIs & SNRIs
(all would make me feel perfect the first 2 to 3 days, but then would make me cycle - usually anxiety, normal, manic (only on lexapro), and sometimes depressedLexapro - made me crazy anxious and gave me panic attacks
Serozone - increased anxiety 10 fold
Cymbalta (cycling every few days
Paxil (same pattern)
Zoloft (same pattern)
Nortryptiline (same pattern)
Effexor (felt good immediately, but got a rash)
Buspar (same pattern)Remeron (very effective, - similar to zyprexa. made me gain a lot of weight and turned me into a zombie
The cocktail that resolved my problems 2 years ago was the following, but I was a zombie that slept a lot and didn't talk much
Geodon
Lamictal
Lyrica
Remeron
KlonopinI had gotten off Lamictal, Lyrica & Remeron. I got my geodon to 20mg but kept that dose for insomnia that would come from tapering off Klonopin. My anxiety came back after I had gotten down to .5mg of Klonopin after being on 2mg.
I am doing better on 225mg of lyrica and 50mg of Insidon (german medication). I'm back on 2mg of klonopin and still on 20mg of Geodon. I still need something more - i will most likely go up on the insidon.
The ones I do best on are the ones that don't touch my 5ht1 receptor - remeron and insidon. Zyprexa seems to be weak at the 5ht1a. Lyrics works 100% when i start it but then drops in effectiveness a week later (dose is irrelevant).
Any other suggestions would be great. I have looked at Trimipramine which doesn't touch that receptor either, but makes me incredibly zombie like the next day for anything over 50mg.
Posted by phidippus on June 11, 2015, at 16:24:53
In reply to Re: Medications that don't touch the 5HT1 receptor?, posted by tiopenster on June 11, 2015, at 15:11:08
>lamictal (somewhat effective)
What was your dose?
>lyrica (very effective, but poops out after a week)
How did it effect you? Less anxiety?
what made you think it pooped out?
>geodon (effective, then dropped in effectiveness)
Your symptoms worsened. I doubt the Geodon lost effectiveness.
>The cocktail that resolved my problems 2 years ago was the following, but I was a zombie that slept a lot and didn't talk much
Geodon
Lamictal
Lyrica
Remeron
KlonopinThat's a bipolar person's regimen. If I were to venture a guess, I would say you're bipolar 2 because of all the anxiety.
>Insidon
Opipramol acts as a high affinity sigma receptor agonist - a mechanism shared by Luvox.
Based on your response to past medications, I would strongly recommend you seek treatment for bipolar disorder.
When treating bipolar disorder it is essential that you start with a mood stabilizer. You responded to Lamictal in the past-I would encourage you to start treatment with it.
Once your mood is stabilized and you still have an excess of anxiety, I would recommend starting an SSRI as this is the best way to treat anxiety. If you have adequate mood stabilization, you shouldn't react to them as you did in the past.
OR, you can take the Remeron, as you have had success with this in the past.
I wouldn't mess with the Geodon. Antipsychoticss are not designed to treat anxiety.
I would instead recommend Keppra, Riluzole or Zonegran-all are glutumate inhibitors and have anxiolytic properties.
Your reaction to 5ht1a agonists is simply bipolar.
Eric
Posted by tiopenster on June 11, 2015, at 17:01:16
In reply to Re: Medications that don't touch the 5HT1 receptor? » tiopenster, posted by phidippus on June 11, 2015, at 16:24:53
I was at 150mg of Lamictal
Lyrics totally erased the anxiety, but then it dropped in how well it worked about 2 weeks in.
I responded to the Geodon similar to SSRIs. Felt great for 2-3 days and then the effectiveness dropped.
Posted by phidippus on June 11, 2015, at 17:05:14
In reply to Re: Medications that don't touch the 5HT1 receptor?, posted by tiopenster on June 11, 2015, at 17:01:16
150 is on the low side. I would try lamictal again and push it to 300/400 mg.
Eric
Posted by tiopenster on June 11, 2015, at 17:35:28
In reply to Re: Medications that don't touch the 5HT1 receptor? » tiopenster, posted by phidippus on June 11, 2015, at 17:05:14
I've been up to 400, but it didn't do much for the anxiety. I'm just saying 150 was the dose I was on in my cocktail
Posted by phidippus on June 12, 2015, at 13:45:23
In reply to Re: Medications that don't touch the 5HT1 receptor?, posted by tiopenster on June 11, 2015, at 17:35:28
Well, at 150 it wasn't quite therapeutic. I'd like to see how you feel with more Lamictal.
Do you ever get racing thoughts?
Eric
Posted by tiopenster on June 12, 2015, at 17:06:26
In reply to Re: Medications that don't touch the 5HT1 receptor? » tiopenster, posted by phidippus on June 12, 2015, at 13:45:23
It, along with 4 other drugs, was therapeutic. It wasn't therapeutic earlier on when I was at 400mg and it was just that and an AD.
I tried zonegran too for weight loss (didn't do anything for the anxiety). I am very interested in your suggestion of rilozule.
No racing thoughts. In the past, it was either panic or the feeling that something was wrong, but I didn't know what. Sometimes I was a hypochondriac though. Now, my anxiety centers around guilt. 2 things that I think I've done wrong. They are ruminating thoughts and obsessive. When my anxiety goes away, then the guilt goes away. It's very bothersome.
Posted by phidippus on June 12, 2015, at 17:49:31
In reply to Re: Medications that don't touch the 5HT1 receptor?, posted by tiopenster on June 12, 2015, at 17:06:26
400 mg and an AD? Well, that's a fine recipe for treating GAD or OCD.
So, from your history, SNRIs and SSRIs seem to worsen your anxiety. Remeron works but makes you flat.
hmmm.
Now a review of your symptoms: panic and a free floating anxiety (feeling something is wrong) in the past. Hypochondriasm. Guilt around two things you think you've done.
I would diagnose you with GAD and OCD based on these symptoms. Hypochondriiasm and the guilt you're experiencing is definitely OCD. Panic and free floatinng anxiety may be due to the OCD but may also stem from GAD.
I would focus on treating the OCD. First, I would find a therapist who specializes in OCD and in particular, treating it with ERP. This is first line treatment for OCD. Second line treatment is a SEROTOGENIC AD. OCD entails a defecit of serotonin in regions of the brain and a surplus of dopamine in others (primarily the nucleas accumbens). SO you have to treat the lowered levels of serotonin with a serotogenic AD. IF SSRIs and SNRIs are backfiring on you, it would be best to try your alternatives: Clomipramine and Mirtazpine. You can also try Trazandone. Viibryd and Brintellix are aternatives, but you seem to think 5ht1a agonists cause you problems...Also, remember it takes higher doses of ADs to treat OCD properly. For instance, if you're taking Remeron, you'd take as much as 90 mg-dosages up to 120 mg have been reported.
To lower dopamine and if their isn't enough response to an AD, the APA recommends augmentation of an AD with an AAP (low dose). Geodon seemed to work well for you when coupled with Remeron.
SO, if you're on an AD and an AAP and you're still having issues with the OCD, the APA recommends the addition of a glutamate inhibitor. You happened upon this strategy when you were taking Remeron, Lamictal (a glutamate inhibitor) Geodon and whatever else you were on. You reported this combination helps.
Other glutamate inhibitors yo can use to treat your OCD are: Zonegran, Topemax, Riluzole, Lyrica, Keppra, Lamictal, memantine, Gabapentin...
Lyrica worked for you for obvious reasons
Now, there are other medicationns you can take to combat the OCD and they are: Tramadol, Dextroamphetamine, Caffeine, Morphine and ondansetron.
How do I know all this? I'm an OCD coach :)
Eric
ps. what are these things you are feeling guilt about?
Posted by tiopenster on June 12, 2015, at 18:43:44
In reply to Re: Medications that don't touch the 5HT1 receptor? » tiopenster, posted by phidippus on June 12, 2015, at 17:49:31
In the span of this thread, I've been diagnosed with bi-polar (because of the way I respond to SSRIs) GAD and OCD.
My whole story started with a panic attack out of the blue. A whole bunch of stress and a change in medication seemed to trigger a panic attack in the middle of the night 9 years ago. I had about 10 panic attacks. I was so obsessed with how my body felt because that's that a panic attack will do to you. I resolved those by figuring out I needed to stop fearing a panic attack. Those went away without medication, but by that time I figure that out, it had gone into my body as a constant vibration (somatic) I started to have GAD (free floating anxiety). In an attempt to solve that problem I became a "hypochondriac" to try and figure out how to solve the anxiety. After 5 years, I finally find the right cocktail, then start tapering off all my meds. Feeling better with each med going by the wayside. I switched from a liquid formulation of Klonopin to the pill form when after I had dropped from 2mg to .5mg to stay there for a month and stabilize. Well, it would appear that the compound pharmacist had added a little extra klonopin to the liquid formulation because 3 days after I made the switch to pill form, I had an anxiety attack out of the blue. I've since figured out that the liquid formulation has about 10% more klonopin in it than the pill form, so I think the change triggered withdrawal anxiety.
My anxiety attack was because I thought I was unintentionally being dishonest to a business contract, where I had no thought of that for months prior. I did lots of legal research to see if I was in the wrong, but I wasn't. I would have no anxiety for days and then another anxiety attack would happen when the same thought would crop up. This happened several times until i was just ruminating on it all day long. Trying to solve a problem that I had already solved.
I started lyrica and within 2 days, the anxiety was demolished. No guilt. nothing. Then as I explained previously, the lyrica would poop out after a week. So I added Insidon which helped tremendously. I was on the lowest dose - 50mg (Insidon doesn't touch the 5ht1). I had a normal response to it. No cycling with a gradual improvement. For the last 2 weeks, I've been feeling about 85-90% normal. I increased my dose of Insidon to 100mg a couple days ago and I've been feeling normal. I'm notorious for poop out so we'll see. I also returned to my dose of 2mg of klonopin because this latest episode was caused because of withdrawal.
A fantastic article to explain how I respond to SSRIs is entitled Treatment-Resistant Anxiety Disorders: Neurotrophic Perspectives by Jeremy Coplan. It's a free article in Psychiatric Times. http://www.psychiatrictimes.com/articles/treatment-resistant-anxiety-disorders-neurotrophic-perspectives
I actually spent $600 for an initial visit with him in NY (I lived in VA). He really saw Lamictal as the key to treating treatment resistant anxiety. He uses the term tachyphylaxis, which described me to a tee. The article is fascinating and may help many out there.
I know OCD is on the anxiety spectrum, but I wouldn't say I have the disorder. I'm going to see a pdoc in one week.
Posted by tiopenster on June 12, 2015, at 19:07:42
In reply to Re: Medications that don't touch the 5HT1 receptor?, posted by tiopenster on June 12, 2015, at 18:43:44
Come to think of it, after I had mood stabilizers on board, I did not cycle on ADs, I would just have poop out after about 2-3 days. This would happen on each dose increase too. I couldn't sustain treatment response. Is there anything to do for that?
Anafranil looks interesting because it has very weak affinity for 5ht1
Posted by phidippus on June 12, 2015, at 19:21:41
In reply to Re: Medications that don't touch the 5HT1 receptor?, posted by tiopenster on June 12, 2015, at 19:07:42
>I couldn't sustain treatment response. Is there anything to do for that?
How long were you on the AD?
So you think you're cycling. Describe it to me.
Eric
Posted by SLS on June 12, 2015, at 21:07:13
In reply to Re: Medications that don't touch the 5HT1 receptor?, posted by tiopenster on June 12, 2015, at 19:07:42
> Come to think of it, after I had mood stabilizers on board, I did not cycle on ADs, I would just have poop out after about 2-3 days. This would happen on each dose increase too. I couldn't sustain treatment response.
This pretty much describes me, too. That sort of tachyphylaxis can put you on an emotional rollercoaster.
I don't know what to do about this. I am currently considering tissue stimulation techniques. rTMS looks interesting. I should be able to stay on my current drug regime during treatment.
Parnate 100 mg/day
nortriptyline 100 mg/day
Lamictal 300 mg/day
lithium 300 mg/day
Abilify 10 mg/day
prazosin 30 mg/day
- Scott
Posted by tiopenster on June 12, 2015, at 21:30:55
In reply to Re: Medications that don't touch the 5HT1 receptor? » tiopenster, posted by SLS on June 12, 2015, at 21:07:13
Yes, an emotional roller coaster is an understatement. I would feel great and have hope that I had found a proper treatment and then back to square one. Someone on the outside would probably describe it as a placebo response, because that's how it appears, but it only mimics the cycle. It's very physical.
How soon do you experience tachyphylaxis (poop out) on a med? It would happen to me after 3 days on an ssri/tricyclic and geodon. It would happen to me after about a week on lyrica?
Posted by tiopenster on June 12, 2015, at 21:36:56
In reply to Re: Medications that don't touch the 5HT1 receptor?, posted by phidippus on June 12, 2015, at 19:21:41
I'm not cycling now. I haven't in 5 years or so. I cycled on lexapro & cymbalta at the very beginning of treatment before I added mood stabilizers. I would feel great, then too great (manic), then really bad anxiety, then normal, then depressed (not in any particular order) I would do this hourly or daily or over several weeks. The more the drug isolated serotonin (i.e. lexapro) the worse it was. Lexapro made me feel possessed and suicidal several types. It really was a devil drug for me. The other ADs, after I had mood stabilizers would work for a couple days and then stop and do the same thing with each dosage increase. I assume that is my serotonin receptors down regulating to compensate. I was on an AD (including Remeron) for 6 or so years. Now the only anti-depressant I'm on now is Insidon (Opipramol)
Posted by tiopenster on June 12, 2015, at 21:39:50
In reply to Re: Medications that don't touch the 5HT1 receptor? » tiopenster, posted by SLS on June 12, 2015, at 21:07:13
What are you suffering from?
Posted by SLS on June 13, 2015, at 0:01:23
In reply to Re: Medications that don't touch the 5HT1 receptor?, posted by tiopenster on June 12, 2015, at 21:39:50
I suffer from chronic bipolar depression with drug-induced psychotic mania. It is a variant of bipolar 1 disorder.
Regarding tachyphylaxis, if a drug is going to produce a robust improvement, I must be on it for 10 - 13 days before it emerges. My mood switches from depressed to euthymic within hours. Unfortunately, the improvement disappears just as rapidly after 3 days. The best I can do now is to take six drugs and maintain an inadequate partial improvement in mental energy. I once responded very well for over 6 months on a combination of Parnate 60 mg/day and desipramine 150 mg/day. Unfortunately, mania emerged and the antidepressants were discontinued. I relapsed into depression 2 months later. I no longer responded to treatment after that.
- Scott
Posted by tiopenster on June 13, 2015, at 0:31:54
In reply to Re: Medications that don't touch the 5HT1 receptor? » tiopenster, posted by SLS on June 13, 2015, at 0:01:23
Yes, we have very similar responses. I'm sorry to hear that. It's maddening. I have one way that boosts serotonin, norepinephrine and dopamine without the tachyphylaxis. Pardon me if you've already heard of it.
Have you been tested to find out if you have the MTHFR genetic polymorphism? I have two parts of the gene that are affected. When I started the treatment, my depression disappeared in 2 days. Simply google bipolar and MTHFR. There are a tone of resources out there that explains the connection. The treatment is methylfolate and methyl B12. Takes a couple weeks to find the right dose, but it seems to lift all the neurotransmitters for me without the tachyphylaxis. I wonder if it would be helpful for you.
Here's just one of a ton of articles https://www.psychologytoday.com/blog/the-integrationist/201409/genetic-mutation-can-affect-mental-physical-health
Deplin is the prescription strength dose of methylfolate, but I wouldn't recommend starting with that. You can get lower doses over the counter. No one I talk to in real life knows about this, but it may be different on this board.
Posted by SLS on June 13, 2015, at 6:03:46
In reply to Re: Medications that don't touch the 5HT1 receptor?, posted by tiopenster on June 13, 2015, at 0:31:54
Thanks for the tip!
> Yes, we have very similar responses. I'm sorry to hear that. It's maddening. I have one way that boosts serotonin, norepinephrine and dopamine without the tachyphylaxis. Pardon me if you've already heard of it.
>
> Have you been tested to find out if you have the MTHFR genetic polymorphism? I have two parts of the gene that are affected. When I started the treatment, my depression disappeared in 2 days. Simply google bipolar and MTHFR. There are a tone of resources out there that explains the connection. The treatment is methylfolate and methyl B12. Takes a couple weeks to find the right dose, but it seems to lift all the neurotransmitters for me without the tachyphylaxis. I wonder if it would be helpful for you.
>
> Here's just one of a ton of articles https://www.psychologytoday.com/blog/the-integrationist/201409/genetic-mutation-can-affect-mental-physical-health
>
> Deplin is the prescription strength dose of methylfolate, but I wouldn't recommend starting with that. You can get lower doses over the counter. No one I talk to in real life knows about this, but it may be different on this board.I tried Deplin twice in combination: once with Nardil, and once with Parate. I felt an immediate boost in mood and energy with Nardil, but not so much with Parnate. I eventually discontinued Deplin because it actually began to make my depression worse. I recovered immediately upon stopping it. Deplin made me feel worse when I tried it again recently.
- Scott
Posted by SLS on June 13, 2015, at 6:10:40
In reply to Re: Medications that don't touch the 5HT1 receptor?, posted by SLS on June 13, 2015, at 6:03:46
What about taking methylene blue? It is not a unique idea.
I started taking methyl-B12 a few months ago. Perhaps I oculd add back the Deplin to see what happens.
- Scott
Posted by phidippus on June 13, 2015, at 8:07:20
In reply to Re: Medications that don't touch the 5HT1 receptor?, posted by tiopenster on June 12, 2015, at 21:30:55
>How soon do you experience tachyphylaxis (poop out) on a med? It would happen to me after 3 days on an ssri/tricyclic
ADs typically take 4-6 weeks to start working.
I would consider the placebo effect.
Eric
Posted by phidippus on June 13, 2015, at 8:14:18
In reply to Re: Medications that don't touch the 5HT1 receptor?, posted by tiopenster on June 12, 2015, at 21:36:56
>The other ADs, after I had mood stabilizers would work for a couple days and then stop and do the same thing with each dosage increase.
Are you telling me that you would start an AD and it would work for a couple days then stop? If this is the case then I'd say you were experiencing a placebo effect because you need to take an AD for about 6 weeks before it really starts working.
If you had been on an AD for 6 weeks, what was the dose and which AD were you taking?
> I assume that is my serotonin receptors down regulating to compensate.
Its not that simple.
Eric
Posted by SLS on June 13, 2015, at 10:06:11
In reply to Re: Medications that don't touch the 5HT1 receptor? » tiopenster, posted by phidippus on June 13, 2015, at 8:07:20
> >How soon do you experience tachyphylaxis (poop out) on a med? It would happen to me after 3 days on an ssri/tricyclic
>
> ADs typically take 4-6 weeks to start working.
>
> I would consider the placebo effect.Certainly, everyone has their right to consider the placebo effect to explain tachyphylaxis. For some people, this might be true. However, for lots of people, it is not. Insisting on dismissing a patient's report of a transient improvement with medication can be confusing and belittling. It is insulting and displays ignorance of the variable phenomenology of biological mood disorders. Ever hear of ultradian rapid cyclicity? In the absence of medication, people with this presentation can complete a mood cycle between mania and depression within 24 - 48 hours without fail. I would not be inclined to call this a placebo effect, especially when someone presents this way as their untreated baseline as their index condition.
- Scott
Posted by tiopenster on June 13, 2015, at 11:22:57
In reply to Re: Medications that don't touch the 5HT1 receptor?, posted by SLS on June 13, 2015, at 10:06:11
I agree with you Scott.
This article describes our rapid tachyphylaxis.
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