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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 14 of 14. This is the beginning of the thread.
Posted by CheckTest on August 7, 2018, at 22:05:04
Hello there- I believe this is my first time posting here but I've read some from over the years. Saw my Psych today and he is leaning toward ECT for my current depression, have a consult scheduled later in August, but they might move it up. Uncertain about ECT.
Right now I am really doing ok, overall. Little flat, some periods of sadness, suicidal ideation, consistent feelings of worthlessness/inability, but nothing quite at a hospital level. Getting through what needs to be done. Eating, sleeping, hours at work (part). Little bit of psychomotor slowing but not consistently, though a couple bad times.
Dx: MDD, some anxiety,
h/o insomnia (maintenance, early) doing fine on mirtCurrent medications:
Mirtazapine - 60 mg
Vortioxetine - 15(20) mg
Bupropion - 75x2 mg
~Methylphenidate ER - 10 mg[2000 IU vitamin D3, magnesium threonate from a sibling, tried various supplements]
Some exercise, good diet. In therapy, consistent.~I haven't been taking the ritalin lately, so I plan to start taking it consistently because it does seem to make me less anxious and get me out of my head some. Just have been not wanting to take medication, I guess.
Cut down on vortioxetine a few weeks ago. Mezza-mezza, don't have any problems with it. It was one of the most effective medications I was on for some time, combined with ritalin.
Bupropion I can't really say. Might stop it some time.
Mirtazapine. Getting sleep. Little sedating. Not sure how well it really is working.
Previously on:
Tranylcypromine - 70 mg
with methylphenidate - 5-15 mg
short period buspirone as well.Was out of depression on ritalin and vortioxetine in past.
Others in past, various combos I can't recall:
Fluoxetine, sertraline, escitalopram
Venlafaxine, duloxetine
Desipramine, amitriptyline, ?nortBupropion in other combinations
BuspironeLithium, lamotrigine
Seroquel
Aripiprazole (hospitalized 2nd day on it - SI)Benzos make me more depressed, absolutely. Don't do much for my anxiety either.
Trazodone is mediocre. There are others too.Did low dose naltrexone for a bit. Might check if my doctor wants to try that again.
rTMS - L DLPFC protocol seemed to be good?
R DLPFC trial didn't seem to do anything?Usually have minimal side effects, most tolerable [wore compression socks for hypotension from parnate, careful with diet]. Switched due to lack of efficacy.
Various: Have a sibling who has done a bunch of 'natural' routes and I have gotten some of her leftovers. The methylation route didn't seem to be as effective as effexor. But some do fantastic- people can have different experiences.
Not taking medications and doing only diet and exercise - went poorly, multiple times.
Ashwagandha - insomnia, ?worse minor.
Rhodiola - nothing notable
Probiotics? - no diff
Magnesium - might make me flatter, glycinate insomnia, may try not taking for a bit
Melatonin - ineffective for sleep over a range of doses (500mcg - actually 50 mg). mood worse?SAMe - can't recall. May try again
Methylfolate - nothing notable5-htp - nothing notable? I think?
l-tyrosine - nothing much. Might have been good for when I worked out too much.
phenylalanine - ""I did some 'nootropics' in the past but at that time I was fairly depressed and mood variable, so nothing reliable and consistently likely can be said. Aniracetam did make me feel worse a few times. Cholinergics(Choline, alpha-GPC) are generally bad news, though not as consistently bad as might be expected.
Possible rash from prescribed modafinil- not sjs but allergic [diffuse]
Tianeptine 12.5 mg x3 - possibly worse. accurate dose.
Opioids after surgeries made me sick and slow. I'm happy to not be an addict. A tough disease.Actually I did have a scopolamine patch that was beneficial during a previous episode. I might try that again. It is used for cognitive impairment and memory studies for a reason, however.
Minocycline for infection- helped the infection, can't say I noticed much for mood. Maybe fuzzier
Thank you for any input! Little scared about ECT, and I might wait it out after the consult, but thought I would check in.
Best of luck to all of you out there! Keep on going! The world is a maddening, perplexing, but interesting place! Hopefully all of you can be part of it and find some comfort!
Posted by CheckTest on August 7, 2018, at 22:32:58
In reply to ECT or switch up medication or stay put, posted by CheckTest on August 7, 2018, at 22:05:04
Oh, I forgot. Did ketamine infusion in January. Perhaps helped some but oddly I had SI the next afternoon.
Agmatine I didn't notice much, perhaps flatter or duller.
I've been doing therapy for a while and am in a good place with my therapist. No notable childhood trauma or anything like that. Therapy can be really good.
Posted by linkadge on August 8, 2018, at 7:38:29
In reply to ECT or switch up medication or stay put, posted by CheckTest on August 7, 2018, at 22:05:04
Ok. You posted a lot.
The first thing that strikes me is that your doctor is recommending ECT when you say you are doing "ok overall". If you're not feeling sure about it, then just tell your doctor you'd rather not (at this time).
Personally, I would lean more towards ECT only if your symptoms move into the severe range and aren't responding at all (or very little) to medications.
Have you tried mirtazapine and venlafaxine together? This combo can work well for some.
I currently take effexor + mirtazapine + lithium (in varying ratios). I use mirtazapine mainly for sleep (it has some antidepressant effect, but not that much, for me). I find lower doses work better (< 7.5mg). Higher doses actually made me more depressed. If you are taking Remeron more for sleep, you might try reducing the dose. The noradrenergic action can induce sadness (mirtazapine blocks a shutoff switch for NE release). Mirtazapine is more sedating in lower doses (mostly an antihistamine) and starts to engage other systems at higher doses (norepinephrine release via alpha-2 blockade). For some people, alpha-2 blockers can induce sadness.
Couple recomendatiosn from reading:- Zinc is very important for depression (more evidence than many other supplements - cheap - enhances the effect of dopamine reuptake inhibitors)
- methylating substances can be used in conjunction with regular antidepressants - folic acid is probably the most important
- scopolamine (have used myself) can be used on an as needed basis (can work quickly and effects can last, for some)
You mentioned that ritalin and vortioxetine worked in the past. When they stopped working, what were the key symptoms that returned?You mentioned that cholinergics make you worse (although not consistently). I notice the same thing. However, choline, somtimes can help me dramatically. Many of the psych meds enhance the monoamine / acetylcholine ratio. This can sometimes cause apathy.
Linkadge
Posted by CheckTest on August 8, 2018, at 8:43:32
In reply to Re: ECT or switch up medication or stay put, posted by linkadge on August 8, 2018, at 7:38:29
Thank you for reading! Yes I didn't realize how long it got as I was writing off and on over the day.
I believe I was on mirtazapine and effexor in the past, but effexor never really made much of an impact. No 'California rocket fuel'. I think the mirtazapine was pushed up to see if it would be more activating, relatively. More multimodal. I did notice things were getting brighter (visually outside) as I started 45.
I believe my Psych is concerned about getting too far down. I've had the unfortunate pattern of dropping precipitously from otherwise functioning at a reasonable level, and it has spooked him. Also some progress on suicidal planning.
Major symptoms include the suicidality, excessive guilt, insomnia with sleep disruption and early awakening (though insomnia has been a constant even when feeling fine), no appetite. Anhedonia. I vary between emptiness at times, but worst is more of a writhing feeling that gets dangerous. Psychomotor retardation that is obvious to others generally (affect, voice basically slow slurred).
Anxiety is variable, it is hard to say with the interplay with depression. So far good on the mirtazapine.
I tried methylfolate again a few months ago, but probably didn't give it long enough. I might even have some deplin left over.
Yeah. I never could figure out choline. Sometimes it really did help, but doses never really lined up.
Thanks again. I will give zinc a shot (maybe I tried it?) along with keeping up the ritalin. Probably will go to the consult for ECT, see what they say, and try the scopolamine before going to a full course.
Posted by linkadge on August 8, 2018, at 9:11:11
In reply to Re: ECT or switch up medication or stay put, posted by CheckTest on August 8, 2018, at 8:43:32
Hmm.
If you're noticing sudden drop-offs in mood...
1) (of course) look at which meds might be kicking out when - i.e. IR methylphenidate. Not sure if you're using a slow release version.
2) perhaps look to resume a low dose of lithium (?) even 150mg might help prevent some of the drop-offs. Also, the use of emergency meds (like Ritalin) can be helpful for this.
When your mood drops off, is it a certain time of day, or is it kind of like a sudden relapse for a few days at a time?
Linkadge
Posted by CheckTest on August 8, 2018, at 15:07:30
In reply to Re: ECT or switch up medication or stay put » CheckTest, posted by linkadge on August 8, 2018, at 9:11:11
I've had the mood inconsistency for some time- was briefly given a tentative bpII diagnosis many years, but had a steady depressed mood for over two years, and certainly never been hypomanic. Was highly anxious and functioning at a previous depression. Mixed. Not bpII by psychs for 5+ years.
I don't appear to be reactive to good stimuli or really bad when I am very off. It is variable. Tried exploring with psychotherapy, but they usually put me back in touch with the psych.
Doesn't appear to be med timing related. 10Mg extended release. Never had problems with low moods from methylphenidate. Sometimes I just wake up very slowed, sometimes it happens during the day. At worst I have bad mornings, gets a bit better, and bad at night. I would guess relapse for days at times.
Oftentimes I have a prodromal period before bad periods of inconsistent thought vs. mood and activity. Can feel very off but have generally positive thoughts, or have rather negative thoughts but function well, or sometimes just be slowed but overall ok. Or a pervasive feeling something is off even though things are good. Out of sync I guess.
Perhaps lithium again. I was on 1200mg, maybe 1500mg and was very flat at the time. Clumsy. Mainly stopped because I still had SI and seemed ineffective. Or a low dose lamotrigine.
Thank you for your time!
Posted by linkadge on August 8, 2018, at 15:57:32
In reply to Re: ECT or switch up medication or stay put, posted by CheckTest on August 8, 2018, at 15:07:30
Lower doses of lithium can still work as a depression adjunct. Some studies suggest a benefit to as low as 150mg. No need for blood monitoring at this dose.
Linkadge
Posted by Christ_empowered on August 8, 2018, at 16:14:24
In reply to ECT or switch up medication or stay put, posted by CheckTest on August 7, 2018, at 22:05:04
hi. i read a small study from the late 90s which found that adequate doses of stimulants helped about as much as ECT. maybe ask about increasing the ritalin or a switch to some sort of amphetamine?
other than that...I think in Europe, doctors go up to 90 or so on Remeron. Not saying think about it or anything, just mentioning that there might be some room to go up there, too.
I see that you're already on 4 psych drugs. As much as I've personally never really enjoyed extensive cocktails, maybe add Lamictal or mirapex? In Bipolar I, 200mgs/Lamictal seems to be what shrinks (read: my shrink) aim for..but I think there's a lot of range, from 100 up to 600 (that's how much a former shrink told me he'd go up to...-shudder-).
id personally avoid ect, if you can. Mine was not voluntary (long story...), and...the ill effects were horrible, and pronounced, for a while there. Clearly, I've made it thru...now I've even regained IQ points, and I have a whole new personality, "Zen and The Art of Motorcycle Maintenance" style.
seriously, though; ECT can be rough, the relapse rates are high, and its usually expensive. I'd try adding lamictal, increasing the stimulant...something, anything else...first. ((personal opinion, clearly)).
hope this helps.
Posted by CheckTest on August 8, 2018, at 18:11:58
In reply to Re: ECT or switch up medication or stay put, posted by Christ_empowered on August 8, 2018, at 16:14:24
Yeah, I was on 400 mg lamotrigine in the past. My psych tested blood levels and apparently I cleared through the drug rather quickly. Same with Lithium- I was at below typical levels for 1200mg.
I am wary about ECT. My family has had some experience with it actually, and done ok, but it does seem to vary. I'll go through with the consult, but I'm not signing up for it right away by any means.
No, barring this period, I actually dislike being on medication, but I'll do it if it works. My psych really isn't a poly-drug guy either. Except for some of my combos. Did do lithium and parnate some. I'm uncertain about the remeron in some ways. I have had an EKG and all that jazz, BP, so I know I am relatively ok.
Sorry that you went through forced hospitalization and ECT, I can't imagine how difficult that was. Switch ing personalities. Glad that you made it through!
Yeah, I'll tweak more and see how it goes.
Posted by beckett2 on August 8, 2018, at 20:08:22
In reply to ECT or switch up medication or stay put, posted by CheckTest on August 7, 2018, at 22:05:04
When I take my transdermal methylphenidate regularly, I do much better. The patch is a hassle in the summer because of perspiration. That and because I tend to drift off until I'm back in the ditch. (Not sure why I do that.) My patch dosage is 30 mg over nine hours.
Have you tried Focalin?
Interestingly, I am taking Trintellix with Ritalin and like it. I'm curious why you're cutting back or might discontinue that before Bupropion.
Posted by Lamdage22 on August 9, 2018, at 7:59:45
In reply to Re: ECT or switch up medication or stay put, posted by CheckTest on August 8, 2018, at 15:07:30
Hey,
i have not seen any people that benefitted, just memory problems/brain damage.
Posted by CheckTest on August 9, 2018, at 9:29:38
In reply to Re: ECT or switch up medication or stay put, posted by beckett2 on August 8, 2018, at 20:08:22
I guess I have had a fear of either being dependent on stimulant medication or doing worse after being on them a while. It is not an entirely rational fear, and has been influenced by previous friends / friends of friends who misused prescribed medication.
I haven't tried focalin, actually. I basically kept with whatever my Psych went for. I had a consuit with another doc who wanted to do dextroamphetamine and something else, not sure. Maybe modafinil.
Yeah, I was really good on ritalin and vortioxetine for a while.
Not exactly a fan of the bupropion. It does increase the levels of vortioxetine, notably.
I'd have to try to get a pharmacy card or something for a daytrana patch. Insurance coverage for an adult without ADD may be tricky, though luckily I've been able to clear a lot.
Posted by KathrynLex on August 12, 2018, at 13:00:50
In reply to Re: ECT or switch up medication or stay put, posted by CheckTest on August 9, 2018, at 9:29:38
Hi there CT -
I was just looking through this thread again, and you seem to mention several times that you're tentative about the idea of ECT. (If you end up doing a consult, I'd be very interested to know what you learn.)
It sounds like you're not doing as well as you'd like, but you're still functioning and looking for ways to augment your current meds with something that might offer the help you need. Finding the right combination is an overwhelming and frustrating process (I'm going through that right now), but I also remain optimistic that I'll get it figured out.
In about 1997, my father went through ECT and I'm not sure if it helped him. It's hard to say. He went through a few treatments, and the impact on his short term memory really scared him. He would come home after treatments, and try to put away the dishes, but even though it was something he'd been doing for over a decade (we don't rearrange our kitchen much), he couldn't remember where anything went. It scared him enough to not complete his treatments. Of course, that being said, he's now hardly on any medication (just the occasional Valium to take the edge off his anxiety and maybe a prescription of Gabapentin for six months to get him through a rough patch. I can't say it he's doing well because of the ECT or because he's older and our body chemistry seems to change with age. He's fairly mellow these days, and seems to have found a way to live that makes him happy. I could credit some of this to the ECT, but I'm really not sure, and it was such a terrifying experience for him, I'm not sure it's something I'd be willing to try - except as a last resort.
I hope you learn some useful things at your consult, and ultimately choose to do whatever you believe will be best for you.
K
Posted by Lamdage22 on August 13, 2018, at 12:25:48
In reply to Re: ECT or switch up medication or stay put » CheckTest, posted by KathrynLex on August 12, 2018, at 13:00:50
Good point... I have met about 10 people that recently underwent ECT. And from what i have seen i can only tell you please dont do it!
This is the end of the thread.
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