Posted by Scott L. Schofield on April 30, 2000, at 12:54:13
In reply to Re: Short Trial Success/Bipolar II Qx, posted by Mark H. on April 30, 2000, at 1:36:16
> I'm fascinated that a few of the posters I most respect, and who have some of the greatest knowledge of biochemistry, support the 6-8 week AD trial theory, which has always seemed to me absurdly dangerous and ineffective.
I share your frustrations with this approach.
If nothing else, it may take several dosage increases to reach the minimum level at which an antidepressant response will occur. I guess titration can be performed more rapidly than has been practiced traditionally.
I would not consider the necessity of 2-4-6 week trials to be so much a theory as an observation. I can't see stopping certain recognized antidepressants prior to the end of the third week. In my mind, these would include tricyclics, MAO-inhibitors, SSRIs, reboxetine, Serzone, Remeron, Wellbutrin, and Effexor. Effexor can elicit an early transient improvement in mood or energy, but it may still take 2-3 weeks to effect a sustained response. When these drugs are added to an ongoing treatment, they may sometimes produce results more quickly. I believe that other drugs show their potential effectiveness for depression (not bipolar) within three to ten days. This usually occurs when they are employed in the role of augmenting agents, either in combination with the traditional antidepressants, or with eachother. These drugs would include amphetamines, psychostimulants, antiobesity drugs, antinarcoleptics, anticonvulsants, neuroleptics, and lithium. Neuroleptics such as Zyprexa, Seroquel, and Solian (amisulpride) also demonstrate effectiveness as monotherapy in some cases.
I have read stories on this board describing almost instantaneous improvements with all of the traditional antidepressants. I believe them. I have not followed-up to see how long these improvements have lasted. I recall that some of them seemed to stick.
I think taking a survey on this board to find out the percentage of immediate vs. latent responses to specific drug treatments and how long these responses have been maintained would provide some incredibly valuable information. Developing a standard brief questionnaire to retrieve this information would make the process more efficient and produce more easily interpretable results.
The first and only time a drug regimen has produced a robust and long-lasting improvement (nine months) for me, I did not begin to feel anything until I was into the third week of treatment. It was a noticeable improvement, but VERY small. My condition improved VERY gradually over the course of three months until I reached the point of maximum benefit. Perhaps this is unusual, and associated with the refractoriness of my case.
To me, something rings true about the idea that those drugs that will be robustly effective will show some early positive results. I don't know. However, there is no doubt in my mind that there are many for whom none of the available drugs will produce this early improvement, and yet ultimately respond well to them.
I guess one could begin a screening process for potentially effective medications using a series of one to two week trials. If nothing comes of them, though, then it might be necessary to initiate longer trials with the understanding that one must return to all of the drugs tried previously. Drugs that had worsened their condition would be excepted.
> I've said it before, but in my experience anything that makes a depressive worse should be stopped immediately, as the clinician is risking that person's life during the two-month "wait and see" period.
I tend to agree with this. No drug that has initially made me feel worse has gone on to produce an improvement.
> I'm with Karen B on this -- when my depression has been lifted by medication, the effect is not subtle, questionable, gradual or attributable to something else.
Why did you not continue with any of these medications?
> At point "x" I added "this" to the mix, and less than 48 hours later the heavy dark curtain of depression had lifted and I could begin my healing. The effect is so dramatic and sudden that I want to think I have simply and naturally gone into some sort of miraculous remission,
It was those medications that you used as adjuncts that demonstrated these rapid improvements? What else were you taking at the time?
> but stopping my AD for EVEN ONE OR TWO DAYS a year or two later causes the curtain to fall
I know. It is scary and demoralizing to realize how totally and perpetually dependant one's brain functon can be on medication.
What drug(s) specifically do you label as being "ADs". Which are "augmenters".
> The quantity of adjunctive meds I need to take fluctuates with my cycle. I'm usually most well in late Nov and all of December, and again in late May and most of June. I'm at my worst usu in late Aug and Sept and again in Feb and March.
A girlfriend of mine who has been diagnosed as bipolar II demonstrates exactly the same cycle. She has just emerged from her March funk.
> I still wonder if the 6-8 week trial period appears to work for some (or even a majority of?) people NOT because SSRIs have stabilized the neurotransmitters, but because the brain itself has found a new equilibium in that time, whether somewhat assisted by the AD or not.
I think there are many who tend to think this way, myself included. Sometimes, I think that it doesn't really matter in which direction you push the system, as long as you force it to reset itself by establishing a new equilibrium. That the French drug tianeptine, a serotonin reuptake accelerator (as opposed to a reuptake inhibitor), works as an antidepressant seems to provide a rationale for this concept.
> Cam and others, whom I greatly respect, may in fact be right.
I don't think that if one is right, that the other needs to be wrong.
> But if they are, then I suspect some other factor is at work for me and others like me.
Exactamundo.
I've seen some researchers go so far as to conceptualize depression as being comprised of many different disorders.
> My depression is refractive and cyclic and long-term. Trials of Prozac, Zoloft, Paxil, Serzone and others were NOT cumulative or helpful for me in any way, regardless of the length -- I remained severely depressed for months and months and months on SSRIs.
Are you O.K. now? What does work and how well? What drugs are you currently taking?
> I'm classed as Bipolar II, but it would be counter-productive to clip my minor "highs," which is when I do my best work and feel most normal, and I have never responded (except negatively) to any of the so-called mood stabilizers. So much for the idea that being given an AD without a mood stabilizer will supposedly flip us bipolar folk over into mania -- either my diagnosis is incorrect or incomplete, or the "expert guidelines 2000" have made far too broad a generalization in this regard.
You may have a bunch of different stuff going on here. Perhaps you are bipolar II with a soft-SAD thing happening, or possibly a double-depression situation.
If you still need help, perhaps it is time to consider an MAO-inhibitor. What a surprise coming from me, right? :-)
I bet Depakote made you feel worse.
Parnate, Lamictal, along with a stimulant or Provigil in combination may be worth a look at.
> By the way, do two "troughs" and two mild "highs" a year make me a "rapid cycler?"
It probably indicates a SAD component.
> Is there even such a thing for Bipolar II?
> I assumed a rapid cycler was someone who either experienced> mixed states
No.
> or vacillated within a few hours or days between states
This is ultra-dian rapid-cyclicity and ultra rapid-cyclicity respectively.
> -- but some of what I've read on this site brings this into question.
How so?
> Any clarification will be appreciated.
>
> Many thanks,
>
> Mark H.Too many words. I hope I haven't muddied things up too much. I'm still pondering all of this stuff. It is extremely relevant, and your thoughts have helped me ponder further.
Thanks.
Sincerely,
Scott
poster:Scott L. Schofield
thread:31659
URL: http://www.dr-bob.org/babble/20000429/msgs/31761.html