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Re: Celexa » pvs321

Posted by Cousin Eddie on February 21, 2001, at 23:47:01

In reply to Re: Celexa , posted by pvs321 on February 21, 2001, at 22:29:21

Hi Alli. I have been in your boat. The two weeks after I began taking Celexa exclusively, after a few months of 150 mg. Zoloft/day, were the worst time in my therapy-SSRI withdrawal was the scariest period of my life, even worse than Lariam prophylaxis. After the two weeks (taking 20 mg. Celexa/day)I began to feel human again. The side effects definitely persisted: the hot flashes, sweating, diarrhea, sleepiness, then insomnia all lasted a good six weeks after starting Celexa. My doc ramped me up pretty quick to 30 mg. (for a week), then to 40 mg., which I'm now taking. So, to answer your question, it will take about a month or two from the end of the transition to another SSRI to feel noticeably better, in a consistent way. I saved this article from last year because it enlightened me as to elementary brain chemistry-like psych meds for dummies, as well as the importance of sticking with a prescribed pill regimen. Please excuse my posting this copyrighted article, I couldn't provide a weblink without paying through the nose to the Wash. Post.
--------------------------------------------------

The Washington Post, June 20, 2000
June 20, 2000, Tuesday, Final Edition

HEADLINE: Making the Three Tenors Sing; In Successful Depression Treatment, the
Brain's Three Neurotransmitters Must 'Harmonize.' Sometimes, a Leading Psychiatrist Says,
More Than One Medication May Be Necessary
BYLINE: Alen J. Salerian , Special to The Washington Post
BODY:
During my first session with Sarah, a married, 40-year-old lawyer, she complained about
frustrating failures she had experienced in treatment of her depression.
"After all this therapy and all these medications, I still don't feel like getting out of bed in
the morning," she said. She leaned forward and gently placed a piece of paper on my desk.
It was a printout of all the medications she had taken during the past two years: Zoloft at
200 mg for six months. Prozac at 60 mg for three months. Sixty mg of Paxil for six months,
then 400 mg of Wellbutrin for three months. Serzone at 600 mg for two months. Finally,
1,500 mg of lithium for two months.
There were two- or three-week breaks between medications. She had seen several doctors.
Her frustration was understandable.
But her worry changed to surprise when I suggested that, instead of continuing to try
different drugs in sequence, she pursue a "combination strategy"--taking more than one of
these drugs at a time.
A combination strategy was something I'd been sharing with medical students and patients
for years. It arises from understanding the role of what I call "the three tenors," the three
key neurotransmitters in the brain that regulate mood--serotonin, dopamine and
norepinephrine. As an opera lover, I like to see them as voices singing in the mind. When
they sing in harmony and balance, they can make a person feel comfortable in life. But
when one of the tenors is out of sync, the music can be disturbing, even frightening.
It may be ordinary knowledge for a psychiatrist to appreciate how each neurotransmitter
works--that serotonin regulates worry and anger, that dopamine is critical for initiative and
pleasure and that norepinephrine controls alertness and energy. But this information is
rarely shared with those being treated. It should be, because it is often the foundation for a
successful treatment, one that manages to work even after many others have failed.

A little history is helpful. From the days when the first antidepressant, iproniazid, was
serendipitously discovered in the 1950s, many advances have occurred in the treatment of
depression. Yet the central biological challenge has remained the same: how to make one,
two or all three tenors sing in harmony.
The first group of antidepressants, called tricyclics and monoamine oxidase inhibitors,
were an effective but unfriendly bunch. They indeed helped all three tenors sing vibrantly,
but they produced very unpleasant noises along the way. To reach their effective levels, one
had to suffer horrible side effects. For example, the trycyclic antidepressant Elavil caused
such intense drowsiness that many patients reported feeling like zombies. Other
medications caused dry mouth, constipation, sedation and other less severe problems.
The introduction in 1988 of Prozac, the first drug of a class called selective serotonin
reuptake inhibitors, or SSRIS, marked a significant breakthrough in treatment. It was based
on the discovery that elevating serotonin levels was crucial in alleviating depression. Prozac
was the first "designer" antidepressant, which selectively targeted serotonin alone.
Consequently it produced significantly fewer and less severe side effects than its
predecessors.
Thanks to the subsequent development of the many similarly targeted SSRIS, by the late
1990s American psychiatrists had at least 20 antidepressants to choose from to treat
depression. Most psychiatrists quickly learned that Prozac and Paxil would increase
serotonin but would not alter norepinephrine or dopamine, whereas Wellbutrin would
elevate brain dopamine concentrations without much effect on serotonin. And Effexor would
increase both norepinephrine and serotonin. Regardless of the mechanism or action, all
were considered similarly efficacious--which is to say sometimes they worked and
sometimes they didn't.
Gradually among American psychiatrists, a simple protocol was adopted to treat cases of
depression: Choose an antidepressant that treated one lead tenor. If that didn't work, try
another. And keep trying different ones until the desired effect was achieved. Yet most
researchers agreed that even with the best combination of psychotherapy and the most
effective single medication, still roughly 30 percent of individuals with depression would not
improve.
Luckily for patients like Sarah, in the last several years many quiet discoveries have been
made in the clinical practice of psychiatry. First, it was discovered that not all
antidepressants are effective for severe depressions. Also, that antidepressants with
dual action--those that influenced two tenors, like serotonin and norepinephrine--often
performed better than the antidepressants that target a solo tenor. And further, that
combining antidepressants often worked better than using a single one.
Sarah's case illustrates the point.
I asked Sarah to tell me more about her depression. "What troubles you most?"
"Worry," she responded. "I keep thinking I'm going to miss something important. That I'm
going to hurt somebody. In reality I know I do a good job as a criminal attorney, yet I'm
afraid I'm going to screw up. I know there's no basis for it, but the fear of hurting one of my
clients paralyzes me. There are days when I can't even leave home because of it."
Sarah stared into her lap, then looked up at me. "So what can you do for me?"


"What I can do for you is put you on Paxil and Wellbutrin."
"I've tried both and neither worked," she said. "Not to mention that Paxil made me sleepy
and edgy."
"Your medication history indicates that you never took these medications in combination.
And there is good evidence that what we call 'augmentation therapy' works better."
She was skeptical. She said this sounded very "aggressive," and wondered whether she was
my "guinea pig" in an experiment.
Six weeks later, after trying the regimen, Sarah had fully recovered.
"I cannot tell you how good and worry-free I feel," she said. "It's like a burden has been
lifted." But recovery had not been an easy ride--or without a change in course.
Extreme fatigue and nausea troubled her, yet once she had decided to try the combination
therapy, she wasn't going to stop her medical trial. By the end of the fourth week--a
reasonable point to evaluate the overall response to treatment--Sarah had reported being
"60 percent better" but said she still lacked energy and zip.
I recommended she add Adderall--an amphetamine-like medication often used to treat
attention deficit disorder--to further boost her dopamine.
And finally, Sarah's tenors began to sing, thanks to a combination of Wellbutrin, Paxil and
Adderall.
Sarah is not an exception. I've treated hundreds of patients who have responded well to
combination strategies.
Recent research is also promising for the use of various hormones--such as testosterone,
estrogen, DHEA and thyroid hormones--to augment the efficacy of various
antidepressants. Again, augmentation therapy appears to be a novel way to stimulate a
pleasant mood.
A few things about treating depression are clear. Poor response to treatment should always
be a reason to search for a new strategy. And it is critical to educate patients about the
chemistry of mood and how serotonin, norepinephrine and dopamine affect the way the
brain responds to life. Just as the three tenors sing best when they work together, the three
neurotransmitters make the best mood music for the brain when they're balanced
harmoniously.
Which is largely why I believe that most depressions are curable--and that most patients
are able, eventually, to hear the music.
Alen 3. Salerian, MD, is medical director of the Washington Psychiatric Center outpatient
facility for the Psychiatric Institute of Washington. He has just completed a novel, "Red
Zone," about abuses in psychiatric managed care.

< end article >
-------------------------------------------------

Please see my previous post six posts above yours to see what I'm taking. I feel SO MUCH better since I went off Zoloft four months ago (I am not dissing the drug). Please take comfort in the power of these meds, and in the strong possibility that your moods at present are chemically induced. My doc always said Give It Time, and with a pretty exotic mix of meds waiting has paid off.

I pray that a disciplined course of treatment pays off for you as well.

-Steve-


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poster:Cousin Eddie thread:3323
URL: http://www.dr-bob.org/babble/20010221/msgs/54637.html