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Re: depression subtypes and med responses » Elizabeth

Posted by jay on November 26, 2001, at 16:40:46

In reply to depression subtypes and med responses » jay, posted by Elizabeth on November 19, 2001, at 17:36:44

> > There is much talk about how the tricyclics somehow aren't good for "atypical" depression.
>
> That's fairly well-established, yes.
>
> > I think, though, that most folks have a number of symptoms that do somewhat indicate atypical depression, but also have many endogenous symptoms. (Irritability, anxiety, bouts of insomnia..etc.)
>
> Irritability, anxiety, and some types of insomnia are common in many different presentations of depression, including "atypical depression," "melancholic depression" (the word "endogenous" isn't used much this way anymore because it can be very misleading), and depressions that fall into neither category.

Actually, I prefer to look at treating symptoms rather than a general Dx. SRI/SNRI's are well documented in causing sleep distrubance, it seems more so than with tricyclics. The sense of 'apathy' brought on by some who use SRI/SNRI's (Effexor) doesn't seem to do much for even 'atypical' depression! Like I said, treating symptoms seems much more useful.


> Anxiety disorders are sometimes said to be more common in atypical depression, and some (notably, social phobia) may be connected specifically to atypical depression (the common feature in social anxiety and atypical depression being excessive interpersonal sensitivity), but anxiety in general occurs in a variety of types of depression.

I don't know about that, because in 'melancholic' depression, frequent restless sleep can exacerbate anxiety further. 'Atypical' seems to indicate a *lack* of most feeling/things, and I think latching interpersonal sensitivity doesn't make a lot of sense. Again...that's why I say look at and treat symptoms first.

> The insomnia that is associated specifically with melancholic depression is called "terminal insomnia" or early-morning awakenings. Trouble getting to sleep at night is not a specific symptom of melancholic depression and is often a problem for people with atypical depression.

Early-morning awakenings is one symptom, but frequent wakenings is also another of melancholic depression. My Dad is a classic text-book example, responded to Doxepin, and sleeps right through later without awakenings.

> IMO, the most important distinctive feature of melancholic depression is the total absence of mood-reactivity.

Absence? I have seen many with melacholic depression who have horrific crying spells, massive amounts of anxiety, panic, and experience moods just as *intense* as any depressive I have seen. This was experience in hospitals and the community with many clients. Again, that is why I have a problem with focusing on just Dx's, and say go for the symptom relief.


> > I also think the reverse of the first statement is true...and that meds for atypical depression can are little to no-good for endogenous depression symptoms, and maybe can make them worse, especially in the long run.
>
> There doesn't seem to be any reason to suppose this. I have fairly clear-cut melancholic depression, and I was helped somewhat by several different MAOIs. Desipramine is about as effective as Parnate was; in fact, the main distinction that I notice is that while I never dreamed on Parnate, I have frequent intense dreams on desipramine.

Again, after I have thought about this, it is an example of why we should not only focus on symptoms, but avoid the "this drug is only good for this Dx", etc.

> Although MAOIs haven't been studied as much as they should be for melancholic depression, the existing research has generally been positive, as long as sufficient doses (e.g., 60 mg/day of phenelzine) were used. (Older studies tended to use lower doses; melancholic depression is almost invariably quite severe and unrelenting, so while 45 mg might be sufficient for atypical depression or dysthymia, it probably won't be adequate for melancholic depression.)

Again, if the studies are broken down into WHAT symptoms are improved, and total quality of life,
I think we could gain more than just saying use this med for this type of depression only.

> > From my little bit of experience (n=1..heh,) it seems the highly activating quality of the newer SRI/SNRI's seem to really complicate endogenous depressive symptoms.
>
> The current thinking is that SSRIs are not very effective for melancholic depression. But there's no evidence that they're more effective than TCAs for atypical depression, either.

I agree with your last statement in particular, and wonder why a doctor wouldn't give say a med like nortiptyline or desiprmaine to a person experiencing more lethargic symtoms, and even older meds like Doxepin or Clomiprmaine for more extreme anxiety prone folks, and of course a benzo thrown in the mix for anxiety present in both situations. I can't *stand* the current massive benzophobia. Similar to the same things with opiates.


> Effexor has been shown to be effective for melancholic depression.

I'd like to see this, in the long run (i.e. 5 years) of Effexor Vs. Nortriptyline. There are some reports of MASSIVE weight gain on some on Effexor, and even though this is true for some on Nortrip, it does have a track record for long-term lack of weight gain, and even loss.

Also, I am concerned about the constant need for dose increase with Effexor. This doesn't seem to be the case with Nortrip. I also found Nortrip FAR more activating without massive anxiety than Effexor. It also didn't seem to have some of the emotional 'numbing' effects of Effexor....good sometimes in the short run, but I don't think good in the long run.

> > I think that is why many only attain partial relief from the newer a.d's. I've noticed that the tricyclics, in particular nortriptyline, help my depression and anxiety in a fairly different way than the newer meds.
>
> I think you're getting too bogged down in classifications. Also, a disorder is much more than any one particular symptom of it. MAOIs can make some atypical depression symptoms (especially overeating) worse, but they are effective for the underlying conditions. All drugs have side effects; the side effects are not what treats the depression.

No, I say serve the symptoms...you can serve the problems. That's what I found with Nortrip, and I honestly think doctors take side effects WAY too lightley. They are a massive reason for non-compliance. If i feel better physically and mentally sharp and calm, not having put on 50 pounds and not being able to party and enjoy myself, that sure as hell is no fugging way to go.:-)

> > Again, this is why I believe folks should consider (especially if you have had many problems with the newer a.d.'s..or they haven't helped.) a tricyclic.
>
> True melancholic depression is actually pretty rare.

Melancholic symptoms aren't, though, and yes, they can be treated. I think we are looking too much at med, and often crappy ones, for *everything*. Like having the feet on the pedal and brake...zap the anxiety with what you can..usually a benzo....juice up against the depression...a slightly more stimulating a.d. that acts on numerous n.t.'s. Get the brake and pedal in sync...I think we feel much better.

All IMHO...:-)
Jay

> -elizabeth


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