Posted by Robert_Burton_1621 on February 14, 2015, at 9:24:19
In reply to Re: Effexor + Mirtazapine MORE effective than PARNATE! » Robert_Burton_1621, posted by SLS on February 14, 2015, at 7:10:34
> Thanks for the mention. Your story is very frustrating for me to read. It is all too common, and I'm sorry you have had to endure ignorance and arrogance. This can be a lethal combination. That any psychiatrist should tell you that you have little or no chance of responding to any treatment is like giving someone who is already depressed a reason to commit suicide. Of course, there is no way anyone in the world could predict such a thing. There is simply too little known about the brain and the drugs that act on it.
>You're right. The attitude initially only intensified and multiplied the instances of the daily suicidal ideation I was already affected by. Until I thought: there is something fishy about his reasoning. In this instance, his "ignorance and arrogance", as you acccurately describe it, prompted me to some further research which revealed that my options were not as limited as he mistakenly, brazenly, led me to believe.
I should make clear that he did not advise that *nothing* could ever benefit me; only that the chances of benefiting from alternative *medication* were small. His reasoning was: ok, you haven't responded to the medication I prescribed, and this must be because your condition is not fundamentally drug-treatable. Therefore, I'm going to send you to psychotherapy.
So, in spite of the fact that I had been suffering for close to two decades all of the signs (especially catatonia/psycho-motor retardation) of a condition which psychotherapy has been shown unlikley to improve and which are pathognomonic for a biological illness, he advised by implication that that was essentially my only hope.
But I've found someone else now, and that's a good thing!
> You must be big-time resilient, and I admire you greatly. I am tempted to tell you to not give up, but it seems to me that you never will. Ok - what the hell. "Don't give up!"
>Your attribution of resilience to me is profoundly reassuring, and I am grateful for it. I think I needed to hear that, in fact, since I have been battling internally the belief that I am viewed by others as pathetically lacking that quality. It is almost inevitable that chronic sufferers of severe depressive conditions will internalise the prejudice that their failure to improve precisely is a reflection of their *lack* of resilience, their fundamental woosiness. I know I have. There are few people who have not suffered severe depression who understand or who can imagine inwardly, and not merely patronisingly, the resilience that is necessary simply to get though the day.
I've noticed there seems to be a kind of uncouth, thuggish, "no-nonsense", "common-sensical", "back-to-basics" reaction in the world to the recent well-meaning campaigns to raise "awareness" of "depression". To some degree the reaction is reasonable, since the definition of what clinically constitutes "depression" has been broadened so much that everyone who suffers a personal set-back is now plausibly diagnosable as a clinical case. But the reaction doesn't limit itself to targeting the *abuse* of definitional parameters: it *assumes* their truth because doing so provides more devastating rhetorical ammunition against any person claiming to be diagnosed with "depression". It's essentially an expression of scepticism about the legitimacy of the clinical category itself; and it's usually most crudely summed up by the moralistic belief that people with depression just need to develop more "resilience".
The Pro-Dean of the Law School I attended made a point recently of publically announcing that the pedagogy of the School was to produce "tough" students. That's the kind of student they want. And the Dean of the same School stated that students who are too "precious" just need to learn the life-lesson that "stuff happens" and get over it. And she went into print belittling the students who had registered with disability services, claiming that they were just indolent because "they couldn't drag themselves out of bed" and were inventing psychiatric diagnoses ex post facto as excuses for this indolence.
She may have been right in some cases. The injustice is that everyone is painted with the same broad brush, no matter how serious or intractable their condition may be. And that may well have been her intention. Injustice can be administratively very convenient.
(I've banged on about this personal example, mostly because it's still a wound I'm trying to get over. Apologies for going on about it.)
There are many people of this type in managerial control of our institutions now: they will never be convinced, I don't think, of the thuggishness of their views.
La Rochefoucauld has a wonderful epigram about people of this type; it diagnoses their worship of "toughness" as essentially a function of their vanity:
"We all have stength enough to endure the misfortunes of others".
Pretty damning, I'd say.
> Take care, and good luck.
>
Thanks, Scott, I will. Same to you. And, no, I won't give up.> ----------------------------------------------
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> > > > I found this study of Parnate vs. a combo of Effexor and Mirtazapine which seems to indicate that the combo is twice as effective for MOST treatment resistant patients.> >
> >
> >
> > > This particular arm of the STAR*D study is meaningless.
> >
> > "The mean daily dose at exit for tranylcypromine was 36.9"
> >
> > The low dosage of Parnate used was woefully inadequate to treat depression. Most people don't respond to Parnate until a dosage of 40 - 80 mg/day is reached.>
> >
> > - Scott
> >
> > Scott, this is so well-said, well-spotted, and well-deserving of repeated emphasis.
> >
> > Your observation is instructive because it prompts all of us who are "treatment-refactory" to pay very close attention to the protocols which are appplied in studies purporting to demonstrate the relative superiority of x strategy over y strategy.
> >
> > Last year I was also, foolishly, excited by the discovery of this paper on ven + mirtaz v. tranyl. The excitement was aroused because I simply could not convince, at that time, any psychiatrist to prescribe parnate. (For one psychiatrist, I printed out and indexed a number recent research papers on the drug published since 2000, by eminent and rigorous psychopharmacologists, which supported its efficacy and corrected misconceptions as to its intrinsic "dangers", but to no avail). Rather, the efforts I went to in order to demonstrate the sincerity of my motivation, my desperation, to overcome my depressive illness were interpreted as evidence of a discreditable belief that there exists a "magic bullet" in the form of a mythical drug which will "cure" this illness once and for all. The particular psychiatrist who delivered this assessment (not the same one to whom I had given all the papers mentioned above), quite a senior and apparently reputable one, remarked that I had done more solid research into possible treatments than any patient he had seen before. It was clear that his remark was not intended as a compliment.
> >
> > So my next strategy was to press the merits of the combination studied in this paper. And he was perfectly happy to prescribe the ven + mirtaz combo, though without any understanding of the mechanisms by which it was claimed to have such an effective, and extraordinarily positive, action in treatment-resistant cases. This same psychiatrist refused to consider an MAOI, on reasons which recent research, which should have been known to him if he were scientifically conscientious, has proven to be entirely erroneous.
> >
> > The lesson I learnt from this experience is that, for psychiatrists, while all forms of ignorance may be equal, some are more equal than others.
> >
> > The effect of this combination was (on me) negligble. The (posited) increase in noradrenergic neuro-transmission may have contributed to an acute, and very unpleasant, episode of troublesome anger I went through. Not wholly unsurprisingly given his deficient learning, the psychiatrist who prescribed this very combination refused to offer any constructive advice about this side-effect ("I don't treat side-effects"); I was simply advised to address my concerns to my GP.
> >
> > The idea that this combo's appeal as an efficacious psychotropic with superb anti-depressant properties should be publicised popularly by the moniker "Californian rocket fuel" may well be some evidence for its source as a marketing ploy. I would, however, not wish to dismiss the positive experiences of people who have benefited from it.
> >
> > Any "anti-depressant" benefit from Mirtazapine may in any case arise predominantly as a result of its extremely potent H1 antagonism. The supposition that it is "dual-action" has been pretty much exploded. But I don't possess sufficient learning to draw any conclusion.
> >
> > Scott, you mention the Star*D trials. I agree that no competent psychopharmacologist could possibly assent to the proposition that their outcome has any clinical bearing on the relative efficacy of parnate. The only point I'd make in response is that the majority of psychiatrists, in my experience, are incompetent or barely competent psychopharmacologists; and the supposed definitiveness of the Star*D outcomes is routinely invoked in a knee-jerk and uncritical way whenever MAOIs are raised.
> >
> > I was informed unequivocally by the same psychiatrist whose "advice" I was subject to for eight months last year that, given the trials of medication to which I had been non-responsive or only partially responsive in the past, there was (if I recall correctly) only a 6 - 10% chance (i.e., a pretty negligible chance) that I'd be responsive to anything else. This ex cathedra declaration was made in full awarenesss of, and must therefore have been taken to have incorporated due consideration of, my desire to trial an MAOI. But the idea that Star*D (or any trial using a similar a protocol as regards MAOIs) has anything at all to say about tranylcypromine is unsupportable; indeed, risible.
> >
> >
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poster:Robert_Burton_1621
thread:1040126
URL: http://www.dr-bob.org/babble/20150129/msgs/1076598.html