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Dr. Bob is Robert Hsiung, MD,
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Posted by linkadge on January 16, 2006, at 8:25:04
In reply to Re: Depressed/agitated/wired - soft bipolar?, posted by 4WD on January 15, 2006, at 18:25:29
>If I take the Depakote and the agitation/fear >goes away, does that mean it IS med-induced >dysphoric mania? I'm kind of looking at this med >trial as a diagnostic tool.
I would have to say no, simply due to the fact that depakote can be used as an adjunctive in severe anxiety, since it has a really strong gaba effect.
But along those lines, if it works then so be it, you could continue to take it.
Linkadge
Posted by ed_uk on January 16, 2006, at 13:26:47
In reply to Re: Depressed/agitated/wired - soft bipolar?, posted by 4WD on January 15, 2006, at 18:25:29
Hi Marsha
You could try imipramine again at a low dose, or maybe one of the more sedating TCAs given as a single dose in the evening.
Ed
Posted by 4WD on January 16, 2006, at 20:57:03
In reply to Re: Depressed/agitated/wired - soft bipolar?, posted by linkadge on January 16, 2006, at 8:25:04
> >If I take the Depakote and the agitation/fear >goes away, does that mean it IS med-induced >dysphoric mania? I'm kind of looking at this med >trial as a diagnostic tool.
>
> I would have to say no, simply due to the fact that depakote can be used as an adjunctive in severe anxiety, since it has a really strong gaba effect.
>
> But along those lines, if it works then so be it, you could continue to take it.
>
>
>
> Linkadge
>So far I'm having no side effects from the Depakote (but I only went up to 500mg last night - 250 mg the 3 nights before that). No real positive effects yet either.
Do you know how long it should take to help? I do think the severity of the depressed part of it might be a little less. OTOH I think I'm experiencing some depression from stopping Celexa and the Effexor not having kicked in yet. It's not suicidal, it's just unutterably sad at the moment.
Yeah, I think if I could take Depakote for anxiety instead of Klonopin, I'd rather.
Thanks,
Marsha
>
Posted by 4WD on January 16, 2006, at 21:02:38
In reply to Re: Depressed/agitated/wired - soft bipolar? » 4WD, posted by ed_uk on January 16, 2006, at 13:26:47
> Hi Marsha
>
> You could try imipramine again at a low dose, or maybe one of the more sedating TCAs given as a single dose in the evening.
>
> EdYeah, that's kind of what I'm thinking. Desipramine (side effects & not as effective as imipramine) is out, nortriptyline is out (increased anxiety) amitriptyline is out (sudden fits of rage)and Sinequan is out (completely screwed up my perceptions). What would be the next option?
And I guess I could take some drug for the inevitable horrible dry mouth.
If this doesn't work, I think that's the route I'll be going.
Why are TCA's less likely to set off dysphoric mania or mixed states or increased agitation/fear than SSRIs?
Thanks,
Marsha
Posted by 4WD on January 16, 2006, at 21:25:20
In reply to Re: Depressed/agitated/wired - soft bipolar?, posted by linkadge on January 16, 2006, at 8:25:04
> >If I take the Depakote and the agitation/fear >goes away, does that mean it IS med-induced >dysphoric mania? I'm kind of looking at this med >trial as a diagnostic tool.
>
> I would have to say no, simply due to the fact that depakote can be used as an adjunctive in severe anxiety, since it has a really strong gaba effect.
>
> But along those lines, if it works then so be it, you could continue to take it.
>
>
>
> Linkadge
If depakote increases gaba then why would it have a rep as sometimes increasing depression?Marsha
Posted by linkadge on January 17, 2006, at 9:41:37
In reply to depakote and gaba » linkadge, posted by 4WD on January 16, 2006, at 21:25:20
Good question, and I don't really know.
I think that gaba may be low in depression, but not as low as it is in mania or epilepsy. So if the dose is too high, an anticonvulsant may decrease neuronal activity too much.
Depakote also has effects on certain ion channels, such as blocking calcium and sodium chanels. It also decreases PKC.
I have to admit, that too much brought be down fairly quickly, but the right dose seemed to help.
Linkadge
Posted by detroitpistons on January 17, 2006, at 10:39:43
In reply to Re: Depressed/agitated/wired - soft bipolar?, posted by linkadge on January 15, 2006, at 16:55:03
"I think there is a group of people who are depressed, but still motivated, (sometimes motivated by obsession - or just running on stress hormones) and that the SSRI's don't correct the HPA axis dysregulation fast enough, at least for me they didn't.
For example with me, I became so afraid of falling behind in school, that even though I wanted to kill myself every day, I would still be doing my homework incessantly. Nobody thought I was depressed - (to be depressed you must have given up). I never give up, I just become more suicidal."Holy sh.it, that's me!! When I was in school, I was the exact same way. Anybody who says that you need to be laid up in bed and not shower for a week in order to be clinically depressed is FULL OF SH.IT. FEAR and anxiety are what keep me going. In school, it was the fear of getting bad grades. Now, it's the fear of not being able to get by and pay the bills and lose my "career."
Great post.
> I just remember that in certain states, the difference between a TCA and an SSRI was like night and day.
>
> For me, the TCA's usually improved sleep and appetite immediately whereas the SSRI's made those symptoms worse for a good 2+ weeks, (which intensified depression, anxiety and panic etc).
>
> I think there is a group of people who are depressed, but still motivated, (sometimes motivated by obsession - or just running on stress hormones) and that the SSRI's don't correct the HPA axis dysregulation fast enough, at least for me they didn't.
>
>
> For example with me, I became so afraid of falling behind in school, that even though I wanted to kill myself every day, I would still be doing my homework incessantly. Nobody thought I was depressed - (to be depressed you must have given up). I never give up, I just become more suicidal.
>
>
> Linkadge
>
>
>
>
>
>
>
Posted by linkadge on January 17, 2006, at 13:34:53
In reply to Re: Depressed/agitated/wired - soft bipolar? » linkadge, posted by detroitpistons on January 17, 2006, at 10:39:43
Thats a good word, fear. Fear is a horrable emotion to have to live with 24/7. It chips away at your sence of humanity. It makes your quality of life zero.
No diagnosis has sat well with me except maybe really bad generalized anxiety. The benzo's help but I ended up stopping them because I was too dumb on them.I tell my doctor. If you're going to give me a treatment, don't give me a treatment that is going to sabatage my best attempt at dealing with the stressors.
Linkadge
Posted by linkadge on January 17, 2006, at 13:35:17
In reply to Re: Depressed/agitated/wired - soft bipolar? » linkadge, posted by detroitpistons on January 17, 2006, at 10:39:43
Glad to find someone who could relate.
Linkadge
Posted by detroitpistons on January 17, 2006, at 14:19:37
In reply to Re: Depressed/agitated/wired - soft bipolar? » detroitpistons, posted by linkadge on January 17, 2006, at 13:35:17
> Glad to find someone who could relate.
>
> Linkadge
Yes, it is.That's the first time I've every heard someone describe "functional" anxiety/depression in that way...
I remember reading something at a very good, and well respected website that had a strong effect on me. In the author's opinion, basically you shouldn't even consider psychiatric meds unless you are staring at the ceiling with a bottle of Jack Daniels for weeks at a time (this statement was later modified)...I started believing that. I thought that as long as I could function in life, I shouldn't be taking meds. Also, people in my family started questioning me about it, implying that I didn't need them and I should stop taking them. I was believing all of this. I tried getting off of meds, and then I crashed into another depression.
That's when I realized, that enough is enough and that I had to take them, and that you don't need to be "staring at the ceiling, etc" to justify taking psych meds. My quality of life was crap. Sure, I got good grades in school, and later on in life I could get myself out of bed in the morning and go to work (although my jobs have not gone too well--I got fired from one, and nearly fired from another). Having FEAR as your primary motivation in life is not fun...No thanks, I'll take the meds if they work well.
Posted by linkadge on January 17, 2006, at 15:46:18
In reply to Re: Depressed/agitated/wired - soft bipolar?, posted by detroitpistons on January 17, 2006, at 14:19:37
Sucess is also another big misconception. Sucess never made me happy.
I needed to have a reason to let go. Because I hated the way I felt so much in the present, it made my goals seem like a necessity.
When I started to get better, I started to care about myself more. I started to like who I was. When that happened, I didn't need sucess so much.
Linkadge
Posted by ed_uk on January 17, 2006, at 16:11:39
In reply to Re: Depressed/agitated/wired - soft bipolar? » ed_uk, posted by 4WD on January 16, 2006, at 21:02:38
Hi Marsha
I'd be tempted to return to imipramine. You can take as little as 5mg at first and increase gradually. The 10mg tablets are useful for titration.
>And I guess I could take some drug for the inevitable horrible dry mouth.
Yes, there are a couple of meds which might help.
Ed
Posted by 4WD on January 17, 2006, at 22:40:10
In reply to Re: Depressed/agitated/wired - soft bipolar? » 4WD, posted by ed_uk on January 17, 2006, at 16:11:39
> Hi Marsha
>
> I'd be tempted to return to imipramine. You can take as little as 5mg at first and increase gradually. The 10mg tablets are useful for titration.
>
> >And I guess I could take some drug for the inevitable horrible dry mouth.
>
> Yes, there are a couple of meds which might help.
>
> Ed
Ed,When I was on imipramine in 1986-87, I was taking 50mg t.i.d. And doing well (except for pretty bad side effects). Is it possible that such a low dose would help without such bad SEs?
Do you know why SSRIs are so much more likely to cause anxiety than TCAs? This seems to be the significant issue here.
I thought serotonin was supposed to the "calming" neurotransmitter. Of course, dopaminergic drugs make me nervous and so so noradrenergic ones.
Go figure.
Marsha
Posted by ed_uk on January 18, 2006, at 9:38:10
In reply to Re: Depressed/agitated/wired - soft bipolar? » ed_uk, posted by 4WD on January 17, 2006, at 22:40:10
Hi Marsha
>When I was on imipramine in 1986-87, I was taking 50mg t.i.d. And doing well (except for pretty bad side effects). Is it possible that such a low dose would help without such bad SEs?
10mg is very unlikely to help - it's a good starting dose though. Starting TCAs at low doses reduces the severity of the side effects. You won't necessarily need 150mg/day though, some people are helped by lower doses eg. 75mg.
>Do you know why SSRIs are so much more likely to cause anxiety than TCAs?
Part of the problem is that people tend to take high(ish) doses of SSRIs right from the start eg. 20mg Prozac. People usually start TCAs at a low dose and work their way up to a therapeutic dose gradually.
>I thought serotonin was supposed to the "calming" neurotransmitter.
SSRIs consistently produce an initial increase in anxiety. After several weeks treatment, an anti-anxiety effect is often observed, especially in patients with OCD or panic disorder. Some find the SSRIs always aggravate their anxiety though - this is especially common in bipolar disorder, but is *not* 'diagnostic' of bipolar disorder.
Regards
Ed
Posted by 4WD on January 18, 2006, at 21:51:36
In reply to Re: Depressed/agitated/wired - soft bipolar? » 4WD, posted by ed_uk on January 18, 2006, at 9:38:10
> Hi Marsha
>
> >When I was on imipramine in 1986-87, I was taking 50mg t.i.d. And doing well (except for pretty bad side effects). Is it possible that such a low dose would help without such bad SEs?
>
> 10mg is very unlikely to help - it's a good starting dose though. Starting TCAs at low doses reduces the severity of the side effects. You won't necessarily need 150mg/day though, some people are helped by lower doses eg. 75mg.
>
> >Do you know why SSRIs are so much more likely to cause anxiety than TCAs?
>
> Part of the problem is that people tend to take high(ish) doses of SSRIs right from the start eg. 20mg Prozac. People usually start TCAs at a low dose and work their way up to a therapeutic dose gradually.
>
> >I thought serotonin was supposed to the "calming" neurotransmitter.
>
> SSRIs consistently produce an initial increase in anxiety. After several weeks treatment, an anti-anxiety effect is often observed, especially in patients with OCD or panic disorder. Some find the SSRIs always aggravate their anxiety though - this is especially common in bipolar disorder, but is *not* 'diagnostic' of bipolar disorder.
>
> Regards
>
> EdEd, thank you so much! I have been trying to find answers to those questions for years and no one has ever been able to explain it to me. I guess the trick is to manage the depression somehow while you work your way up to a therapeutic dosage. If I remember correctly i was started on 100mg of imipramine and pushed up to 150 in a couple of weeks.
So I guess you are saying that if I had started on a lower dosage and gone up much more gradually the side effects would never have been as intense?
No SSRI except low dose (37.5) Effexor has ever had an axiolytic effect for me, no matter how long I took it. I'm glad to know this is not a definitive indicator of bipolar. I really don't want to be rapid cycling bipolar/mixed states because it is apparently one of the hardest Dxs to treat. I'd rather just think I'm "allergic" to SSRIs and SNRI and Wellbutrin. Of course that only leaves the TCAs or MAOIs.
Don't you want to quit pharmacy school and be a pdoc? I'd come to England for treatment...
Marsha
What area of England btw?
Posted by ed_uk on January 19, 2006, at 14:45:39
In reply to Re: Depressed/agitated/wired - soft bipolar? » ed_uk, posted by 4WD on January 18, 2006, at 21:51:36
Hi
> If I remember correctly i was started on 100mg of imipramine and pushed up to 150 in a couple of weeks.
100mg is a very high starting dose. I'd recommend starting at 10mg and increasing in steps of 10mg as tolerated.
>So I guess you are saying that if I had started on a lower dosage and gone up much more gradually the side effects would never have been as intense?
They would probably have been milder - though still present.
>What area of England btw?
I live in Yorkshire.
Regards
Ed
Posted by 4WD on January 19, 2006, at 17:39:13
In reply to Re: Depressed/agitated/wired - soft bipolar? » 4WD, posted by ed_uk on January 19, 2006, at 14:45:39
> Hi
> 100mg is a very high starting dose. I'd recommend starting at 10mg and increasing in steps of 10mg as tolerated.
>
>And in the meantime while you are waiting to reach therapeutic dose levels, do you just somehow get through the depression resulting from not being on much of anything?
Or maybe taper off the old whilst starting the new?
Marsha
Posted by ed_uk on January 20, 2006, at 13:53:49
In reply to Re: Depressed/agitated/wired - soft bipolar? » ed_uk, posted by 4WD on January 19, 2006, at 17:39:13
Hi M
>And in the meantime while you are waiting to reach therapeutic dose levels..........
I don't think starting at a low dose necessarily delays the onset of the therapeutic effects. The onset of the therapeutic effects is delayed by several weeks whatever dose you start at. High initial doses can actually aggravate symptoms such as anxiety and restlessness. You can increase the dose as fast as your body permits eg. start at 10mg/day. Stay on 10mg for a few days. If 10mg is well tolerated, increase to 20mg. Stay on 20mg for a couple of days, if 20mg is well tolerated increase to 30mg...........etc.......etc......increase to 80mg (for example) for a couple of days, if 80mg is not well tolerated don't increase any further until the side effects have reduced. If the side effects were severe you might have to reduce the dose.
>...........do you just somehow get through the depression resulting from not being on much of anything?
>Or maybe taper off the old whilst starting the new?.....but if your current medication isn't helping......
Ed
Posted by 4WD on January 20, 2006, at 21:12:39
In reply to Re: Depressed/agitated/wired - soft bipolar? » 4WD, posted by ed_uk on January 20, 2006, at 13:53:49
> Hi M
>
> >And in the meantime while you are waiting to reach therapeutic dose levels..........
>
> I don't think starting at a low dose necessarily delays the onset of the therapeutic effects. The onset of the therapeutic effects is delayed by several weeks whatever dose you start at. High initial doses can actually aggravate symptoms such as anxiety and restlessness. You can increase the dose as fast as your body permits eg. start at 10mg/day. Stay on 10mg for a few days. If 10mg is well tolerated, increase to 20mg. Stay on 20mg for a couple of days, if 20mg is well tolerated increase to 30mg...........etc.......etc......increase to 80mg (for example) for a couple of days, if 80mg is not well tolerated don't increase any further until the side effects have reduced. If the side effects were severe you might have to reduce the dose.
>
> >...........do you just somehow get through the depression resulting from not being on much of anything?
> >Or maybe taper off the old whilst starting the new?
>
> .....but if your current medication isn't helping......
>
> Ed
>
Well, there's being in the black hole. And then there's being at the bottom of the black hole. ANd then, of course there's being buried under the bottom of the black hole.Anyway, thanks for your reply. It told me just what I needed to know. If the current Effexor + Depakote doesn't do it or improve the situation in the next couple of weeks, I'm going back to imipramine. I want to give the Effexor at least three weeks to see if I see any improvement (that'll be 1 week at 37.5 and 2 weeks at 75 - if I can stand the 75.) Seems like the Depakote has stabilized my moods somewhat, now I'm depressed every day, not just five days a week. But the Effexor hasn't had time to kick in yetand I guess I'm having some Celexa withdrawal too.
I just hope that a year off the Effexor will allow it to work again. Or maybe I don't. By the time I got off it, I hated it. It wasn't working anymore and all I had were the side effects. I mean maybe tricyclics are less *damaging* somehow. They feel less threatening. Effexor is scary.
Marsha
Posted by ed_uk on January 21, 2006, at 11:40:54
In reply to Re: Depressed/agitated/wired - soft bipolar? » ed_uk, posted by 4WD on January 20, 2006, at 21:12:39
Hi M
>I mean maybe tricyclics are less *damaging* somehow. They feel less threatening. Effexor is scary.
Effexor has received some bad publicity. Old, off-patent drugs like imipramine don't receive the same attention.
Ed
Posted by detroitpistons on February 1, 2006, at 15:56:58
In reply to Re: Depressed/agitated/wired - soft bipolar? » ed_uk, posted by 4WD on January 20, 2006, at 21:12:39
Posted by detroitpistons on February 1, 2006, at 16:01:07
In reply to Re: Depressed/agitated/wired - soft bipolar? » ed_uk, posted by 4WD on January 20, 2006, at 21:12:39
Marsha, how have you been doing? Any better?
Posted by 4WD on February 1, 2006, at 17:11:02
In reply to Re: Depressed/agitated/wired - soft bipolar? » 4WD, posted by detroitpistons on February 1, 2006, at 16:01:07
> Marsha, how have you been doing? Any better?
Hi. Thanks for asking. I was better after raising the Effexor to 75mg and the Depakote to 500 mg. But after about a week, the Effexor caused the muscle spasms in my neck and shoulders to get really bad and I had to go back down to 37.5mg. It was a bad few days but I am better now and doing okay on 37.5mg. It's only been four days though, so I'm keeping my fingers crossed. But I really hate taking Effexor. My head buzzes all the time, like a staticky radio.
I see my pdoc tomorrow. I'm thinking of giving imipramine a shot.
How are you doing? Okay, I hope?
Marsha
Posted by detroitpistons on February 2, 2006, at 8:33:00
In reply to Re: Depressed/agitated/wired - soft bipolar? » detroitpistons, posted by 4WD on February 1, 2006, at 17:11:02
I'm doing a little bit better, but I imagine it's going to be a few more weeks until I am significantly better...It takes 5 weeks just to get up to 100 mg of Lamictal. I was diagnosed as bipolar II and I guess I'm kind of rapid cycling with mixed state right now. I am taking my Effexor dose down from 225 to 150, and today was the first day on 150 (took 187.5 for a week). It's really hard to have patience waiting for these meds.
I posted my complete update on the "When are benzos justified?" thread if you want to take a look.
Take care,
Marc
Posted by 4WD on February 2, 2006, at 21:59:35
In reply to Re: Depressed/agitated/wired - soft bipolar? » 4WD, posted by detroitpistons on February 2, 2006, at 8:33:00
> I'm doing a little bit better, but I imagine it's going to be a few more weeks until I am significantly better...It takes 5 weeks just to get up to 100 mg of Lamictal. I was diagnosed as bipolar II and I guess I'm kind of rapid cycling with mixed state right now. I am taking my Effexor dose down from 225 to 150, and today was the first day on 150 (took 187.5 for a week). It's really hard to have patience waiting for these meds.
>
> I posted my complete update on the "When are benzos justified?" thread if you want to take a look.
>
> Take care,
>
> MarcMarc,
I've experienced plain, deep clinical depression, straight anxiety, anhedonia and dysthymia. The only times I've been truly suicidal was during mixed states. I'm sure there are other people on this board who have experienced that combination of fear, horror and despair all at once but I hope not too many. What I'm trying to get at is that in the 25+ years, I've been depressed, mixed states is the worst feeling I've ever had. So I deeply sympathize.
I truly hope Lamictal works for you. Depakote seems to be helping me a bit. So far side effects are headache and a slight skin rash. I wish I could have stayed on Lamictal. By the time I got to 50mg I could tell a slight improvement.
I'll read your update.
Hang in,
Marsha
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