![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 126 to 150 of 281. Go back in thread:
Posted by desolationrower on September 20, 2009, at 0:15:28
In reply to Re: Going back to old-school - lithium. » Bob, posted by SLS on September 19, 2009, at 6:02:42
transient responses are sort of the classic placebo response. So it might be better to work on finding a hope/program that you can do a little bit on everyday to capture that, since there is something there thats working for you, however shortly.
0d.r
Posted by SLS on September 20, 2009, at 6:47:00
In reply to Re: Going back to old-school - lithium., posted by desolationrower on September 20, 2009, at 0:15:28
Hi.
> transient responses are sort of the classic placebo response.
I wish I were the classic patient. When I did come in to see the doctor while feeling these brief improvements, there would be no doubt in their minds that I indeed had a biological affective disorder. The difference was so dramatic. Only did Columbia in 1983 "throw me out" because they thought I was a placebo responder. They hadn't noticed that I was an ultra-rapid cycler when I was first treated by them. They thought that these were emotional highs and lows. They wanted me to see a psychologist instead. I said no. I left, but not before requesting that they put me on bupropion, which had not come out yet. They laughed when I came to them with my own dopaminergic theory of depression. I told them that they should at least try bromocriptine on me. Again, they laughed.
I have never had a problem with psychotherapy, as long as it was made clear that I needed somatic treatments as well. I had had quite a bit of psychotherapy before being diagnosed with affective disorder. It, of course, didn't help with depression. I am currently being treated psychotherapeutically. I am grateful to find a therapist who works closely with a psychopharmacologist. It is understood that the priority to treat the depression must be biological since is a biological disorder that I suffer from. I took advantage of the offer for psychotherapy because I wanted to deal with an unhealthy past, have coping tools to live and function while depressed, and to sweep up the psychological mess that the depression produced.
I had been a member at a mental health clinic day program to add structure to my days. However, after 8 years, I felt it was time for me to leave. Taking a few classes at a community college was good for me. Again, it provided structure. At this point, I am working towards seeking employment. Of course, this will be orders of magnitude easier if my improvement to the addition of lithium grows. At the moment, I expect that it will. Of course, I have been wrong countless times before. Stupid optimism.
- Scott
Posted by SLS on September 20, 2009, at 6:48:50
In reply to Re: Going back to old-school - lithium., posted by desolationrower on September 20, 2009, at 0:15:28
Sorry. I forgot to thank you for your concern and thoughtful suggestions.
Thanks.
- Scott
Posted by mogger on September 24, 2009, at 22:37:03
In reply to Re: Going back to old-school - lithium. » desolationrower, posted by SLS on September 20, 2009, at 6:48:50
Scott,
Hang in there man.Your knowledge of treatments is so vast that I am sure you are aware of this but have you tried massive amounts of high EPA fish oil? I mean far past the 3 grams a day of EPA that is mostly prescribed? I take 10 grams a day (20 capsules) and it has been marvelous for my deep depression and rapid cycling. I only have trouble with my ocd which I am still working out (which you have given me great advice on thank you). I take CountryLife Omega 3 Mood and as I say I take 7 capsules morning, 7 afternoon and 6 evening. I tried 3 grams and it didn't cut it so went for the gold and went to 10 grams! :)
Joseph
Posted by SLS on September 25, 2009, at 0:21:49
In reply to Re: Going back to old-school - lithium., posted by mogger on September 24, 2009, at 22:37:03
Hi Joseph.
> Scott,
> Hang in there man.Thanks. :-)
> Your knowledge of treatments is so vast that I am sure you are aware of this but have you tried massive amounts of high EPA fish oil? I mean far past the 3 grams a day of EPA that is mostly prescribed? I take 10 grams a day (20 capsules) and it has been marvelous for my deep depression and rapid cycling. I only have trouble with my ocd which I am still working out (which you have given me great advice on thank you). I take CountryLife Omega 3 Mood and as I say I take 7 capsules morning, 7 afternoon and 6 evening. I tried 3 grams and it didn't cut it so went for the gold and went to 10 grams! :)Wow. I've tried fish oil, but not at that dosage. I will definitely keep that in mind. I bet there is more to fish oil than just a supplement of omegas. I think there is something pharmacological going on there.
Thanks for the suggestion!
- Scott
Posted by morganator on September 25, 2009, at 1:12:09
In reply to Re: Going back to old-school - lithium. » mogger, posted by SLS on September 25, 2009, at 0:21:49
We should all be taking fish oil regardless of whether we notice a anything significant. It may be doing good things for our brains even if it does not give us a much needed lift.
It is the different types of Omega 3s in fish oil that have different mechanisms. I'm talking about the difference between EPA and DHA. Some do better on fish oil that has a 4 to 1 EPA to DHA ratio. Others do just fine on a 4 to 3 ratio of EPA to DHA.
It is definitely worth trying high doses, maybe 6 to even 10 grams a day.
Posted by Ron Hill on September 26, 2009, at 2:46:05
In reply to Re: Going back to old-school - lithium. » mogger, posted by SLS on September 25, 2009, at 0:21:49
> Wow. I've tried fish oil, but not at that dosage. I will definitely keep that in mind. I bet there is more to fish oil than just a supplement of omegas. I think there is something pharmacological going on there.
I'm sure most of us are familiar with the 1999 study by Andrew Stoll MD which showed efficacy in the treatment of bipolar disorder with omega-3 fatty acids.The source of the omega-3 fatty acids was menhaden fish body oil concentrate. Subjects received a total daily omega-3 fatty acid dosage of 6.2 g of eicosapentanoic acid (EPA) and 3.4 g of docosahexanoic acid (DHA).
Stoll discusses the pharmacological action of omega-3 fatty acids. There are similarities to the action of lithium. In particular, regarding the pharmacological action of omega-3 fatty acids, see the "Introduction", the last section of the paper titled "Comments", and the cool diagram in Figure 3.
Here is a link to the full text paper:
http://archpsyc.ama-assn.org/cgi/content/full/56/5/407
The downside to this treatment is the expense. Using a high quality liquid fish oil like Carlson's, the dosage set forth in Stoll's paper costs me more than $60 per month.
However, prescription grade omega-3 fatty acid oil is available. So, if the patient can talk his/her p-doc into writing a script, it can become more affordable.
-- Ron
dx: Bipolar II with ultra rapid cycling and mild OCPD
600 mg/day Trileptal
200 mg/day Lamictal
500 mg/day Keppra
90 mg/day Nardil
Posted by desolationrower on September 26, 2009, at 3:23:39
In reply to Re: Going back to old-school - lithium. » SLS, posted by Ron Hill on September 26, 2009, at 2:46:05
w-3s do lots of things.
but theres no need for "high quality fish oil" unless you already bought celtic sea salt and still have more money than you want
-d/r
Posted by SLS on September 26, 2009, at 5:20:38
In reply to Re: Going back to old-school - lithium. » SLS, posted by Ron Hill on September 26, 2009, at 2:46:05
I bet there is more to fish oil than just a supplement of omegas. I think there is something pharmacological going on there.
> Stoll discusses the pharmacological action of omega-3 fatty acids. There are similarities to the action of lithium.
I hadn't read that. This was just a deduction on my part. Thanks for the link.
I am encouraged to see you posting again. Keep them coming!
:-)
- Scott
Posted by Ron Hill on September 26, 2009, at 5:26:12
In reply to Re: Going back to old-school - lithium., posted by desolationrower on September 26, 2009, at 3:23:39
Hi d/r.
> but theres no need for "high quality fish oil" unless you already bought celtic sea salt and still have more money than you want
I don't like mercury.
-- Ron
Posted by morganator on September 28, 2009, at 22:57:39
In reply to Re: Going back to old-school - lithium. » desolationrower, posted by Ron Hill on September 26, 2009, at 5:26:12
Unless companies like Kirkland are lying, there are undetectable levels of mercury, pcb's, and other toxins in many fish oil products that are VERY affordable. Kirkland enteric coated capsules go for about 17 dollars for 180 capsules and the normal capsules go for about 10 dollars for 400-Dirt Cheap!!!! The only drawback to buying Kirkland fish oil may be that you have to settle for the typical 4 to 3 DHA to EPA ratio.
I know companies like Carlson's and Nordic naturals are producing high quality fish oil, but how much higher quality is it and is it worth paying the price for?
Scott, I think the pharmacological activity comes from the 2 distinct types of omega 3s that are found in fish oil, DHA and EPA.
Posted by desolationrower on September 29, 2009, at 16:38:47
In reply to Re: Going back to old-school - lithium., posted by morganator on September 28, 2009, at 22:57:39
fish oil is mostly made from cheap tiny fish like sardines, anchovies, herring, etc. the big apex predator fish are mostly used for more expensive preprations like sushi
-d/r
Posted by Questionmark on September 29, 2009, at 22:43:50
In reply to Re: Going back to old-school - lithium., posted by bleauberry on July 4, 2009, at 19:36:14
This post was absolutely brilliant, and so important.
I heartily agree that the ideal method of starting psych meds is to start very low and gradually increase until the optimal dose is observed. And I am so impressed and glad to hear that a psychiatrist actually uses this method to such an extreme, and so successfully.
SLS i agree with Bleauberry i think your best bet would be to start low w lithium (maybe 100mg; maybe even less?), wait, and then slowly increase if need be.
Thank you Bleauberry for this sharing this important piece of advice.
I think one of the most counter-effective practices of most psychiatrists (and oh my are there many) is the prescribing of excessively high doses (which is also a major reason for the high rate of noncompliance, imo).> I know my comments sometimes go against the grain of academia. But I believe shooting for a predetermined target dose of anything, including lithium, based on a general consensus of what happens in the general population, is bogus. I think it causes more failure than success. I think more success is attainable by slowing increasing doses, after starting at very low doses, so as to find "the" place and not shoot past it. If the mind numbing stuff of lithium is already kicking in, the dose in my opinion is already too high. It perhaps needs a lower dose and longer time, versus higher dose and shorter time. Lithium should feel invisible at the right dose.
>
> Totally different drug, but an example. My LLMD claims to have never had a failure at fixing anyone's depression. His arsenal consists mostly of just lexapro or zoloft. The trick is not the drugs, but the doses. He has patients in complete remission from treatment resistant drug sensitive depression on things like: 1 drop of liquid lexapro up to 5mg of lexapro. 1 drop is 1/10th of 1mg. Psychiatrists and pharmicists would scoff at the idea and probably laugh hysterically. The only problem is, it works over and over in very difficult populations.
>
> We accept dosing targets as if they came out of a bible. They didn't. They are just as flawed as the clinical studies they came from.
>
> I see no problem with lithium except in two areas:
>
> 1)When it is combined with a serotonin med, which in your case doesn't apply, so that's cool. I think it works best in norepinephrine or multi-neurotransmitter meds, but not pure serotonin meds.
>
> 2)When a preconceived dose target is set, as if anyone on the planet could have the slightest clue how much lithium you need. Example, I know someone who had the lithium numbing at 300mg, totally zombied at 600mg, but pleasantly energized and feeling good at 75mg.
>
> I think the version of lithium you take is also important. They are not the same. If one bombs, try the other. I don't know if you have the citrate version or what, but they are different.
Posted by SLS on September 30, 2009, at 0:19:46
In reply to Re: Going back to old-school - lithium. » bleauberry, posted by Questionmark on September 29, 2009, at 22:43:50
I started at 300mg and worked my way up to 600mg over the course of a few weeks. After some experimentation, I discovered that, for me, 600mg is the minimum effective dose. I based my dosage choices on a study done at Harvard/Mass General and some lab experiments performed at the NIH. Using a little math, I figured that 0.3 mmol/L would make a good target. My blood level of lithium at 600mg is 0.31 mmol/L, which is exactly where I wanted it to be.
Anyway, that was my method for determining dosage targets.
So far, so good.
- Scott
Posted by Ron Hill on October 1, 2009, at 5:31:11
In reply to Re: Going back to old-school - lithium., posted by morganator on September 28, 2009, at 22:57:39
> Unless companies like Kirkland are lying, there are undetectable levels of mercury, pcb's, and other toxins in many fish oil products that are VERY affordable. Kirkland enteric coated capsules go for about 17 dollars for 180 capsules and the normal capsules go for about 10 dollars for 400-Dirt Cheap!!!! The only drawback to buying Kirkland fish oil may be that you have to settle for the typical 4 to 3 DHA to EPA ratio.
The product you reference in the above link has a sum of 300 mg of EPA, DHA, and other Omega 3 added together in each soft gel. As you know, not all omega 3 oil is EPA or DHA. Therefore, it is impossible to determine the quantity of EPA and DHA in this product based on the information provided in the Product Details.
> http://www.google.com/url?sa=t&source=web&ct=res&cd=1&url=http%3A%2F%2Fwww.costco.com%2FBrowse%2FProduct.aspx%3FProdid%3D11248464&ei=EYXBSsfZNs_JlAf1pNDqBA&usg=AFQjCNF-KGdqjRBmR2erdGTKs5Xq2qebCw&sig2=9yQyBOD8PQIRcWOg0zRn7gIn the Product Details section for the item in your link above, it is stated that the mass of EPA and DHA are reported "as the ethyl esters" of these compounds. The molecular weight of EPA ethyl ester is greater than the molecular weight of the pure EPA compound. The same is true for the DHA ethyl ester verses DHA.
One would need to calculate the ratio of the molecular weights in order to determine the actual amount of EPA and, similarly, DHA. I could dig out my dusty organic chemistry book and do the math, but I don't want to take the time.
In order to compare the cost of Carlson's liquid verses Kirkland softgels, I used the following two products:
http://www.iherb.com/The-Very-Finest-Fish-Oil-Lemon-Flavor-16-8-fl-oz-500-ml/2796?at=0
http://www.ecrater.com/product.php?pid=3806313
In fairness, the Kirkland Natural Fish Oil Omega 3 CONCENTRATE can be found on the internet for a much less cost than on the above website. I included the above link because it provides the amounts of EPA and DHA, whereas, the website with the lowest cost does not contain these data.
Here is the website with the lowest price that I could find for Kirkland Natural Fish Oil Omega 3 CONCENTRATE:
Here are the calculations to compare Carlson's liquid in a bottle compared to Kirkland Natural Fish Oil Omega 3 CONCENTRATE. Recall that in the study conducted by Stoll MD et. al., (EPA + DHA = 9.6 g/day) was used:
For the Kirkland product:
Price: $17.49 for two bottles of 400 softgels each (i.e.; 800 total softgels).
Serving Size: 1 softgel per day = 300 mg of (EPA + DHA). {Side note: 300 mg = 0.3 g}.($17.49/2 bottles)(1 serving/0.3 g)(2 bottles/800 servings)(9.6 g/day)(30 day/month) = $20.99/month
For the Carlson's liquid bottled Fish Oil:
Price: $26.55 per 500 ml bottle
Serving Size: 5 ml = 1.3 g of (EPA + DHA).($26.55/bottle)(1 serving/1.3 g)(1 bottle/100 servings)(9.6 g/day)(30 day/month) = $58.52/month
> I know companies like Carlson's and Nordic naturals are producing high quality fish oil, but how much higher quality is it and is it worth paying the price for?
Yep, you're right. The math doesn't lie. Carlson's cost about three times as much as the high quality Kirkland product. Thanks for pointing this out to me.
-- Ron
dx: Bipolar II with ultra rapid cycling and mild OCPD
600 mg/day Trileptal
200 mg/day Lamictal
500 mg/day Keppra
90 mg/day Nardil
Posted by Phillipa on October 1, 2009, at 19:35:37
In reply to Re: Going back to old-school - lithium. » morganator, posted by Ron Hill on October 1, 2009, at 5:31:11
Ron isn't Kirkland Costco? And Carlson's Supposedly is the best. Personally I'd pay for the Carlson's Phillipa
Posted by morganator on October 1, 2009, at 22:17:10
In reply to Re: Going back to old-school - lithium. » morganator, posted by Ron Hill on October 1, 2009, at 5:31:11
All I know is that I have taken the Costco/Kirkland product for years and it has worked just fine for me. I noticed a big difference the first week I started using it 9 years ago. Some people may like the enteric coating version better for digestive reasons. If Kirkland brand works for you, it is by far the best deal on the market.
Posted by SLS on October 3, 2009, at 10:34:54
In reply to Re: Going back to old-school - lithium. » Questionmark, posted by SLS on September 30, 2009, at 0:19:46
> I started at 300mg and worked my way up to 600mg over the course of a few weeks. After some experimentation, I discovered that, for me, 600mg is the minimum effective dose. I based my dosage choices on a study done at Harvard/Mass General and some lab experiments performed at the NIH. Using a little math, I figured that 0.3 mmol/L would make a good target. My blood level of lithium at 600mg is 0.31 mmol/L, which is exactly where I wanted it to be.
>
> Anyway, that was my method for determining dosage targets.
>
> So far, so good.
Not so good anymore.I attribute my current deterioration to my having discontinued Abilify. However, I am going to increase my dosage of lithium to 900mg before restarting Abilify. Let's see what happens.
- Scott
Posted by floatingbridge on October 3, 2009, at 11:14:06
In reply to Re: Going back to old-school - lithium., posted by SLS on October 3, 2009, at 10:34:54
Best wishes for you Scott. I'm sorry this has been so tough. What does your pdoc think at this point?
thinking of you,
fb
Posted by SLS on October 3, 2009, at 13:53:54
In reply to Re: Going back to old-school - lithium. » SLS, posted by floatingbridge on October 3, 2009, at 11:14:06
> Best wishes for you Scott. I'm sorry this has been so tough. What does your pdoc think at this point?
My doctor was cautious in his interpretation of my description of mood variability after discontinuing Abilify. I was hoping this instability was only a withdrawal effect. He hinted that there was plenty of room to increase the lithium. Right now, it is my impression that I will need to restart the Abilify, but I thought adjusting the lithium first was the logical next step.
I appreciate your warm sentiments.
:-)
- Scott
Posted by Bob on October 3, 2009, at 19:40:25
In reply to Re: Going back to old-school - lithium. » floatingbridge, posted by SLS on October 3, 2009, at 13:53:54
> > Best wishes for you Scott. I'm sorry this has been so tough. What does your pdoc think at this point?
>
> My doctor was cautious in his interpretation of my description of mood variability after discontinuing Abilify. I was hoping this instability was only a withdrawal effect. He hinted that there was plenty of room to increase the lithium. Right now, it is my impression that I will need to restart the Abilify, but I thought adjusting the lithium first was the logical next step.
>
> I appreciate your warm sentiments.
>
> :-)
>
>
> - ScottScott -
Do you have any experience with amitriptyline? Although it's dirty, it's apparently effective.
Bob
Posted by SLS on October 4, 2009, at 5:23:14
In reply to Re: Going back to old-school - lithium. » SLS, posted by Bob on October 3, 2009, at 19:40:25
> > > Best wishes for you Scott. I'm sorry this has been so tough. What does your pdoc think at this point?
> >
> > My doctor was cautious in his interpretation of my description of mood variability after discontinuing Abilify. I was hoping this instability was only a withdrawal effect. He hinted that there was plenty of room to increase the lithium. Right now, it is my impression that I will need to restart the Abilify, but I thought adjusting the lithium first was the logical next step.
> >
> > I appreciate your warm sentiments.
> >
> > :-)
> >
> >
> > - Scott
>
>
>
> Scott -
>
> Do you have any experience with amitriptyline? Although it's dirty, it's apparently effective.
>
> Bob
The success rate of amitriptyline probably exceeds that of Effexor. Aside from the pronounced anticholinergic side effects, some people experience profound sedation and somnolence with amitriptyline. I hated the way I felt on it. However, others seem unaffected and do extremely well. If you do experience sedation immediately upon taking amitriptyline, that does not mean that you will be affected long-term. Sedation often resolves with continued use. The anticholinergic side effects can mitigate as well.
- Scott
Posted by Bob on October 4, 2009, at 22:43:42
In reply to Re: Going back to old-school - lithium. » Bob, posted by SLS on October 4, 2009, at 5:23:14
> > Scott -
> >
> > Do you have any experience with amitriptyline? Although it's dirty, it's apparently effective.
> >
> > Bob
>
>
> The success rate of amitriptyline probably exceeds that of Effexor. Aside from the pronounced anticholinergic side effects, some people experience profound sedation and somnolence with amitriptyline. I hated the way I felt on it. However, others seem unaffected and do extremely well. If you do experience sedation immediately upon taking amitriptyline, that does not mean that you will be affected long-term. Sedation often resolves with continued use. The anticholinergic side effects can mitigate as well.
>
>
> - Scott
Did you experience the sedation/somnolence?
Posted by SLS on October 8, 2009, at 6:11:59
In reply to Re: Going back to old-school - lithium. » SLS, posted by Bob on October 4, 2009, at 22:43:42
Doing better.
:-)
Currently:
Parnate 80mg
nortriptyline 150mg
Lamictal 200mg
lithium 600mg
Patience seems to have paid off.
- Scott
Posted by sowhysosad on October 8, 2009, at 9:26:45
In reply to Re: Going back to old-school - lithium., posted by SLS on October 8, 2009, at 6:11:59
> Doing better.
>
> :-)
>
> Currently:
>
> Parnate 80mg
> nortriptyline 150mg
> Lamictal 200mg
> lithium 600mg
>
>
> Patience seems to have paid off.
>
>
> - ScottGreat news.
So you decided not to restart the Abilify then?
Go forward in thread:
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.