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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 37. This is the beginning of the thread.
Posted by former poster on June 12, 2010, at 4:15:35
I've been plagued with sluggish cognitive tempo, anhedonia and lack of motivation all my life. If someone out there can help me feel alive before I die of old age, I would be most appreciative. I have had some relief with Dextroamphetamine/Nardil combo. My doctors won't prescribe it anymore because of the addiction propertys. However I am on Vyvanse, Bupropion and i just started emsam. it works but only for about 3-4hrs and then I'm sluggish again.
Posted by zonked on June 12, 2010, at 9:09:58
In reply to Best med for anhedonia, lack of motivation, SCT?, posted by former poster on June 12, 2010, at 4:15:35
What is your Vyvanse dosage and schedule? You may need a higher dose.
Do you ever take "holidays" from your stimulant? Unfortunately, as much as stimulants helped with anhedonia and my ADD-inattentive I found that my brain likes to compensate quickly and I develop tolerance rather quickly without increasing the dose. Had I stayed on Adderall, I'd probably have asked about taking a drug holiday on the weekends to fight tolerance.
Do you have a history of substance abuse? If not, tell your doctor what you told the board--perhaps you really do need Dexedrine if it's helped you more than Vyvanse. If your pdoc is still concerned, or if you do have a substance abuse history, perhaps (s)he will agree to give you your stimulant scripts weekly. This strategy has worked well for a friend of mine with ADD and a previous history of methamphetamine abuse.
Also, when Parnate still was effective for me, I found it helped a lot more with motivation and energy than Nardil did, although when they worked, both were equally effective for depression. (Currently on Marplan, which is finally kicking in after a month.)
I have ADD-inattentive as well as a mood disorder (currently back to major depression, treatment-refractory--has also been DXed as cyclothymic disorder, and
Bipolar II.)I know your pain--once I have been stabilized on Marplan at least a month, if my ADD symptoms are still bugging me, I will bring up adding back a stimulant if the energy/concentration/focus problems are still bugging me. (The anhedonia is largely gone tho!)
Also have heard good things about Mirapex--someone who's taken it can comment perhaps.
Best of luck, hang in there--
-z
> I've been plagued with sluggish cognitive tempo, anhedonia and lack of motivation all my life. If someone out there can help me feel alive before I die of old age, I would be most appreciative. I have had some relief with Dextroamphetamine/Nardil combo. My doctors won't prescribe it anymore because of the addiction propertys. However I am on Vyvanse, Bupropion and i just started emsam. it works but only for about 3-4hrs and then I'm sluggish again.
Posted by Christ_empowered on June 12, 2010, at 9:11:21
In reply to Best med for anhedonia, lack of motivation, SCT?, posted by former poster on June 12, 2010, at 4:15:35
Maybe up the Vyvanse? Its weird that your docs would Rx dexedrine, then nix it, then prescribe Vyvanse which is just dexedrine in a new, supposedly abuse-proof and longer-acting form. Shrinks can be ridiculous.
I read on one shrink's blog that its kind of difficult to get the dosage right with Vyvanse, and usually it seems like he and other docs are erring in prescribing too little. It seems like upping the amphetamine would fix things pretty quickly, but who knows.
It seems like your docs are going all out to keep your amphetamine dose low--hence mixing emsam and wellbutrin, both stimulating. I guess if you can't get a switch back to dexedrine or up the vyvanse, then you can up the emsam or maybe the wellbutrin (although I've heard that some people start to feel kind of "dulled out" on wellbutrin, kind of like with the SRIs or TCA reuptake inhibitor-type antidepressants).
Have you considered a new doc? Sometimes, you just need to switch if your shrink is being uncooperative. When shrinks work together in a group practice, sometimes you have more problems than when you get one who's working solo (although if the solo shrink is a jackass, the opposite is true). Also, often shrinks who work on a "self-pay" (old term: "cash only") basis are more helpful. They don't have to deal with insurance and all that, and they seem more willing to get their patients better instead of going on power trips.
Good luck.
Posted by SLS on June 12, 2010, at 9:41:46
In reply to Re: Best med for anhedonia, lack of motivation, SCT? » former poster, posted by zonked on June 12, 2010, at 9:09:58
> (Currently on Marplan, which is finally kicking in after a month.)
Great!
I hope it continues.
- Scott
Posted by Conundrum on June 12, 2010, at 10:05:28
In reply to Re: Best med for anhedonia, lack of motivation, SCT? » former poster, posted by zonked on June 12, 2010, at 9:09:58
I've wondered about Parnate. Is it really good for anhedonia and "sluggish cognitive" tempo as the OP described it? Have there been success stories with Parnate curing anhedonia on this board?
Does Parnate decrease norepinephrine levels over time?
According to the not-so-accurate wikipedia, nardil decrease norepinephrine.
http://en.wikipedia.org/wiki/Phenelzine
"Notably, although phenelzine inhibits the breakdown of norepinephrine and epinephrine (which in concept should lead to increased levels of these two respective neurotransmitters), it actually typically significantly decreases their overall activity with time via a complex interaction with octopamine. This is the cause of the side effect of orthostatic hypotension commonly seen with phenelzine and the other MAOIs. Importantly, it has been demonstrated that the antidepressant effects of serotonin are actually mediated through norepinephrine.[9] As a result, this depletion of norepinephrine and epinephrine may significantly inhibit the full therapeutic potential of phenelzine and the other MAOIs. For this reason, augmenting with an adrenergic agent such as a norepinephrine reuptake inhibitor (NRI) or releasing agent (NRA) in conjunction may be desirable, though strict professional supervision is advised to minimize the risk of a potentially dangerous drug interaction such as hypertensive crisis."
Does Parnate do the same thing? Is this how Parnate makes people light headed? Although not cure, I've found glimmers of color with Pristiq that I never got with SSRIs, so I'm guessing norepinephrine reuptake inhibition could help with anhedonia. Some have mentioned Parnate+Nortriptyline, but I wonder what psychiatrist would actually prescribe that?
For the OP I think that maybe a NE reuptake inhibitor could help especially with motivation and concentration and might even make you feel pleasure. I don't really know since I've never been allowed to take a TCA. :( BTW wellbutrin isn't really a NE reuptake inhibitor from studies I've read.
Posted by zonked on June 12, 2010, at 10:25:02
In reply to Re: Parnate good for anhedonia? » zonked, posted by Conundrum on June 12, 2010, at 10:05:28
> I've wondered about Parnate. Is it really good for anhedonia and "sluggish cognitive" tempo as the OP described it? Have there been success stories with Parnate curing anhedonia on this board?
In my case, yes and yes. Was great for both--don't let the fact that Parnate pooped out and required megadoses for me discourage you. I think I am unusually treatment-resistant.
> Does Parnate decrease norepinephrine > levels over time?
Not that I know.-z
Posted by former poster on June 12, 2010, at 12:54:32
In reply to Re: Parnate good for anhedonia? » Conundrum, posted by zonked on June 12, 2010, at 10:25:02
I appreciate all the info. I did give parnate about a 2 month trial. As I recall it did help with motivation, I had some problems with nervousness due to over-stimulation. I travel abroad often and am afraid to take MAOI's.
Mirapex is another good idea, but my insurance wont cover it unless its for RLS which doesn't get me up to the 4mg level needed for depression.
Posted by Phillipa on June 12, 2010, at 13:10:25
In reply to Re: Best med for anhedonia, lack of motivation, SCT? » former poster, posted by zonked on June 12, 2010, at 9:09:58
Congrats Zonked you have found your med. Phillipa
Posted by jade k on June 12, 2010, at 16:27:13
In reply to Re: Parnate good for anhedonia? » zonked, posted by Conundrum on June 12, 2010, at 10:05:28
> I've wondered about Parnate. Is it really good for anhedonia and "sluggish cognitive" tempo as the OP described it? Have there been success stories with Parnate curing anhedonia on this board?
>Hello,
I took Parnate for roughly a year and it was definately a success story for me (at higher doses) for the symptoms you describe. Especially when combined with a stim. Very effective for MDD and TRD. Its a risky business however and I had to stop both. You'd want to take as small a dose as needed, and have close pdoc supervision.
As for light headedness, I had a real problem with that due to LOW blood pressure. The stim brought my blood pressure back to normal.
For anhedonia without mdd or trd, parnate may be overkill. jmho. Hope that helps.
~Jade
Posted by Conundrum on June 12, 2010, at 19:49:25
In reply to Re: Parnate good for anhedonia?, posted by jade k on June 12, 2010, at 16:27:13
Thanks for the replies guys.
Jade, I believe you have tp be diagnosed with something other than anhedonia. At this point anhedonia and cognitive slowing, or as Gilman puts it "Mental Aenemia," isn't recognized as a stand alone disorder in pyschiatry. Iatrogenic anhedonia most certainly isn't. That would be a profit killer.
So you would have to be diagnosed with some other disorder like depression, schizo, or BP to get drugs that help with anhedonia, unless you are dealing with a particularly enlightened doctor.
I've been told I have depression by my GP and OCD from one pdoc and possibly mood stability issues according to another pdoc. I don't think anyone is really sure, but it doesn't seem like they're comfortable prescribing drugs unless you fit into one of those boxes.
The thing I find most annoying is that they just go from one type of drug to another and never look for a moment at partial responses and how it related to pharmacology. For example I noticed an increase in what I call "color" from pristiq for the first 2 weeks, which then faded and felt more like an SSRI. Now SSRIs for me are dulling. So one would think logically, why not try taking a NRI tricyclic and see if those feelings will be intensified and not dull since there won't be as great an increase in serotonin. But noooooo they throw the baby out with the bathwater. Now I'm taking lamictal 250 mg and it feels like a placebo. Some headaches but other than that it does nothing.
Or another example. Low doses of prozac increase motivation for me. Prozac is a 5 HT2C antagonist. SO why not prescribe another relatively safe drug that is a 5 HT2C antagonist but not an SSRI, instead of prescribing a 5 HT2A antagonist that could cause liver failure in someone with an already elevated liver function?
I'm trying to trust doctors but its hard after all that has happened. I'm hoping lamictal will help with my symptoms but I'm doubtful. In someways this is worse than being depressed. Atleast being depressed is accepted as an actual disorder in most parts of the industrialized world. But if you say anhedonia people tell you that you are bored, or you are lazy, or tell you that you need to go out and party and drink and you will feel better. Thats why I want a brain scan so badly, because I think it will prove that something is not functioning correctly, and I can point to this and say, "Look, this proves I'm f#&ked up, but unlike an xray of a broken leg it won't get better."
Posted by jade k on June 12, 2010, at 20:23:53
In reply to Re: Parnate good for anhedonia? » jade k, posted by Conundrum on June 12, 2010, at 19:49:25
My God, what else would one have to add to serious anhedonia combined with cognitive slowing to be considered depressed? Lack of pleasure and a foggy mind deserves careful treatment. As for parnate, I take it back. I think it could be useful depending on the severity of those symptoms.
My new pdoc is a pharmocologist and I'm pleased about that. We'll see.
Cheers~jade
Posted by Conundrum on June 12, 2010, at 21:01:53
In reply to Re: Parnate good for anhedonia? » Conundrum, posted by jade k on June 12, 2010, at 20:23:53
I'd like to try some tricyclics and remeron first and then parnate. Maybe dexedrine or adderall. Seems like most pdocs are really into anticonvulsants and AAP these days and I don't wanna take an AAP. One permanent problem is enough don't need TD.
Posted by violette on June 12, 2010, at 21:41:50
In reply to Best med for anhedonia, lack of motivation, SCT?, posted by former poster on June 12, 2010, at 4:15:35
I feel for you.
I am so damn confused right now. I don't feel a need for any meds for depression or mood, just for anxiety on occasion and to sleep...but the lack of motivation is torture. I'm starting to think any dysthmia/depression symptoms I have are a direct result from one symptom-lack of motivation. I don't know what to do anymore. Amphetamines helped somewhat and I mean just enough to get me out of bed and going, but they don't work anymore. I doubled and tripled my dose to see if I had a tolerance built, but taking more just made me sleepy. It makes little difference if I do not take any-I don't even get withdrawal symptoms. Sometimes I wasn't even motivated enough to take the amphetamine-it was like indifference-total apathy-nothing mattered.
So after giving up on meds for the most part and trying to approach this from the psychological end-but can't figure it out with my therapist. The result from medications leads me to prefer the the therapeutic approach over drugs-anything I've taken makes me worse-I either sit and stare or feel agitated. I don't normally get symptoms of agitation except when I take medications. Six psychiatrists told me I was not bipolar and I read a ton about it and agree. But what is this from?
http://en.wikipedia.org/wiki/Aboulia
There's a link to read..if anyone could figure out what's going on with the group of us who have this problem-you sure would be a hero. !
Posted by violette on June 12, 2010, at 21:57:28
In reply to Best med for anhedonia, lack of motivation, SCT?, posted by former poster on June 12, 2010, at 4:15:35
I'm sorry Former Poster, I can't identify with feeling like you do-all your life? that sounds incomprehensible...
I've only had the problem for about a year, its a new symptom for me, but I have to say its worse than anxiety or depression, for me, since for 30 some years, I was the opposite-motivated. I had one epidsode of depression, which remitted, but the was prescribed all the ADs for anxiety for 10 years afterwards. Turns out xanax as needed is much better for me than all those ADs which have made me worse. But the doctors I had before would not prescribe me anything but ADs for anxiety.
I'm about to go insane from this one symptom. I don't know how you could tolerate it-so glad to hear your most recent med trial has helped. Good for you :)
Posted by Phillipa on June 12, 2010, at 22:20:20
In reply to Re: Best med for anhedonia, lack of motivation, SCT? » former poster, posted by violette on June 12, 2010, at 21:57:28
Violette benzos only thing that semi work for me also. Taking xanax and a tiny dose of valium and weaning off baby dose of luvox. Think down to about 35 mg now. Phillipa
Posted by g_g_g_unit on June 12, 2010, at 22:59:07
In reply to Re: Parnate good for anhedonia? » Conundrum, posted by zonked on June 12, 2010, at 10:25:02
>
> In my case, yes and yes. Was great for both--don't let the fact that Parnate pooped out and required megadoses for me discourage you. I think I am unusually treatment-resistant.
>
> > Does Parnate decrease norepinephrine > levels over time?
> Not that I know.
>
> -zdid nardil have much of an effect on your ADD symptoms? also, did you have trouble sleeping on nardil/parnate?
Posted by zonked on June 12, 2010, at 23:11:41
In reply to Re: Parnate good for anhedonia? » zonked, posted by g_g_g_unit on June 12, 2010, at 22:59:07
>
> did nardil have much of an effect on your ADD symptoms? also, did you have trouble sleeping on nardil/parnate?
>Nardil didn't do much for my ADD symptoms--when I was still working, I was consuming 2-3 energy drinks a day to stay focused...especially on things I found routine or uninteresting. But it certainly made them no worse, either.
I've had trouble sleeping ever since I started psychiatric meds--it goes with the territory for me, unfortunately. Parnate was worse, tho--I had to switch to taking all of it at wake time instead of twice a day because otherwise it'd keep me awake at night.
-z
Posted by g_g_g_unit on June 13, 2010, at 0:05:38
In reply to Re: Parnate good for anhedonia? » g_g_g_unit, posted by zonked on June 12, 2010, at 23:11:41
> Nardil didn't do much for my ADD symptoms--when I was still working, I was consuming 2-3 energy drinks a day to stay focused...especially on things I found routine or uninteresting. But it certainly made them no worse, either.
Hmm, my lifestyle + work routine (when it existed) are/were constructed around stuff I find interesting, which is why that aspect of meds isn't particularly bothersome; problems arise, however, when I'm feeling anhedonic because I can't even tap into my natural reward system.
My concern is more with fogginess. I gave up on Nardil the first time after 3 months because between the short-term memory loss and sleep deprivation, I could barely think straight.
My present psych is recommending I give it another shot at a lower dose (~60mg or so).
>
> I've had trouble sleeping ever since I started psychiatric meds--it goes with the territory for me, unfortunately. Parnate was worse, tho--I had to switch to taking all of it at wake time instead of twice a day because otherwise it'd keep me awake at night.
>
> -zSo when you took Parnate in the morning, were you able to sleep unassisted?
Posted by zonked on June 13, 2010, at 9:19:32
In reply to Re: Parnate good for anhedonia? » zonked, posted by g_g_g_unit on June 13, 2010, at 0:05:38
> Hmm, my lifestyle + work routine (when it existed) are/were constructed around stuff I find interesting, which is why that aspect of meds isn't particularly bothersome; problems arise, however, when I'm feeling anhedonic because I can't even tap into my natural reward system.
You certainly phrased that well--as I've said in another post, a lot of people who've never had SERIOUS depression don't understand that anhedonia means you CAN'T experience reward for good things happening, even some (less experienced) "mental health" workers! The example I used is that I could win the lottery and not feel reward, except perhaps some anticipation that I'd be able to see the best psychopharmacologists in the world and fix this. :)
That's why I get so frustrated when people suggest walks or deep breathing or meditation when I am severe--doing things like that do not work until there is some relief--THEN they come into play.
I digress.
> My concern is more with fogginess. I gave up on Nardil the first time after 3 months because between the short-term memory loss and sleep deprivation, I could barely think straight.The sleep thing has always been an issue for me with Nardil and its cousin, Marplan. Sometimes even when I get the requisite number of hours (7-8 is my sweet spot), I don't wake up feeling refreshed... Looking for a new hypnotic to address this.
> So when you took Parnate in the morning, were you able to sleep unassisted?
>
No, in fact; I have taken benzos or Ambien to sleep for the last 10 years. But I was able to get a refreshing night's sleep on 30mg temazepam taking Parnate that way. I stay away from Ambien because it caused me to wake up in the middle of the night and do ODD things, like make strange snacks and hav e incoherent instant message conversations--lol. My roommate in college was amused but it scared the heck outta me!I also tried trazodone (too groggy and cranky at wake time) and the only time an antipsychotic has ever entered my body was when a doctor thought 1/4 of a 25mg Seroquel tab might help me sleep. I felt like a walking robot/zombie for the next TWO days. That was enough to scare me away from APs for the rest of my life.... YMMV of course, many folks on here find APs very helpful for sleep and do not have the reaction I did.
Let us know how you do...
-z
Posted by europerep on June 13, 2010, at 9:26:20
In reply to Re: Parnate good for anhedonia? » jade k, posted by Conundrum on June 12, 2010, at 21:01:53
> Seems like most pdocs are really into anticonvulsants and AAP these days and I don't wanna take an AAP. One permanent problem is enough don't need TD.
Seriously, that's exactly it.. it seems like they feel it makes them "hip" to prescribe antipsychotics for augmentation of an AD, especially the new ones as with aripiprazole in my case, of which I took two doses and then stopped because it made me feel extremely weird and uncomfortable.. as if all my perception or the processing was slowed down, someone said something and the words came in so slowly..
and I think pdocs do not at all take the perspective of tardive dyskinesia for what it is, let alone the still not accepted tardive psychosis. she even told me that the atypical AP "do not produce tardive dyskinesia anymore".. and that was a doc at a university clinic..
Posted by zonked on June 13, 2010, at 9:38:19
In reply to Re: Parnate good for anhedonia?, posted by europerep on June 13, 2010, at 9:26:20
> and I think pdocs do not at all take the perspective of tardive dyskinesia for what it is, let alone the still not accepted tardive psychosis. she even told me that the atypical AP "do not produce tardive dyskinesia anymore".. and that was a doc at a university clinic..
>
>
Some docs just believe what the drug companies tell them. I have two friends who have Bipolar I with psychotic features... One has TD and akathisia from years of Seroquel (controlled somewhat with propanonol) and the other has TD and akathisia from not-even-a-year of Abilify, controlled somewhat with cogentin.These folks need their APs for sure, and I am glad they're working for them. But it's a bunch of bull that the atypicals don't cause EPS.
If SSRIs were the trend of the 1990s, atypical APs were the trend of the 2000s. I have a feeling in another 5-20 years antidopaminergic drugs will be considered crude, especially if the NMDA agonists work out as well as people hope for psychosis.
-z
Posted by violette on June 13, 2010, at 15:11:35
In reply to Best med for anhedonia, lack of motivation, SCT?, posted by former poster on June 12, 2010, at 4:15:35
Dr. Bob,
I've seen post after post of people complaining of ahedonia, and/or lack of motivation, who can't find relief. Many don't feel "depressed"....or have felt worse after taking SSRIs...I've seen similar concerns on all the other mental health forums.
What is the opinion of mental health clinicians for this specific scenerio? Are these usually symptoms a type of depression, axis 2 traits, medical problems...all, some, none?
It seems like some people spend years going from med to med to find relief and just don't get there....as if there is a subset of people where this trait is their primary symptom who end up posting on the internet because doctors have been unable to help.
There are posts after posts on this forum, referencing lack of relief from amotivation, ahedonia, what is your general opinion?
Posted by Deneb on June 13, 2010, at 18:53:47
In reply to Dr. Bob - question, posted by violette on June 13, 2010, at 15:11:35
Hi Violette
Dr. Bob only acts as administrator here and doesn't answer questions that are not related to administration or the site.
Posted by Phillipa on June 13, 2010, at 19:21:25
In reply to Re: Dr. Bob - question » violette, posted by Deneb on June 13, 2010, at 18:53:47
It's a shame he doesn't as some sites do have a doc weight in on some issures. And this topic is a good one. Phillipa
Posted by Conundrum on June 13, 2010, at 19:51:30
In reply to Dr. Bob - question, posted by violette on June 13, 2010, at 15:11:35
I don't know I'm really interested in seeing a neuropsychiatrist and getting some brain scans and seeing whats going on in some areas. Maybe that could help direct treatment? All I know is that if pdocs don't start prescribing things that I think will help. I might just order drugs online myself. Its not like their job is hard. Give a drug they like, watch for side effects and if it doesn't work try another drug randomly.
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