![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 30. This is the beginning of the thread.
Posted by lynn on January 4, 2000, at 12:46:24
Hi everyone. I am writing to get feedback from those of you who have tried both Prozac and Wellbutrin. I am currently on 40mg. of Prozac and would really like to think about Wellbutrin because of the sexual side effects of Prozac. I have tried various antidotes and only Viagra has helped. However, my distress with the sexual side effects of Prozac is such that I am not satisfied merely treating the anorgasmia. Instead, I feel like the Prozac has made me very asexual, and in this way, has really shut me off from an important part of my personality (and relationship). I also feel a bit numbed by Prozac, and sometimes I feel like I am living without 50% of my feelings. At the same time, however, I suffer from extremely severe, lethargic depressions (virtually every antidepressant has sedated me heavily except prozac), and I have a very hypochondriacal OCD streak to my depressions. I am frequently obsessing about brain tumors, MS, etc. This is very embarrassing to write about, but I really need some input from you guys. I am in therapy and would not mind confronting the OCD/hypochondria issues to some degree. What is paramount, however, is that I keep my depression under check. My father died a little over a month ago (I am in my 20s and he was a best friend to me), and I am in a major transition period in my career. In addition, I have recently reunited with my husband and we are trying to work things out between us. I most definitely need the stability that and AD affords me; the last major depressive episode I had left me suicidal -- but I am also tired of not feeling sexual and sensual, not feeling quite as artistic, and not "feeling my feelings." Sometimes I feel like I can't even cry. But I also fear my feelings so much, and I feel like I have progressed so much on Prozac that I fear "undoing" what I have done. But I want my feelings back, a little more than they are, particularly my sexual feelings. Because I feel like I have reached a point where I am almost apathetic about making postive changes in my life because the meds have sort of numbed me. I have always thought about Wellbutrin because I need something stimulating and I know that it is touted for its lack of sexual side effects. However, my OCD/hypochondriacal side fears the risk of seizures and fears having it be less effective than Prozac. Can anyone please offer their thoughts? I am sorry to drone on and on about this, but I thought some context would be helpful. Thank you, Lynn
Posted by dove on January 4, 2000, at 13:16:35
In reply to Switching from Prozac (?) Please inform/advise, posted by lynn on January 4, 2000, at 12:46:24
I was also taking prozac and got very suicidal, very numb, just blah and hopeless. I am no longer taking prozac but I am taking Wellbutrin, only 150 mgs a day at this point. It has had no negative effect on my sexual moods, unlike prozac (asexual is right) and may even had a positive effect. I don't feel so numb, actually I can cry now, I can laugh again, which is what I had missed the most while taking prozac.
My best wishes to you, and I know how scary it is to quit, I was so worried that I would actually do myself in if I stopped taking the prozac because of how awful I was feeling on it! But within one day I felt really really much better. I don't know why the prozac makes some people feel worse and even more afraid of going without it. Keep us updated, and take care, you're in a very trying period with lots of life-changes and my blessings go out to you.
dove
Posted by JohnL on January 4, 2000, at 13:51:58
In reply to Switching from Prozac (?) Please inform/advise, posted by lynn on January 4, 2000, at 12:46:24
As a fellow Prozac user, I can sure understand. I have found my sex life in all areas (interest, ability, sensation) are normal to slightly enhanced at 20mg. But at 40mg all the troubles you mentioned take over. So I stay at 20mg but will take 40mg or 60mg every three days or so. I am currently in the mode of trying to enhance the Prozac's effectiveness on symptoms of apathy/anhedonia. This week I will see my doc and he is likely to add a psychostimulant to my Prozac. The stimulants apparently have the potential to increase antidepressant response and counter sexual side effects also. We'll see. My hopes aren't very high, but this approach seems to be quite popular in literature.
Adding Wellbutrin would be similar. I can't take Wellbutrin because of the severe tinnitus it causes me. I'm worried a stimulant will do the same.
Anyway, I think you are on the right track. Add either Wellbutrin or a stimulant. But I think with the combination you should be able to lower the Prozac dosage down to 20mg which should help even more. That sounds like a reasonable way to treat the apathy and the sex simultaneously. It works for others. Hope it works for you and me! JohnL
Posted by MA on January 4, 2000, at 15:04:53
In reply to Re: Switching from Prozac (?) Please inform/advise, posted by JohnL on January 4, 2000, at 13:51:58
Lynn,
I concur with JohnL. Adding a stimulant or Wellbutrin would be the way to go initially. Once you have added one of these you should be able to lower the Prozac to 20 mg.For myself, I went off Prozac onto Wellbutrin alone and relapsed, so my advice would be to ADD another med to the Prozac, not to discontinue it.
I currently take Celexa and Wellbutrin and had some return of emotions and sexual feelings. I still think I need to reduce my dose of Celexa but it's safer to do these changes very, very slowly.
Good luck with whatever you try.
MA
Posted by Zeke on January 4, 2000, at 17:39:43
In reply to Re: Switching from Prozac (?) Please inform/advise, posted by MA on January 4, 2000, at 15:04:53
For many people with OCD, a lower dose of an SSRI is as effective as a higher dose. BTW, other SSRIs and Anafranil would likely have the same anti-sexual effects.
Wellbutrin is a possibility, but that might increase the risk of seizures somewhat (combined with an SSRI vs alone). A stimulant conversely, ie, amphetamine, has anticonvulsant properties and in some people has an anti OCD effect also. (search PubMed for OCD and amphetamine) It would not be unreasonable for your doc to try this with you. A stimulant or Wellbutrin could also reduce SSRI anergia.
Posted by CraigF on January 4, 2000, at 18:43:49
In reply to Re: Switching from Prozac (?) Please inform/advise, posted by Zeke on January 4, 2000, at 17:39:43
I can agree with all these responses; they offer good advice.
I concurr you should add Wellbutrin first. Then increase that dose (in addition maybe to lowering the SSRI dose) and look for sexual improvement. If you want to switch completely, do it gradually.
I am doing a similar thing with Serzone and WB but will not likely elimate the Serzone, It's great for GAD.
Be warned that while WB lets more "uplifted" emotions through, it is less likely to stop any racing thoughts, anxiety, or obsessional behavior. It does not really act on seretonin receptors.
Posted by Abby on January 4, 2000, at 21:32:07
In reply to Re: Switching from Prozac (?) Please inform/advise, posted by CraigF on January 4, 2000, at 18:43:49
I know very little about prozac, except for its long half-life.
Zoloft worked for me on the first try, amazingly well at first.
I have read that OCD does seem to require SSRIs.Add wellbutrin to a lower dose of prozac. I think that the seizure risk is overrated. I mean, it's completely unavailable in the UK.
The combo is pretty common.
Posted by lynn on January 5, 2000, at 9:58:26
In reply to Re: keep an SSRI for OCD, posted by Abby on January 4, 2000, at 21:32:07
You are all so helpful and kind -- I can't tell you how much I appreciate your responses. I realize that what I failed to mention in my previous post is that I have in fact tried adding Wellbutrin to Prozac. For 3 months or so, I took 75 mg Wellbutrin IR with 20 mg Prozac to try to combat the sexual side effects (which were not nearly as intense for me on 20 mg as they are on 40mg). Unfortunately, this combination did nothing for me but made me feel a little out of it and drugged in a sort of wired, nauseated, distracted way (not anxious, really, but a little over-medicated). I am quite small in stature and perhaps there was something about the way I metabolized the medications that just made me feel out of whack. So, for me, the switch would have to be entirely to Wellbutrin. Adding a stimulant is a very interesting suggestion. John L, do you know which stimulants are usually added, and why the positive effect on sexual function occurs? Another complicating factor is that I have anxiety on top of a very anergic depression, so it is hard to treat both of these things simultaneously. I find that almost everything makes me unbearably exhausted (except Prozac), but I have to treat my anxiety at the same time. Interestingly, Prozac does not make me anxious -- rather, I find it mildly sedating. So, in addition to the 40 mg Prozac, I take .5 mg Klonopin every night. The Klonopin stays in my system for 18 hours, so I usually feel pretty good the next morning until later afternoon. I think I am at my best with Klonopin, Prozac, and about 10 oz of black coffee in my system. I find that I am the most relaxed and focused at this time. So, I guess I feel overwhelmed by all the elements here that I need to treat -- OCD, anxiety/panic, and anergic depression. Someone mentioned a low dose of Elavil, too, and told me that Elavil gets a bad rap because it is usually prescribed in very high doses. Does anyone have any experience with it? As a teenager, I was on a very high dose of imipramine and felt better depression-wise, but was overwhelmed with the cholinergic side effects.
Posted by dove on January 5, 2000, at 12:54:29
In reply to Thank you so much -- further info/questions, posted by lynn on January 5, 2000, at 9:58:26
I take Elavil (Amitriptyline) 75 mgs. before bed, and it makes a world of difference in my sleep quality, as for any effect on my depression and anxiety, I really can't say. It does prevent my migraine headaches, so that's a big plus. I also taked a stimulant (Adderall) morning and around noon, 40mgs. This has helped my feelings of being overwhelmed and hopeless in relation to the overwhelmed feelings. It also has enabled me to to do one thing at a time, instead of running around like a chicken with my head cut-off.
When the prozac was added to this combo I bottomed out big-time, causing the discontinuation of the prozac. The Wellbutrin added to the above combo has helped with my sadness and depression that hits me in the evenings. I can't say that it has helped with my anxiety, I seem to be having more frequent panic-attacks since removing the prozac and adding the Wellbutrin, but your mileage may vary, as it always seems to do.
My obsessive-compulsive stuff has improved significantly with the wellbutrin, but my p-doc says the results are not connected to the wellbutrin but to the stimulant, I can't figure it out. But, the OCD has only improved with the wellbutrin, nothing else has touched it ever, besides making it worse that is.
I hope this helps, my best wishes to you.
dove
Posted by JohnL on January 5, 2000, at 17:59:15
In reply to Re: further info/questions, posted by dove on January 5, 2000, at 12:54:29
Concerning stimulants Lynne, I checked out everything in Dr Bob's Psych Tips and also searched around. Methylphenidate (Ritalin) seems to be the most popular. Other choices are Desoxyn, Bromocriptine, Amantadine, Pemoline. The theory is that dopamine is down-regulated by other antidepressants, causing sexual problems and apathy. The stimulants are dopiminergic enhancers. That's the theory anyway.
The stimulants seem to be like ADs in that if one doesn't work, another might, even though they are similar in action. Results are supposedly fast, when they work. Anywhere from 2 days to 2 weeks. So a couple or several could be tried in a short period of time. I would think a stimulant would not be good for anxiety symptoms. BUT considering your (and my) atypcial response to Prozac, a stimulant might work great. They seem to calm down millions of hyper kids, right? I have no experience with any of these 'yet', but will likely come home with a prescrip for one of them Thursday. I've just been reading up a lot. Hope any of this might help. JohnL
Posted by Amanda on January 5, 2000, at 22:15:45
In reply to Re: further info Lynn, posted by JohnL on January 5, 2000, at 17:59:15
Lynn, I can't believe this! I am going through the exact situation myself! I have been taking 20mg Prozac for over a year and find it effective, except that it has numbed me to a lot of my feelings. I, too, feel asexual. Going so long without any sexual feelings has become unbearable, so I am in the process of switching to Wellbutrin. I don't really have advice to offer because I don't know what will happen myself. My doctor told me to take my last dose of Prozac today and take my first dose of Wellbutrin tomorrow. I guess we'll see what happens. Please keep in touch, b/c I am really interested to know how things turn out for you. Good luck! abalazs@agnesscott.edu
Posted by Abby on January 5, 2000, at 23:58:20
In reply to Re: further info Lynn, posted by Amanda on January 5, 2000, at 22:15:45
I'm told that Zoloft is supposed to be good for anxious depressions. I don't know about sexual side effects really. I mean, when I firat got depressed, I was so tired and lethargic, my concentration was so poor, and I just felt nothing. I was sad only when I realized that I couldn't do anything that would make me feel better.
Zoloft was like a miracle. I think I might have mild bipolar tendencies, because if anything, I felt that my awareness of the physical world was heightened by the drug.Good luck whichever route you try.
Abby
Posted by Zeke on January 6, 2000, at 18:09:38
In reply to Re: further info Lynn, posted by Amanda on January 5, 2000, at 22:15:45
If you consider amitryptline(Elavil), you might consider nortryptline(Pamelor) instead. The former is metabolized to te latter, but it lacks many of the side effects. The downside is that Pamelor is more expensive than Elavil.
As for stimulants, stay away from pemoline(Cylert) as it may be toxic to the liver, and is also weaker and slower acting than amphetamine or methylphenidate. There is some evidence for an antiobsessive effect of stimulants.
An interesting point about clonazepam(Klonopin) and alprazolam(Xanax) is that they also act on serotonin, as well as GABA systems. BTW clonazepam probably stays with you longer than 18h as its half life is 19-60h.
Posted by lynn on January 6, 2000, at 22:49:52
In reply to Re: further info Lynn, posted by Zeke on January 6, 2000, at 18:09:38
Zeke, dove, Abby, JohnL and everyone, thank you again for your help. I am intrigued to hear that Klonopin acts on 5HT receptors. Does anyone think that Klonopin ALONE could be used as an AD? Or Klonopin with a stimulant, to combat the anergia but also the anxiety? ALso, about the Pamelor, Zeke, what are the major side effects? Is sedation a side effect, as at is with so many of the other older ADs? Is anorgasmia a side effect? Does anyone know of any literature on the anti-OCD qualities of stimulants? I would really like to do some reading on that. Also, does literature on the specific combos used to treat multiple diagnoses exist? Dove, your combination sounds pretty effective. How do you like it? In my heart, I would like to ditch the Prozac altogether and get away from the SSRIs for a time. I just wonder if there is any way to combat the anergia, severe anxiety, depression, OCD and mild (very mild) cyclothymia at the same time. Right now I feel overwhelmed about all of this and kind of discouraged. I can't begin to tell you how helpful you all have been. If you have time, please continue to share your knowledge of effective "cocktails" with me. I have always been treated with monotherapy -- and very unsuccessfully, or should I say, incompletely -- so my knowledge of what to mix is very limited...and I would like very much to bounce some of this off of my psychopharm when I see her next. --lynn
JOHNL: How was your appointment today?
Posted by JohnL on January 7, 2000, at 3:21:50
In reply to lynn again, posted by lynn on January 6, 2000, at 22:49:52
> JOHNL: How was your appointment today?Hi Lynn. Thanks for asking. Let me attempt to answer some of your questions.
I know of one poster who found Klonopin+Selegiline to be a wonderful combination. That would imply that Klonopin with a stimulant might indeed be a good combination. But you know how we are all so different. There's really no way to tell without trying different things. The best we can do is make educated guesses to narrow the list of choices. The fastest way to try different choices is to start with fast-acting meds first. While ADs take at least a month, you'll know in mere days if an anxiety med or a stimulant med is going to be helpful or not. No need to waste time. Move quickly to another if needed.
Pamelor's primary side effects are dry mouth, maybe transient constipation, and some sedation, maybe slight transient blurred vision. I found things like Remeron and Serzone to be much more sedating than Pamelor though. I actually found Pamelor's side effects rather mild. Dry mouth was the most obvious side effect for me. I did have anorgasmia. It seemed dose-related. Lower doses were OK. I was also taking Prozac though, so I don't know whether it was the combination or one or the other that was guilty. I did not have anorgasmia when I took Pamelor with Zoloft (just a total lack of desire due to the Zoloft).
You have so many good questions, and yet we all respond so differently. I would like to make the following suggestion: Spend a few days or a few weeks doing this. Click on "tips' at the top of the main page. When you get to the tips page, go down the righthand side and click on search, leaving the search box blank. Then, one by one, click on each topic and read the doctor discussions on all the various issues. There are dozens of topics on everything you can imagine, and hours of reading. Maybe even take notes. You will come across a lot of information that is not relevent. But you will also discover a lot of information that will spark some really good ideas. You will discover what successes and failures doctors are having with symptoms just like yours. And since this information is real-world stuff by real doctors, you'll learn some tricks of the trade. I think anyone who studies Dr Bob's Tips can become more of an expert at pharmacology than a majority of practicing psychiatrists in a rather short amount of time.
Back to my appointment. My pdoc prescribed Ritalin no problem. He said I'll know almost immediately if it's right for me or not. If not, I am to call him and he will then call in a sample prescription to my pharmacy for a different stimulant. After a short trial on that, he will yet call in another prescription for a third if needed. So within two weeks I should know whether the psychostimulant route for me is appropriate or not. What a cool pdoc. I was lucky to find him. But as I said above, it was a result of banging on a lot of doors. He's an old timer, weeks away from retirement. But I was pleasantly surprised to find out he will still make himself available to a handful of clients and he will also offer consultation to my GP. So I'm not losing him as I had feared. Anyway, I'm wishing you progress and hope. JohnL
Posted by Noa on January 7, 2000, at 5:42:38
In reply to Re: lynn again, posted by JohnL on January 7, 2000, at 3:21:50
hey, John, I am so glad to hear you can stay with your doc. let us know how the ritalin goes. Btw, I find the sr better than the regular, because with the regular, I had definite mood and energy dips/crashes mid-day and early evening. The sr feels much more even, and the second dose wears off at the right time, before bed. Oh, and it doesn't hurt to have to remember only 2 doses, vs 3. I'm curious: does your insurance company hassle you about covering the ritalin? Mine requires prior approval for anyone over age 19, which of course, is a lot of hogwash. Good luck.
Posted by MA on January 7, 2000, at 9:22:31
In reply to Re: lynn again, posted by Noa on January 7, 2000, at 5:42:38
Noa,
You just reminded me that when I tried Ritalin about 1 month ago, the pharmacy did not cover the Ritalin. They said it was only allowed in children for ADD. I had forgotten about that and paid out of pocket. Let's see, just dug out my receipt for 33.39 for 30 tabs of 20 mg.My trial of perhaps a week made me hyper and very dry mouthed. I believe I took 10 mg 2x/day to start but couldn't get beyond that dose. Now I'm thinking that a lower dose, i.e. 5 mg, might have worked. Why do we always get these revelations once the time has passed to do something.
Good luck JohnL, hope it works for you.
MA
Posted by Noa on January 7, 2000, at 12:14:20
In reply to Ritalin Coverage:Noa, JohnL, posted by MA on January 7, 2000, at 9:22:31
MA,
I am now up to 20 mg of the SR version. Before that I took 10 mg regular, 3 times a day. But to START, my doc recommended 2.5 mg for a week, then 5 for two weeks, then 7.5, etc. Very gradual. He is conservative that way, which I like, especially since my earliest experience with ADs landed me in the ER because of the severe sedating and agitating effects of the initial dose.
Go submit that receipt after the fact to your insurance. Get your doc to communicate with them about coverage.
Posted by JohnL on January 7, 2000, at 12:54:47
In reply to Re: Ritalin Coverage:Noa, JohnL, posted by Noa on January 7, 2000, at 12:14:20
> Go submit that receipt after the fact to your insurance. Get your doc to communicate with them about coverage.My co-pay for Ritalin was $17. But the total cash price was $23. Not much difference. I had no idea though that Ritalin was so dirt cheap. JohnL
Posted by Zeke on January 8, 2000, at 21:24:23
In reply to Re: Ritalin Coverage, posted by JohnL on January 7, 2000, at 12:54:47
KLONOPIN
Not sure about the AD effects. I think the 5HT properties have been touted as added benefit to anxiety dx. But then Xanax -- which also has 5HT properties -- is said to have some AD effects I believe.
I did a MedLin search last week but am a little hazy on the details.
PAMELORI found the effects of Pamelor very tolerable. I'd say the two noticable side effects are eye fatigue (blurry vision) and dry mouth (somewhat). I didn't notice anororgasmia nor sedation -- but then I took the whole dose at bedtime. My old Merck Manual says:
..................Sedation.....Anticholonergic
Amitriptyline.....+++..........+++
Nortriptyline.....++...........++
Imipramine........++...........++
Desipramine.......+............+
STIMULANTSHere's a few PubMed links
there are re OCD. also click on the "related articles" link at top of each to find othershttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=1680885&form=6&db=m&Dopt=b
http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=3429704&form=6&db=m&Dopt=b
this one isn't about OCD but is a case includes a case report of amphetamine withdrawl precipitating agoraphobiahttp://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?uid=7085580&form=6&db=m&Dopt=b
here's one more just for general info on the ADs (from the current online Merck Manual)http://www.merck.com/pubs/mmanual/tables/189tb6.htm
Posted by Zeke on January 8, 2000, at 21:45:13
In reply to Re: Ritalin Coverage, posted by JohnL on January 7, 2000, at 12:54:47
First, the Ritalin is cheaper cause with the wide use there are several competing generics. Some docs were skeptical about the generics being bioequivalent so you might want to try both and also ask your doc.
I feel almost INFURIATED that your insurance companies would have such an outrageous policy. Do they do this with any other meds??? If I were you guys, I'd call the company and ask to speak to their physician consultant who reviews neuropsychiatric cases (or if its for ADD, I might even be tempted to ask for the neurologist consultant) -- and get this cleared up. I just can't believe this. I guess there could be some cost saving motive but I see it as largely moral/political. (Like you say, Ritalin is fairly cheap, so the cost saving angle can't be that big a motive.) Adult ADD is now well documented and stimulants are the front line med -- don't these folks read the journals? But I guess you could remind them how much more expensive psychotherapy is than pharmacotherapy!!!
Sorry about ranting about this but kinda yanks my chain just hearing this!
Please keep me posted on what they say to you. (You guys are in HMOs or more traditional insurance?)
Posted by Noa on January 8, 2000, at 23:32:27
In reply to JohnL & Noa: Ritalin Coverage--can't believe this!, posted by Zeke on January 8, 2000, at 21:45:13
Zeke, thanks for your outrage. I think it is ridiculous, too. My insurance will cover it, but only with prior approval, ie, paperwork and hoop-jumping. A pain in the butt.
My insurance is a dual HMO/non HMO combo. But the prescription plan is definitely managed.
Posted by Noa on January 8, 2000, at 23:34:06
In reply to Re: JohnL & Noa: Ritalin Coverage--can't believe this!, posted by Noa on January 8, 2000, at 23:32:27
Oh, and BTW, the ritalin (actually I use the generic) is not for ADHD, but to augment my antidepressants. That shouldn't matter, though. I think it should be up to the physician.
Posted by Renee N on January 9, 2000, at 0:48:53
In reply to Re: JohnL & Noa: Ritalin Coverage--can't believe this!, posted by Noa on January 8, 2000, at 23:34:06
> Oh, and BTW, the ritalin (actually I use the generic) is not for ADHD, but to augment my antidepressants. That shouldn't matter, though. I think it should be up to the physician.
I totally agree that physicians should decide what medicine their patients need. I could understand if the insurance company required the prescribing doctor to be a psychiatrist for psychotropic meds.
My HMO which is RushPrudential, didn't balk at ritalin, but did at ADDerall and dexadrine. I persisted in calling the HMO and my sychiatrist's office until I finally got it approved. There were two or three months when I spent $40-$78 for a stimulant. I now take ADDerall, Wellbutrin, and Effexor XR. I understand thatthe Effexor alone would cost over $200 per month without insurance. Wouldn't they have saved money if I would have been helped by ADDerall alone without the added ADs, as MANY are many adults with diagnosies of ADD. I just don't get it! Wake up and smell the coffee, HMO's,---ADD symptoms do not always magically dissapear at age 16, 18, or 99 for that matter! We don't like depending on drugs to get through life any more than you like payinng for them. I guess people who don't really have ADD problems and abuse stimulants make it very hard for those of us who need them to keep our jobs, sposes, kids, and sanity. Boy, am I on a roll tonight!
Posted by Noa on January 9, 2000, at 10:01:37
In reply to Ritalin Coverage--can't believe this!, posted by Renee N on January 9, 2000, at 0:48:53
I really wonder what the true stats are on ritalin abuse, compared with abuse of any other drug. Think of all the percoset that gets prescribed every time someone has a tooth pulled! Isn't that more of a risk than ritalin? Besides, you can't get more than a month's scrip of ritalin, anyway, because it's controlled. How much abuse could a person manage on a one month supply?
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.