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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 4 to 28 of 30. Go back in thread:
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?
Posted by Noa on January 9, 2000, at 10:09:53
In reply to Re: Ritalin Coverage--can't believe this!, posted by Noa on January 9, 2000, at 10:01:37
The whole thing just doesn't make sense to me. The gov't controls the ritalin--no refills, need new scrip, etc. It really isn't an expensive drug anymore, esp. the generic. And if I were someone going around to different docs getting scrips so I could abuse it, insurance coverage wouldn't be the thing to stop me. In any event, the insurance company only covers a one month supply of any med anyway. If they really are worried about abuse, they could implement checks like if there is an increase in dose within a month's time, that could require checking with the doc, or something. But I don't think it is abuse that is the concern. I think it is cost. Some actuary told the insurance industry about the numbers of ADHD kids on ritalin and what it would cost over a life time. It is stupid, cuz the ritalin is relatively cheap, but I guess the macro numbers must be where the insurance companies want to save.
Posted by Zeke on January 10, 2000, at 2:03:30
In reply to Re: Ritalin Coverage--more, posted by Noa on January 9, 2000, at 10:09:53
I ponder the psychostimulant issue from several angles:
One could say that the HMOs place special controls because it's a controlled substance. But I doubt that they demand preauthorization from having a script for Percodan or other schedule 2 opiates filled. (Do they?) An exception may be that they would review high doses or ongoing prescriptions as would be given to a person with cancer. Of course, we have (had) undermedication or even lack of medication for such persons with narcotics just as with stimulants. Granted, doctors need to use special care with these substances because of abuse potential and persons becoming dependent on them. And in practice doctors fear state medical boards' critical oversight: investigations and potential discipline. But the conservatism creates craziness where doctors fear 'addiction' (dependence) by using appropriate (high) doses in terminal cancer patients. More in our perspective, this means using stimulants -- even if some dependence develops -- because they more importantly allow a person to be functional and have a better quality of life.
The thing that really strikes me about what was said, is that the companies demand preauthorization for stimulants in adults -- but not in children. This implies that they are inappropriately prescribed for adults? Consider that Ritalin and amphetamines are a first line medication for Narcolepsy, a condition that typically presents itself in young adults.
Now certainly there are many more people with ADD and depression than narcolepsy. And also the stimulants have been used primarily for childhood ADD -- not long ago ADD was thought to be just a childhood condition. But research and practice has shown that ADD symptoms continue into adulthood, and that adult ADD and often depression can be treated (find relief) with stimulants. So here come the insurance companies and HMOs who say, you need our approval, not just your doctor's approval (prescription)!
Do these companies similarly demand preapproval for adults for say Retin-A? Retin-A is an acne medication, and acne is largely a teenage condition. There are probably even better examples than this. But I doubt the companies demand reapproval in these cases?
I even wonder if they require approval for Cylert(pemoline) to be covered for adults? Cylert is a schedule 4 drug, with minimal abuse potential compared to Ritalin or amphetamines. JohnL and Noa, you might ask your pharmacy about this. I'm curious about the response. Given, Renee's experience that Ritalin is OK but amphetamine needing approval, I rather doubt they would be so critical towards Cylert. This again would point to schedule 2 drugs being the main issue. This is why claim morality is a big motivation behind the policy (excuse the pun)!
This irritates me because eight years ago I had a somewhat similar experience. When I was first treated for ADD, I had a doctor that used rather high doses of Ritalin. The pharmacy refused to fill the Rx because it exceeds 60mg/day. They didn't have any similar policy about other meds. (They also wouldn't stock Dexedrine -- though they did dispense Percodan etc., which makes little sense to me.)
Again, they thing that strikes me here is that the preauthorization is limited to adults.
What my doctors have sometimes done and can eliminate some problems, is to write 'for ADD' or 'for depression' etc. on the scripts.
I have a friend at CHADD and may inquire if this is a widespread problem. I'll keep you posted.
Back to the crazy world!!!
Posted by torchgrl on January 10, 2000, at 15:52:04
In reply to Re: Ritalin Coverage, posted by Zeke on January 10, 2000, at 2:03:30
As far as Retin-A goes, once everyone jumped on the cosmetic use bandwagon, they started requiring special approval for rxs for adults--I remember having to deal with this a few years back, but don't remember all the details. I suppose that's not nearly as big a deal as the ridiculous Ritalin policy, though. I'm just sick of medication being such an ISSUE--between the formularies not including anything, to the special approvals, to the prohibitive cost without insurance... But that's another thread.
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