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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 5 of 5. This is the beginning of the thread.
Posted by sarahcat on August 21, 2001, at 23:25:40
Hi everyone,
I'm delurking after a few years of periodically reading and searching psycho-babble for true life information about various meds. I want to thank everyone on the board for being so open and honest about their experiences... it's very helpful to read.
Now for my question: I've been in treatment for dysthymia with superimposed major depressive episodes for six and a half years (I'm 24 now). Over the years, I've tried Prozac, Zoloft, Celexa, and Wellbutrin; Depakote, Cytomel, Trazodone, Ritalin, and occasional Ativan have been tried as augmenters or adjunct meds. Now I'm on 300mg of Effexor XR, 900 mg of Lithium (300 tid), 1200mg Neurontin (300, 300, and 600mg dosing), and 2mg Risperdal (1mg bid).
I was in the hospital for the first time a couple of weeks ago, and while in the hospital the psychiatrist there had me on 450mg of the Effexor, which my regular doc promptly returned back to 300mg (my regular doc was on vacation while I was in the hospital, preventing communication between the doctors) for fear of potential side effects.
It's been a week since my Effexor was lowered, and I've steadily suck lower and lower each day. I know 450 is a high dose of Effexor (Walgreen's wouldn't even fill it without hassle), but I'm starting to believe that I need that dose to feel better. Does anyone here have any experience with taking that amount (or higher) of Effexor? Were your side effects increased? I don't really have any side effects with Effexor, but my doc is worried that it will increase my blood pressure. At this point I'm really starting to worry that I'm just treatment resistent.
Thanks in advance, and I look forward to becoming a more active part of psycho-babble.
Sarah
Posted by Zo on August 22, 2001, at 2:13:45
In reply to Delurk... recently released from hospital, posted by sarahcat on August 21, 2001, at 23:25:40
Hi Sarah,
It's too soon to tell, you may very well just be going thru withdrawal from too big a dose reduction too abruptly.. . .which, just by coincidence, is what *I* am doing this week.
If you don't feel better in a week, by all means return to the dose that makes *you* feel best. I'd do some more research on the dangers of HBP before I accepted that edict. Doctors oughtn't to mess with anything that's helping, unless one is in *grave* danger. When they do so, they're just worrying about themselves, not acting on the patient's behalf.
I think JohnL had a post on how to put it to a resistant pdoc. . .something about, Let me give it a week's trial. And then you come back feeling good. . .Got to jolly along the insecure buggers.
Good luck!
Zo
Posted by sarahcat on August 22, 2001, at 6:57:45
In reply to Re: Delurk... recently released from hospital » sarahcat, posted by Zo on August 22, 2001, at 2:13:45
Thanks Zo,
I was worried that there would be some withdrawal in reducing from 450 to 300mg, but my pdoc said that it shouldn't be an issue. I didn't really think that my lowering mood could be withdrawal, but that would make some sense.
Before I went into the hospital, my pdoc wanted to reduce the Effexor to 225mg because of his high blood pressure fears, but I successfully convinced him to leave it at 300 for a while. I haven't had any increase in BP, and I've tried telling him that I really don't care if it does raise it a little. I'd rather feel better and then worry about the BP if I have to.
Ironically, my primary care doc is completely unconcerned about this. He said that if my BP did go up, he'd just put me on some HCTZ (a water pill).
Effexor is the first AD to work for me (others either had _really_ intolerable side effects or they didn't work at all, even at high doses), even though it has pooped out on me, necessitating the increases in dose. But I don't want to give up on it unless I really have to.
I'm seeing my pdoc next week, and I'll try to be more assertive with my thoughts about the Effexor dose. Thanks again, Zo.
Sarah
> Hi Sarah,
>
> It's too soon to tell, you may very well just be going thru withdrawal from too big a dose reduction too abruptly.. . .which, just by coincidence, is what *I* am doing this week.
>
> If you don't feel better in a week, by all means return to the dose that makes *you* feel best. I'd do some more research on the dangers of HBP before I accepted that edict. Doctors oughtn't to mess with anything that's helping, unless one is in *grave* danger. When they do so, they're just worrying about themselves, not acting on the patient's behalf.
>
> I think JohnL had a post on how to put it to a resistant pdoc. . .something about, Let me give it a week's trial. And then you come back feeling good. . .Got to jolly along the insecure buggers.
>
> Good luck!
>
> Zo
Posted by Elizabeth on August 22, 2001, at 10:54:01
In reply to Delurk... recently released from hospital, posted by sarahcat on August 21, 2001, at 23:25:40
Hi, Sarah. Welcome to babble-land. (insert handshake here) It's great that you feel comfortable delurking. I think that having a moderated forum for discussing this stuff (without having to worry about being verbally attacked) is a special gift.
I agree with what Zo said, and I have a few additional remarks.
> Now for my question: I've been in treatment for dysthymia with superimposed major depressive episodes for six and a half years (I'm 24 now).
"Double depression." Ouch. I have recurrent depression and panic attacks superimposed on ADD, which is sort of similar in some ways -- when I was just diagnosed with depression, the antidepressants got rid of the mood disorder, but the general problems that have been there all my life (and that may have contributed to the depression in the first place, although the depression is basically considered to be primary and "endogenous") were still there, so I wasn't functioning well anyway. Now I'm trying to figure out how to deal with the ADD. The first step was going off MAO inhibitors and switching to desipramine (which seems to work just as well without many side effects -- for me, the new drugs haven't done much, it's been the old tried-and-true stuff that really works)
> Over the years, I've tried Prozac, Zoloft, Celexa, and Wellbutrin; Depakote, Cytomel, Trazodone, Ritalin, and occasional Ativan have been tried as augmenters or adjunct meds. Now I'm on 300mg of Effexor XR, 900 mg of Lithium (300 tid), 1200mg Neurontin (300, 300, and 600mg dosing), and 2mg Risperdal (1mg bid).
Huh. How do you feel all that stuff is helping? Like, what helps with what?
What are your dysthymia and major depressive episodes like? What kind of symptoms do you get? (A project of mine has been trying to figure out what medications work for what types of depression by asking around and keeping track of stuff. Don't worry, it's not formal research and your name won't be mentioned if I ever do manage to put together some kind of paper on this! :-) )
> I was in the hospital for the first time a couple of weeks ago, and while in the hospital the psychiatrist there had me on 450mg of the Effexor, which my regular doc promptly returned back to 300mg (my regular doc was on vacation while I was in the hospital, preventing communication between the doctors) for fear of potential side effects.
How did you feel about being in the hospital? For a lot of people, it's a frustrating and demoralising experience, I think.
> I know 450 is a high dose of Effexor (Walgreen's wouldn't even fill it without hassle), but I'm starting to believe that I need that dose to feel better.
Ahh, don't you just love it when pharmacists try to second-guess your doctor without knowing anything about your history?
> Does anyone here have any experience with taking that amount (or higher) of Effexor?
Not Effexor (I got the serotonin syndrome after decreasing it from 225 to 187.5!), but I'm on a dose of desipramine right now that is probably resulting in higher-than-normal serum concentrations (due to slower-than-normal metabolism). I was taking 300 mg/day (this is the recommended maximum dose for *inpatients* -- for outpatients it's 200), but my serum level turned out to be very high so I cut back to 150. That didn't seem to be working nearly as well, though, so now I'm on 225 as a compromise. I haven't had a serum level test since I've been on the decreased amount, so I don't know how it is, but it's probably still well outside the accepted range (which is something like 100-300 ng/mL, IIRC -- my level was well over 600 when I was on 300 mg/day). So it might be that I just need a higher concentration of desipramine than the "normal" therapeutic range. My pdoc doesn't seem too worried since I'm not getting bad side effects. He does want me to get an ECG to make sure I'm not having cardiac toxicity, but that's going to be difficult, since I'm, uh, in between health insurance plans!
> Were your side effects increased? I don't really have any side effects with Effexor, but my doc is worried that it will increase my blood pressure. At this point I'm really starting to worry that I'm just treatment resistent.
No, if it was working at the higher dose, you should see if your blood pressure is elevated. (You might want to get a BP monitor for yourself; the digital ones are around $75-100, but the manual-inflating ones are more like $20-30, and it's pretty easy to learn to use one.) If so, consider antihypertensive therapy to compensate. (The antihypertensives that are considered least likely to exacerbate depression are the ACE inhibitors, I believe.) Finding an AD that works when you've failed to respond to other ADs is a precious gift; as Zo says, it's best not to mess with something that's helping, and to attempt to deal with the side effects if possible before giving up and moving on to something else. This is especially true if you have been unresponsive to many treatments already.
> Thanks in advance, and I look forward to becoming a more active part of psycho-babble.
I look forward to talking to you some more. Again, welcome.
-elizabeth
Posted by sarahcat on August 22, 2001, at 21:54:23
In reply to Re: Delurk » sarahcat, posted by Elizabeth on August 22, 2001, at 10:54:01
Hi Elizabeth,
Thanks for your response and your wonderful questions.
> > I'm on 300mg of Effexor XR, 900 mg of Lithium (300 tid), 1200mg Neurontin (300, 300, and 600mg dosing), and 2mg Risperdal (1mg bid).
>
> Huh. How do you feel all that stuff is helping? Like, what helps with what?
The Effexor is my primary antidepressant, and it helps with the constant sadness, poor motivation, hopelessness... general depression stuff. The Neurontin helps a lot with anxiety-- I also have generalized anxiety, but I figured it would almost be redundant to mention that along with the double depression. The Neurontin also helps me maintain a calmer, more even keel (slightly mood stabilizing), as well as helping me sleep at night. Incidentally, pre-hospitalization I was on 3000mg Neurontin daily, but the pdoc in the hospital was under the impression that it has no psychotropic effect. I disagree... Neurontin has been very helpful for me. The Lithium is primarily to augment the Effexor, but it adds a mood stabilizing element. The Risperdal really helps stop obsessive and intrusive rumination about suicide. Each of these meds has been added one at a time, and dose changes are one at a time (except in the hospital) to help determine what's responsible for what.
>
> What are your dysthymia and major depressive
When I'm at my baseline (dysthymic) I feel moderately down and misanthropic, I have low self esteem, overeat, sleep too much, have low energy, and am fairly hopeless. When I fall into a major depressive episode, I obsess about suicide, am severely sad, feel worthless, hopeless and helpless, lose interest in _everything_, am easily agitated, and can't concentrate for anything in the world. I've been dysthymic approximately since the age of 9 (15 years) but I didn't get help until college when I was severely depressed. I've had the marked changes into major depressive episodes since college (about 7 years).> How did you feel about being in the hospital? For a lot of people, it's a frustrating and demoralising experience, I think.
I felt like I got a lot of help in the hospital. I was literally at the end of my rope, and I checked myself in. My therapist has mentioned hospitalization off and on over the years, but I used to tell him that I'd run away if he tried to commit me (because I was afraid it would be an unhelpful, frightening experience). My therapist and I had contracted that I would check myself in if I knew I needed it, and I honored that contract. I don't think I would have accepted any of the help there if I hadn't initiated the whole process myself, knowing how badly I really needed it.> Ahh, don't you just love it when pharmacists try to second-guess your doctor without knowing anything about your history?
Yeah, the pharmacist pulled out the information sheet for Effexor to show me the potential side effects. I tried telling him that I was aware of _everything_ on that sheet, but he insisted on trying to track down my hospital pdoc to make sure the pdoc knew the "risk" I was at by taking such a high dose. I got a little bit of humor out of it when the pharmacist asked me why I had been in the hospital. Instead of telling him it was none of his business, I told him the truth, something along the lines of "I wanted to kill myself, I had a plan, I had the means, and I was about to do it but I checked myself in instead." The poor guy swallowed hard and squeaked out "Oh, I thought it might have been for panic attacks or something." Which is a really ignorant thing to say anyway.
> Not Effexor (I got the serotonin syndrome after decreasing it from 225 to 187.5!), but I'm on a dose of desipramine right now that is probably resulting in higher-than-normal serum concentrations (due to slower-than-normal metabolism). I was taking 300 mg/day (this is the recommended maximum dose for *inpatients* -- for outpatients it's 200), but my serum level turned out to be very high so I cut back to 150. That didn't seem to be working nearly as well, though, so now I'm on 225 as a compromise. I haven't had a serum level test since I've been on the decreased amount, so I don't know how it is, but it's probably still well outside the accepted range (which is something like 100-300 ng/mL, IIRC -- my level was well over 600 when I was on 300 mg/day). So it might be that I just need a higher concentration of desipramine than the "normal" therapeutic range. My pdoc doesn't seem too worried since I'm not getting bad side effects. He does want me to get an ECG to make sure I'm not having cardiac toxicity, but that's going to be difficult, since I'm, uh, in between health insurance plans!
It sucks that you're currently without insurance. I got lucky because I'm still covered by my dad's plan for another month and my own insurance started just before I went in. My pdoc is making sure I get my lithium level done on a regular basis, so I'm not too concerned about that, but I hadn't considered that serotonin syndrome could become a factor. In the hospital they did EKG's on everyone to make sure we had adequate cardiac health for all our meds.> No, if it was working at the higher dose, you should see if your blood pressure is elevated. (You might want to get a BP monitor for yourself; the digital ones are around $75-100, but the manual-inflating ones are more like $20-30, and it's pretty easy to learn to use one.) If so, consider antihypertensive therapy to compensate. (The antihypertensives that are considered least likely to exacerbate depression are the ACE inhibitors, I believe.)
I have a digital BP monitor, but I'm waiting for a larger arm cuff to come in the mail. Now it won't work with the smaller cuff on my arm.>Finding an AD that works when you've failed to respond to other ADs is a precious gift; as Zo says, it's best not to mess with something that's helping, and to attempt to deal with the side effects if possible before giving up and moving on to something else. This is especially true if you have been unresponsive to many treatments already.
>I completely agree with you. I thought Effexor was a godsend when I was first on it, and now I feel as though my pdoc and I are trying to stretch it as far as we can before trying something else. Before hospitalization I was taking Wellbutrin along with the Effexor, Lithium, and Neurontin, but the hospital pdoc d/c'd the Wellbutrin, saying that increasing the Lithium would do a better job of augmenting things. I just have to hold out hope that I will get better eventually. Until that happens, I have therapy to help me get through it.
Thanks again for your response,
Sarah
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