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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 7 of 7. This is the beginning of the thread.
Posted by margaret on September 18, 2001, at 19:41:41
I like many of you have gone on and off and on my AD. I originally started on paxil for post partum dep. It worked wonderfully. I went off it and had a relapse. I have struggled since weaning myself off only having to go back on it. This time around I have had to move up the dose in order to get back to the same place I was when I went off it about a month ago. Although I am feeling somewhat better it is not as effective as before. My question to all is " will it eventually kick back in to the same level, or will I need to change? I would like to try something with less side effects but I would be happy for now getting back to where i was. Some words of encouragement would be great. I would like to take a moment to say thank you all who contribute to this board and know that I am very appreciative of all who contribute. I have had many of my questions answered here. I am most greatful.
Posted by Cam W. on September 18, 2001, at 21:50:12
In reply to The AD merry-go-round, posted by margaret on September 18, 2001, at 19:41:41
Margaret - I have not seen much on a theory that I am going to talk about now, but I have wondered about this theory for a few years now, and would like anyone to comment on it; perhaps by weakening my argument, or even by strenghthening it.
Many, perhaps most, people who stop a particular antidepressant (any antidepressant) and then restart it after a relapse occurs, end up having the same efficacy from the same dose.
There are however a significant subgroup of people who seem to have recurrent depression, that seems to worsen upon each subsequent episode. These people need to take higher and higher doses of the same antidepressant, as was used in the previous depressive episode.
I would hazard a guess that this occurs with the SSRI class of antidepressantsmore often than with other AD classes (it could be that SSRIs only seem more prevalent in these cases, because they are the ADs that are most prescribed and are used the most.
The mechanism that may be occurring in this subgroup of people with depression could be described as being analogous to the "kindling effect" seen in bipolar disorder. The kindling effect theory in bipolar disorder states that with every episode of mania &/or depression, the next episode comes sooner, lasts longer, and is more severe. This can and did continue until the person had to be institutionalized, for their own safety. Lifelong medication is needed in these cases, to ultimately interfere with and decrease the number of lifelong episodes. Breakthrough episodes do occur, even in those who seem to be in perfect control of their treatment modalities (eg. taking combinations medication, cognitive-behavioral therapy, social skills training, and money management courses).
Could something similar be happening in this subgroup of people with depression? Could a "kindling effect" be occuring in this type of depression. I guess, if we assume that this "is" happening, then the treatment would be contiuous maintenance antidepressant therapy (maybe avoiding the SSRIs), with group, interpersonal therapies; as well as other therapy aimed at recognizing the prodromal symptoms of relapse.
Just some thoughts. Whaddaya think?
Margaret, maybe the reason that you have to take higher doses, may be becase of kindling. Perhaps a switch to Effexor™ (venlafaxine) may be a good choice; ask your doc about this. In fact, print this off for him/her, and take it in to your next appointment.
Remember, at work here is only the rambling mind of Cam.
Posted by Jane D on September 18, 2001, at 23:18:47
In reply to A Theory. - Comments? » margaret, posted by Cam W. on September 18, 2001, at 21:50:12
Cam - That wasn't rambling. THIS is rambling! Actually, this may be more like a drunken stagger. Something that will make me feel foolish in the morning! :-)
I think that your reasoning makes a great deal of sense. I'm curious about a few things. Outside of bipolar is there any evidence that lack of treatment makes future episodes worse? Or is this one of those logical leaps that was accepted by clinicians as a "maybe" because it made sense that then became gospel without ever being tested? Of course I have no clue what is really bipolar anymore.
Do future episodes get worse? Or are those the only ones that we hear about? Or do they just become more intolerable to the victims because of the cumulative affects of underemployment, disrupted social life etc.
AD's may not work upon restarting. But they also "poop out" for people who continue to use them. Maybe it doesn't matter whether you stop or not - for a certain number of poeple they will stop working. Perhaps base conditions - thyroid, hormone levels, diet and who knows what else - might interact to determine which AD works at a given time.
Your post deserves far more time and more (and clearer) thought then I've given it here. Tomorrow maybe. I guess I'm just trying to bait you into saying more in the meantime. - Jane
Posted by pellmell on September 19, 2001, at 11:45:07
In reply to A Theory. - Comments? » margaret, posted by Cam W. on September 18, 2001, at 21:50:12
> Could something similar be happening in this subgroup of people with depression? Could a "kindling effect" be occuring in this type of depression. I guess, if we assume that this "is" happening, then the treatment would be contiuous maintenance antidepressant therapy (maybe avoiding the SSRIs), with group, interpersonal therapies; as well as other therapy aimed at recognizing the prodromal symptoms of relapse.
>I think I remember Stephen M. Stahl hypothesizing about this very thing in _Essential Psychopharmacology_. He even went as far as to say that antidepressants might prevent and repair the physical changes to the brain that depression causes, partly by stimulating regrowth of the axons that get pruned during an extended depressive episode.
I think another factor is something that is one of the primary themes of Dr. Peter Kramer's _Listening to Prozac_. On antidepressants many of us feel "better than well," better than we've ever felt, and start to think (probably often rightly) that we've been depressed all our lives. Our self-expectations are changed both qualitatively and quantitatively by these drugs, and life without them (the very same life we lived until we filled our first prescription for Zoloft) just doesn't feel right anymore.
Of course, it seems quite often life doesn't feel right *on* them either...
So, who's next? :)
-pm
Posted by pellmell on September 19, 2001, at 12:58:17
In reply to Re: A Theory. - Comments? » Cam W., posted by pellmell on September 19, 2001, at 11:45:07
Cam,
Sorry. I should brush up on my reading comprehension skills. I just reread your post and realized that you're speaking of a *subgroup* of depressives, not all of us.
So yeah, what I said in my last post is probably irrelevant when talking about the people you defined.
I'll finish my thought anyway, though:
> Of course, it seems quite often life doesn't >feel right *on* them either...
...which leads to a see-sawing sort of nostalgia, where you feel awful and miss your medicated self when you're off the drugs, but want your "deeper"-feeling, more emotionally reactive self back when you're on them. Or some variation on this theme.Which of course, along with life circumstance, major depressive episodes, etc., leads you to cycle on and off drugs.
This is probably more applicable to those of us closer to the dysthymic end of the spectrum.
Thus concludes a true ramble.
Posted by margaret on September 19, 2001, at 19:57:11
In reply to The AD merry-go-round, posted by margaret on September 18, 2001, at 19:41:41
> Hey Cam, any info coming from you is greatly recieved. I wonder if I have not done myself a great injustice by on and off the darn things. I definitely seem to respond to the ssri's, but as I indicated, just not as fast lately as I would like. I probably feel better now than before the post partum when I suffered with bouts of anxiety and depression, but just as pellmell said, I believe I have come to enjoy the freedom from mental anguish. I definitely could live with the way I feel right now, which I know makes me luckier than those who do not respond. I think the theory you put forth has some validity. I do think I will switch over to the effexor after a few more months on the paxil though and see if it does work a little more efficiently. To think most of my fooling around with meds has come from my hatetred of being heavier now. I need to remind myself that feeling mentally fit feels better to me than being thin. Thanks so much for your thoughts. I hope things are good for you. Are you on effexor? Have you experienced any major side effects? Take care, and thanks to those who answered.
Posted by galtin on September 19, 2001, at 22:27:02
In reply to A Theory. - Comments? » margaret, posted by Cam W. on September 18, 2001, at 21:50:12
> Margaret - I have not seen much on a theory that I am going to talk about now, but I have wondered about this theory for a few years now, and would like anyone to comment on it; perhaps by weakening my argument, or even by strenghthening it.
>
> Many, perhaps most, people who stop a particular antidepressant (any antidepressant) and then restart it after a relapse occurs, end up having the same efficacy from the same dose.
>
> There are however a significant subgroup of people who seem to have recurrent depression, that seems to worsen upon each subsequent episode. These people need to take higher and higher doses of the same antidepressant, as was used in the previous depressive episode.
>
> I would hazard a guess that this occurs with the SSRI class of antidepressantsmore often than with other AD classes (it could be that SSRIs only seem more prevalent in these cases, because they are the ADs that are most prescribed and are used the most.
>
> The mechanism that may be occurring in this subgroup of people with depression could be described as being analogous to the "kindling effect" seen in bipolar disorder. The kindling effect theory in bipolar disorder states that with every episode of mania &/or depression, the next episode comes sooner, lasts longer, and is more severe. This can and did continue until the person had to be institutionalized, for their own safety. Lifelong medication is needed in these cases, to ultimately interfere with and decrease the number of lifelong episodes. Breakthrough episodes do occur, even in those who seem to be in perfect control of their treatment modalities (eg. taking combinations medication, cognitive-behavioral therapy, social skills training, and money management courses).
>
> Could something similar be happening in this subgroup of people with depression? Could a "kindling effect" be occuring in this type of depression. I guess, if we assume that this "is" happening, then the treatment would be contiuous maintenance antidepressant therapy (maybe avoiding the SSRIs), with group, interpersonal therapies; as well as other therapy aimed at recognizing the prodromal symptoms of relapse.
>
> Just some thoughts. Whaddaya think?
>
> Margaret, maybe the reason that you have to take higher doses, may be becase of kindling. Perhaps a switch to Effexor™ (venlafaxine) may be a good choice; ask your doc about this. In fact, print this off for him/her, and take it in to your next appointment.
>
> Remember, at work here is only the rambling mind of Cam.
Hi Cam,The "kindling" theory fits my experience. I experienced my first three depressive episodes in my late 20s. All three were undiagnosed and they remitted on their own after six to ten months. The fourth episode did not self-remit and was eventually properly diagnosed. Over the last 20 years I have tried about a dozen A-Ds and found two--Parnate and Effexor--that work well. The others were useless.
I eventually switched from Parnate after my dosage reached 60 mgs a day. While taking Effexor I have tried to come off medication twice. I have succeeded each time, but in each case I relapsed after three or so months medication free. In addition, I had one relapse while on the meds. After each of these relapses I needed an increase of 75mgs. to recover. Thankfully, once the right dosage was reached, I got better fast--within three or four days.
My doctor believes that I will likely be on A-D meds the rest of my life. At this point, I do not need much convincing. My self-take is that genetics, plus heavy drinking in my younger years, plus several untreated episodes have worn a depressive groove in my brain into which I will always tend to slide in the absence of ongoing pharmacologic treatment. After each such slide, the groove will wear a bit wider and a bit deeper. Since my last episode 30 months inaugerated my first exposure to the local inpatient mental health unit, I have no inclination to challenge my doctor when he asks, grimly, "Why fool around with this stuff?" By which he means both depression and medication.
I am not sure, Cam, but this sounds like kindling in action.
galtin
This is the end of the thread.
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