![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 19 of 19. This is the beginning of the thread.
Posted by jay on November 15, 2001, at 0:59:18
There is much talk about how the tricyclics somehow aren't good for "atypical" depression. I think, though, that most folks have a number of symptoms that do somewhat indicate atypical depression, but also have many endogenous symptoms. (Irritability, anxiety, bouts of insomnia..etc.) I also think the reverse of the first statement is true...and that meds for atypical depression can are little to no-good for endogenous depression symptoms, and maybe can make them worse, especially in the long run.From my little bit of experience (n=1..heh,) it seems the highly activating quality of the newer SRI/SNRI's seem to really complicate endogenous depressive symptoms. I think that is why many only attain partial relief from the newer a.d's. I've noticed that the tricyclics, in particular nortriptyline, help my depression and anxiety in a fairly different way than the newer meds.
Again, this is why I believe folks should consider (especially if you have had many problems with the newer a.d.'s..or they haven't helped.) a tricyclic. Two of the more popular ones seem to be desipramine and nortriptyline. As far as side-effects go...some are different than the newer meds, but I don't think much worse in the long-term. Weight-gain is not much different, from what long-term experience seems to show.
There are a vast number ot tricyclics to try...so I would suggest taking a shot.
Jay
Posted by JohnX2 on November 18, 2001, at 16:19:54
In reply to Atypical a.d's make Endogenous depression worse?, posted by jay on November 15, 2001, at 0:59:18
I was thinking about trying nortriptyline.What would I expect from the side effects of
these older tricyclics vs the new meds?I tend to do better on stimulating meds.
They usually don't make me anxious or jittery
and are more likely to lift my depression.
The sedating meds like Paxil are disasterous.
While Zoloft and Wellbutrin were great.Anyways, I haven't found a "majic bullet" that
sticks. I always get an elesuve anti-depressant
response and was wondering what some of these
older NRIs do in the brain that is different
from meds like Wellbutrin or Effexor or Reboxetine?One of those older meds is supposed to be
good for tension headaches, I don't remember
which, but it was a noradrenergic med and I
get tension headaches from meds.thanks for any info,
john>
> There is much talk about how the tricyclics somehow aren't good for "atypical" depression. I think, though, that most folks have a number of symptoms that do somewhat indicate atypical depression, but also have many endogenous symptoms. (Irritability, anxiety, bouts of insomnia..etc.) I also think the reverse of the first statement is true...and that meds for atypical depression can are little to no-good for endogenous depression symptoms, and maybe can make them worse, especially in the long run.
>
> From my little bit of experience (n=1..heh,) it seems the highly activating quality of the newer SRI/SNRI's seem to really complicate endogenous depressive symptoms. I think that is why many only attain partial relief from the newer a.d's. I've noticed that the tricyclics, in particular nortriptyline, help my depression and anxiety in a fairly different way than the newer meds.
>
> Again, this is why I believe folks should consider (especially if you have had many problems with the newer a.d.'s..or they haven't helped.) a tricyclic. Two of the more popular ones seem to be desipramine and nortriptyline. As far as side-effects go...some are different than the newer meds, but I don't think much worse in the long-term. Weight-gain is not much different, from what long-term experience seems to show.
>
> There are a vast number ot tricyclics to try...so I would suggest taking a shot.
>
> Jay
Posted by Elizabeth on November 19, 2001, at 17:36:44
In reply to Atypical a.d's make Endogenous depression worse?, posted by jay on November 15, 2001, at 0:59:18
> There is much talk about how the tricyclics somehow aren't good for "atypical" depression.
That's fairly well-established, yes.
> I think, though, that most folks have a number of symptoms that do somewhat indicate atypical depression, but also have many endogenous symptoms. (Irritability, anxiety, bouts of insomnia..etc.)
Irritability, anxiety, and some types of insomnia are common in many different presentations of depression, including "atypical depression," "melancholic depression" (the word "endogenous" isn't used much this way anymore because it can be very misleading), and depressions that fall into neither category.
Anxiety disorders are sometimes said to be more common in atypical depression, and some (notably, social phobia) may be connected specifically to atypical depression (the common feature in social anxiety and atypical depression being excessive interpersonal sensitivity), but anxiety in general occurs in a variety of types of depression.
The insomnia that is associated specifically with melancholic depression is called "terminal insomnia" or early-morning awakenings. Trouble getting to sleep at night is not a specific symptom of melancholic depression and is often a problem for people with atypical depression.
IMO, the most important distinctive feature of melancholic depression is the total absence of mood-reactivity.
> I also think the reverse of the first statement is true...and that meds for atypical depression can are little to no-good for endogenous depression symptoms, and maybe can make them worse, especially in the long run.
There doesn't seem to be any reason to suppose this. I have fairly clear-cut melancholic depression, and I was helped somewhat by several different MAOIs. Desipramine is about as effective as Parnate was; in fact, the main distinction that I notice is that while I never dreamed on Parnate, I have frequent intense dreams on desipramine.
Although MAOIs haven't been studied as much as they should be for melancholic depression, the existing research has generally been positive, as long as sufficient doses (e.g., 60 mg/day of phenelzine) were used. (Older studies tended to use lower doses; melancholic depression is almost invariably quite severe and unrelenting, so while 45 mg might be sufficient for atypical depression or dysthymia, it probably won't be adequate for melancholic depression.)
> From my little bit of experience (n=1..heh,) it seems the highly activating quality of the newer SRI/SNRI's seem to really complicate endogenous depressive symptoms.
The current thinking is that SSRIs are not very effective for melancholic depression. But there's no evidence that they're more effective than TCAs for atypical depression, either.
Effexor has been shown to be effective for melancholic depression.
> I think that is why many only attain partial relief from the newer a.d's. I've noticed that the tricyclics, in particular nortriptyline, help my depression and anxiety in a fairly different way than the newer meds.
I think you're getting too bogged down in classifications. Also, a disorder is much more than any one particular symptom of it. MAOIs can make some atypical depression symptoms (especially overeating) worse, but they are effective for the underlying conditions. All drugs have side effects; the side effects are not what treats the depression.
> Again, this is why I believe folks should consider (especially if you have had many problems with the newer a.d.'s..or they haven't helped.) a tricyclic.
True melancholic depression is actually pretty rare.
-elizabeth
Posted by sjb on November 20, 2001, at 14:19:34
In reply to depression subtypes and med responses » jay, posted by Elizabeth on November 19, 2001, at 17:36:44
> I think you're getting too bogged down in classifications. Also, a disorder is much more than any one particular symptom of it. MAOIs can make some atypical depression symptoms (especially overeating) worse, but they are effective for the underlying conditions. All drugs have side effects; the side effects are not what treats the depression.
Elizabeth,
I sure appreciate all of your responses and will be them to my PDoc tomorrow. The biggest problem, for me, is the overeating. I have all the other classic symptons of atypical, but wonder sometimes what comes first, the chicken or the egg? Do I get depressed, withdraw socially, cry too much, become overly sensitive because I just overate or do I overeat because of the depression? Anyway, Parnate did not help my underlying depression other than, perhaps, the crying spells. I wasn't on it for very long though. My husband is very concerned about me trying it again as his recollection was that it was horrible. I have to respect this, as my memory is not what it once was, and I've been on so many things I can't always recall how things really were.
I seemed to crave even more sweets on Parnate, so I became more depressed on it and therefore, less tolerant of the side effects. I will take the insomnia, sexual side effects, etc if I could get some help with compulsive overeating on sweets/carbs. Do you know of other MAOI's that don't tend to have this side effect? From most of the posts I've read, Nardil seems to be worse for most folks than Parnate, as far as food cravings, weight gain is concerned.
I also may need to accept that something other than a pill can help my compulsion. I've tried OA, cognitive therapy, group therapy, etc but that hasn't helped as yet. Maybe I didn't stick with it long enough.
Thanks.
Posted by Mitch on November 20, 2001, at 23:29:22
In reply to Re: depression subtypes and med responses, posted by sjb on November 20, 2001, at 14:19:34
> > I think you're getting too bogged down in classifications. Also, a disorder is much more than any one particular symptom of it. MAOIs can make some atypical depression symptoms (especially overeating) worse, but they are effective for the underlying conditions. All drugs have side effects; the side effects are not what treats the depression.
>
> Elizabeth,
>
> I sure appreciate all of your responses and will be them to my PDoc tomorrow. The biggest problem, for me, is the overeating. I have all the other classic symptons of atypical, but wonder sometimes what comes first, the chicken or the egg? Do I get depressed, withdraw socially, cry too much, become overly sensitive because I just overate or do I overeat because of the depression? Anyway, Parnate did not help my underlying depression other than, perhaps, the crying spells. I wasn't on it for very long though. My husband is very concerned about me trying it again as his recollection was that it was horrible. I have to respect this, as my memory is not what it once was, and I've been on so many things I can't always recall how things really were.
>
> I seemed to crave even more sweets on Parnate, so I became more depressed on it and therefore, less tolerant of the side effects. I will take the insomnia, sexual side effects, etc if I could get some help with compulsive overeating on sweets/carbs. Do you know of other MAOI's that don't tend to have this side effect? From most of the posts I've read, Nardil seems to be worse for most folks than Parnate, as far as food cravings, weight gain is concerned.
>
> I also may need to accept that something other than a pill can help my compulsion. I've tried OA, cognitive therapy, group therapy, etc but that hasn't helped as yet. Maybe I didn't stick with it long enough.
>
> Thanks.sjb,
I just happened to read this thread and maybe could offer you some advice. If MAOI's aren't the ticket, you might try a combination of Prozac (or) Celexa and Wellbutrin. Prozac and Celexa were the two SSRI's (of ALL of them I have tried) that clearly reduced appetite. Also SSri's are known to help food obsessions generally. The Wellbutrin I just started recently curbs appetite even more than they do. I have lost a couple of pounds in just the few days I have started it. I even *forgot* to eat lunch a few times. It was like I had to remind myself to eat lunch-dinner, etc.
Hope this helps,Mitch
Posted by sjb on November 21, 2001, at 7:24:41
In reply to Re: depression subtypes and med responses » sjb, posted by Mitch on November 20, 2001, at 23:29:22
Mitch,
Thanks for the input. I've tried Prozac and Wellbutrin and was on Prozac off and on (mostly on) for many years. Your experience is very common for a lot of people, unfortunately not for me. I did have decreased appetite initially on Prozac and Wellbutrin (and even had a spell of taking them together) but it wore off and my old disgusting habits came back. I've never tried Celexa, however, and may ask about that at next appt. Thanks, again.
Posted by jazzdog on November 21, 2001, at 9:57:21
In reply to Re: depression subtypes and med responses, posted by sjb on November 20, 2001, at 14:19:34
Perhaps you should be tested for postprandial hyperinsulinism, also known as insulin resistance. It causes carbohydrate craving, and signals the body to store everything as fat. Treatment with metformin, aka glucophage, alleviates this, and causes a dramatic reduction in cravings.
- Jane
Posted by Elizabeth on November 21, 2001, at 19:59:38
In reply to Re: depression subtypes and med responses, posted by sjb on November 20, 2001, at 14:19:34
> The biggest problem, for me, is the overeating. I have all the other classic symptons of atypical, but wonder sometimes what comes first, the chicken or the egg?
It's important to be clear that classifications such as "atypical depression" are strictly descriptive. There's no assumption about whether the depression causes the oversleeping and overeating or vice versa, for example; it's just been noted that depression with these features responds better to certain medications than to others (statistically, of course).
> Anyway, Parnate did not help my underlying depression other than, perhaps, the crying spells. I wasn't on it for very long though.
How long?
> Do you know of other MAOI's that don't tend to have this side effect? From most of the posts I've read, Nardil seems to be worse for most folks than Parnate, as far as food cravings, weight gain is concerned.
Usually, but the reverse can be true for some people. Selegiline is probably the MAOI that's least likely to cause weight gain, FWIW. Another thing that might work would be to add a stimulant (Dexedrine, Ritalin, Cylert, phentermine, etc.) to the MAOI. If you do try this, you will need to monitor your blood pressure; some people can't tolerate stimulants with MAOIs, but many can, and it's often a very effective augmentation strategy.
-elizabeth
Posted by sjb on November 26, 2001, at 10:31:33
In reply to Re: depression subtypes and med responses » sjb, posted by Elizabeth on November 21, 2001, at 19:59:38
Thanks. I was on the Parnate, I believe, for close to a month. It was long enough that PDoc said to forget it, it wouldn't work for me.
Tried Serzone - lasted one day. Couldn't go anywhere at all for T-Day, not that I wanted to anyway. Slept way too much, headachy. Now I have to narrow search to non-sedating ADs. I know everyone is different, but after I asked for Serzone, I found most on board had similar experience with this drug, as far as the drowsiness is concerned. Duh, like didn't do my homework too well. I'm now investigating the following:
Celexa
Zofran
Luvox
Metformin (for insulin resistance - have to get tested first)
AdderrallLet me know your comments, recommendations, warnings, etc on the above. Thanks
Posted by jazzdog on November 26, 2001, at 10:41:39
In reply to Re: depression subtypes and med responses, posted by sjb on November 26, 2001, at 10:31:33
If you're tested for insulin resistance, make sure it's about an hour after you've eaten something with carbs. A fasting test won't reveal it. Also, with metformin, be prepared for a week or so of diarrhea and gastric upset. The side effects are very shortlived - they disappeared completely for me after ten days.
- Jane
Posted by svevo1922 on November 26, 2001, at 15:46:16
In reply to Re: depression subtypes and med responses, posted by sjb on November 26, 2001, at 10:31:33
It's not your job do your homework, it's your doctor's (although a lot of people do reading on the side). Perhaps you should make sure in the future that he or she discusses all the possible side effects that would concern you, for example, somnolence, although, as you note, one's mileage may vary. This is a field rife with trial and error.
The only cynical calculation I make when reading the side effects lists is to assume that the percentages for weight gain and sexual dysfunction are far too low. It's a cynicism born of reading those reports.
I took Celexa a while ago; it didn't help, but I don't recall any terrible side effects. Some people have had success with it.
> Thanks. I was on the Parnate, I believe, for close to a month. It was long enough that PDoc said to forget it, it wouldn't work for me.
>
> Tried Serzone - lasted one day. Couldn't go anywhere at all for T-Day, not that I wanted to anyway. Slept way too much, headachy. Now I have to narrow search to non-sedating ADs. I know everyone is different, but after I asked for Serzone, I found most on board had similar experience with this drug, as far as the drowsiness is concerned. Duh, like didn't do my homework too well. I'm now investigating the following:
>
> Celexa
> Zofran
> Luvox
> Metformin (for insulin resistance - have to get tested first)
> Adderrall
>
> Let me know your comments, recommendations, warnings, etc on the above. Thanks
Posted by jay on November 26, 2001, at 15:58:34
In reply to Re: Atypical a.d's make Endogenous depression worse? » jay, posted by JohnX2 on November 18, 2001, at 16:19:54
John:
Sorry so late getting back. After many years, nortriptyline (name brand, atually), in smaller doses...25-50mg's, plus benzo...got me employed...got me my first serious relationship (no, I wan't manic...just felt so much better about myself..)...got me socializing...I lost weight on it....got a new and good job.
I sadly jumped on the Effexor XR bandwagon...not that there is anything wrong with it...but I just tried it because it was so 'new'. I just realized a month or so ago that after several years, the Effexor was justmaking me fat, and the problems outweighed the good.
So, I am back to nortriptyline, slowly losing the pounds...I go shopping for nice clothes now...enjoy thinks a bit better...feel *good* about myself...have sexual energy back...and the bit of benzo just takes a tad off the regular anxiety tomake it all that much more better.
BTW...Nortiptyline and Protriptyline are the only tricyclics to have a proven "thermogenic" effect on many...not all. (I have the medline reference if you want.) Yes, weight IS a big deal, I don't care what they say, because in the long run, being obese is very unhealthy and damaging to depression further. Doctors take it WAY too lightly.
Anyhow...give it a shot..honestly....you might really be surprised. Start and go slow...it is a powerful med, and the benzo's do great for the anxiety!
I will catch up on the rest of the posts now...:-)
Best wishes...
Jay>
> I was thinking about trying nortriptyline.
>
> What would I expect from the side effects of
> these older tricyclics vs the new meds?
>
> I tend to do better on stimulating meds.
> They usually don't make me anxious or jittery
> and are more likely to lift my depression.
> The sedating meds like Paxil are disasterous.
> While Zoloft and Wellbutrin were great.
>
> Anyways, I haven't found a "majic bullet" that
> sticks. I always get an elesuve anti-depressant
> response and was wondering what some of these
> older NRIs do in the brain that is different
> from meds like Wellbutrin or Effexor or Reboxetine?
>
> One of those older meds is supposed to be
> good for tension headaches, I don't remember
> which, but it was a noradrenergic med and I
> get tension headaches from meds.
>
> thanks for any info,
> john
>
> >
> > There is much talk about how the tricyclics somehow aren't good for "atypical" depression. I think, though, that most folks have a number of symptoms that do somewhat indicate atypical depression, but also have many endogenous symptoms. (Irritability, anxiety, bouts of insomnia..etc.) I also think the reverse of the first statement is true...and that meds for atypical depression can are little to no-good for endogenous depression symptoms, and maybe can make them worse, especially in the long run.
> >
> > From my little bit of experience (n=1..heh,) it seems the highly activating quality of the newer SRI/SNRI's seem to really complicate endogenous depressive symptoms. I think that is why many only attain partial relief from the newer a.d's. I've noticed that the tricyclics, in particular nortriptyline, help my depression and anxiety in a fairly different way than the newer meds.
> >
> > Again, this is why I believe folks should consider (especially if you have had many problems with the newer a.d.'s..or they haven't helped.) a tricyclic. Two of the more popular ones seem to be desipramine and nortriptyline. As far as side-effects go...some are different than the newer meds, but I don't think much worse in the long-term. Weight-gain is not much different, from what long-term experience seems to show.
> >
> > There are a vast number ot tricyclics to try...so I would suggest taking a shot.
> >
> > Jay
Posted by jay on November 26, 2001, at 16:40:46
In reply to depression subtypes and med responses » jay, posted by Elizabeth on November 19, 2001, at 17:36:44
> > There is much talk about how the tricyclics somehow aren't good for "atypical" depression.
>
> That's fairly well-established, yes.
>
> > I think, though, that most folks have a number of symptoms that do somewhat indicate atypical depression, but also have many endogenous symptoms. (Irritability, anxiety, bouts of insomnia..etc.)
>
> Irritability, anxiety, and some types of insomnia are common in many different presentations of depression, including "atypical depression," "melancholic depression" (the word "endogenous" isn't used much this way anymore because it can be very misleading), and depressions that fall into neither category.Actually, I prefer to look at treating symptoms rather than a general Dx. SRI/SNRI's are well documented in causing sleep distrubance, it seems more so than with tricyclics. The sense of 'apathy' brought on by some who use SRI/SNRI's (Effexor) doesn't seem to do much for even 'atypical' depression! Like I said, treating symptoms seems much more useful.
> Anxiety disorders are sometimes said to be more common in atypical depression, and some (notably, social phobia) may be connected specifically to atypical depression (the common feature in social anxiety and atypical depression being excessive interpersonal sensitivity), but anxiety in general occurs in a variety of types of depression.I don't know about that, because in 'melancholic' depression, frequent restless sleep can exacerbate anxiety further. 'Atypical' seems to indicate a *lack* of most feeling/things, and I think latching interpersonal sensitivity doesn't make a lot of sense. Again...that's why I say look at and treat symptoms first.
> The insomnia that is associated specifically with melancholic depression is called "terminal insomnia" or early-morning awakenings. Trouble getting to sleep at night is not a specific symptom of melancholic depression and is often a problem for people with atypical depression.
Early-morning awakenings is one symptom, but frequent wakenings is also another of melancholic depression. My Dad is a classic text-book example, responded to Doxepin, and sleeps right through later without awakenings.
> IMO, the most important distinctive feature of melancholic depression is the total absence of mood-reactivity.
Absence? I have seen many with melacholic depression who have horrific crying spells, massive amounts of anxiety, panic, and experience moods just as *intense* as any depressive I have seen. This was experience in hospitals and the community with many clients. Again, that is why I have a problem with focusing on just Dx's, and say go for the symptom relief.
> > I also think the reverse of the first statement is true...and that meds for atypical depression can are little to no-good for endogenous depression symptoms, and maybe can make them worse, especially in the long run.
>
> There doesn't seem to be any reason to suppose this. I have fairly clear-cut melancholic depression, and I was helped somewhat by several different MAOIs. Desipramine is about as effective as Parnate was; in fact, the main distinction that I notice is that while I never dreamed on Parnate, I have frequent intense dreams on desipramine.Again, after I have thought about this, it is an example of why we should not only focus on symptoms, but avoid the "this drug is only good for this Dx", etc.
> Although MAOIs haven't been studied as much as they should be for melancholic depression, the existing research has generally been positive, as long as sufficient doses (e.g., 60 mg/day of phenelzine) were used. (Older studies tended to use lower doses; melancholic depression is almost invariably quite severe and unrelenting, so while 45 mg might be sufficient for atypical depression or dysthymia, it probably won't be adequate for melancholic depression.)
Again, if the studies are broken down into WHAT symptoms are improved, and total quality of life,
I think we could gain more than just saying use this med for this type of depression only.
> > From my little bit of experience (n=1..heh,) it seems the highly activating quality of the newer SRI/SNRI's seem to really complicate endogenous depressive symptoms.
>
> The current thinking is that SSRIs are not very effective for melancholic depression. But there's no evidence that they're more effective than TCAs for atypical depression, either.I agree with your last statement in particular, and wonder why a doctor wouldn't give say a med like nortiptyline or desiprmaine to a person experiencing more lethargic symtoms, and even older meds like Doxepin or Clomiprmaine for more extreme anxiety prone folks, and of course a benzo thrown in the mix for anxiety present in both situations. I can't *stand* the current massive benzophobia. Similar to the same things with opiates.
> Effexor has been shown to be effective for melancholic depression.I'd like to see this, in the long run (i.e. 5 years) of Effexor Vs. Nortriptyline. There are some reports of MASSIVE weight gain on some on Effexor, and even though this is true for some on Nortrip, it does have a track record for long-term lack of weight gain, and even loss.
Also, I am concerned about the constant need for dose increase with Effexor. This doesn't seem to be the case with Nortrip. I also found Nortrip FAR more activating without massive anxiety than Effexor. It also didn't seem to have some of the emotional 'numbing' effects of Effexor....good sometimes in the short run, but I don't think good in the long run.
> > I think that is why many only attain partial relief from the newer a.d's. I've noticed that the tricyclics, in particular nortriptyline, help my depression and anxiety in a fairly different way than the newer meds.
>
> I think you're getting too bogged down in classifications. Also, a disorder is much more than any one particular symptom of it. MAOIs can make some atypical depression symptoms (especially overeating) worse, but they are effective for the underlying conditions. All drugs have side effects; the side effects are not what treats the depression.No, I say serve the symptoms...you can serve the problems. That's what I found with Nortrip, and I honestly think doctors take side effects WAY too lightley. They are a massive reason for non-compliance. If i feel better physically and mentally sharp and calm, not having put on 50 pounds and not being able to party and enjoy myself, that sure as hell is no fugging way to go.:-)
> > Again, this is why I believe folks should consider (especially if you have had many problems with the newer a.d.'s..or they haven't helped.) a tricyclic.
>
> True melancholic depression is actually pretty rare.Melancholic symptoms aren't, though, and yes, they can be treated. I think we are looking too much at med, and often crappy ones, for *everything*. Like having the feet on the pedal and brake...zap the anxiety with what you can..usually a benzo....juice up against the depression...a slightly more stimulating a.d. that acts on numerous n.t.'s. Get the brake and pedal in sync...I think we feel much better.
All IMHO...:-)
Jay> -elizabeth
Posted by sjb on November 27, 2001, at 14:47:33
In reply to Re: depression subtypes and med responses, posted by svevo1922 on November 26, 2001, at 15:46:16
> It's not your job do your homework, it's your doctor's (although a lot of people do reading on the side).
Yeah, in an ideal world. It's been my experience that if I wait for them to get up-to-date on all the research and new stuff on my particular problem, I'll be even more disappointed and frustrated. I look up information on my problem(s) just like most folks.
Popular PDoc's have a lot of patients and treat many disorders. I do not think it is realistic for them to be up on the latest for each and every disorder and to spend a lot of time researching for each patient. I have, however, been disappointed when I think, as I often do, that they are not doing enough for the patient outside of the session.
The bottom line is that this is a business. I still can't get over how you go in there, share the most intimate things and then, ok, times up, you hand over a check and then you pass the next patient waiting to go in on the way out. I also am surprised that some folks on this board are scared to tell their PDocs if they are not getting better because they don't want to let them down. Hello. I don't think so. We whine and cry at the same time they mull over the options they want on their new Mercedez, Lexus, Beemer, whatever, and life goes on.
I believe most of them do want us to get better, if for no other reason than a patient who makes progress, gives them a sense of accomplishment and adds to their ego. However, most aren't loosing any sleep over any of these, even though a lot of us are.
Posted by Noa on November 27, 2001, at 15:08:31
In reply to Re: depression subtypes and med responses, posted by sjb on November 26, 2001, at 10:31:33
I take Metformin (Glucophage) for insulin resistance. It does work. My test was the oral glucose tolerance test, which takes a couple of hours--they keep drawing blood at intervals before and after I drank this awful syrup. I should be exercising more to really make the best use of the medicine, but have been quite the slug lately.... Be aware, though, that metformin has a life-threatening adverse effect and you need to have your kidney and liver functions tested and monitored to make sure you aren't at risk.
The only other med on your list that I am familiar with is Adderall. I find it helps me be focused and calmer but I don't see it having much AD effect on its own. It is a potentiator of my other ADs. I recently started wondering if I need it as much any more. I started on it when I was hypothyroid and having sleep apnea(should you rule these out, too?), and therefore exhausted all the time. I guess I could wean off of it and check it out--it is short acting so it wouldn't be so complicated to test out. I find adderall much more smooth than ritalin, even the ritalin sr. I haven't tried dexadrine or concerta, though. As far as adverse effects of adderall for me, I suspect that it contributes to my jaw tightening (don't know how much is effexor or serzone and how much is adderall) and possibly adding to the sleep problems (restless legs, etc.)--I think it is mostly from the effexor, but I suspect the adderall adds to it.
Posted by Mitch on November 27, 2001, at 23:18:07
In reply to Re: depression subtypes and med responses, posted by sjb on November 27, 2001, at 14:47:33
> > It's not your job do your homework, it's your doctor's (although a lot of people do reading on the side).
>
> Yeah, in an ideal world. It's been my experience that if I wait for them to get up-to-date on all the research and new stuff on my particular problem, I'll be even more disappointed and frustrated. I look up information on my problem(s) just like most folks.
>
> Popular PDoc's have a lot of patients and treat many disorders. I do not think it is realistic for them to be up on the latest for each and every disorder and to spend a lot of time researching for each patient. I have, however, been disappointed when I think, as I often do, that they are not doing enough for the patient outside of the session.
>
> The bottom line is that this is a business. I still can't get over how you go in there, share the most intimate things and then, ok, times up, you hand over a check and then you pass the next patient waiting to go in on the way out. I also am surprised that some folks on this board are scared to tell their PDocs if they are not getting better because they don't want to let them down. Hello. I don't think so. We whine and cry at the same time they mull over the options they want on their new Mercedez, Lexus, Beemer, whatever, and life goes on.
>
> I believe most of them do want us to get better, if for no other reason than a patient who makes progress, gives them a sense of accomplishment and adds to their ego. However, most aren't loosing any sleep over any of these, even though a lot of us are.
I agree with you about the *expectations* of the patient toward your doctor about this issue. Perhaps when "pdocs" start to commonly be specialists in specific disorders (schizophrenia, bipolar, personality disorders, panic, mixed/atypical dx, etc.) ..as neurologists specialize in epilepsy, parkinsons's, neuropathic pain, etc., will we start to see an up-to-date fully informed pdoc in front of us. AND, if that pdoc can see that we should be seeing a different pdoc instead-there will be no ego/transferance issues to get in the way of a referral. There is far too much "data smog" out there if you take all of the mental pathology in total and try to deal with everything for everybody. There are too many potential med combinations and limited time to play trial and error ad infinitum.Mitch
Posted by sjb on November 28, 2001, at 13:06:22
In reply to Re: depression subtypes and med responses, posted by Noa on November 27, 2001, at 15:08:31
> I take Metformin (Glucophage) for insulin resistance. It does work. My test was the oral glucose tolerance test, which takes a couple of hours--they keep drawing blood at intervals before and after I drank this awful syrup. I should be exercising more to really make the best use of the medicine, but have been quite the slug lately.... Be aware, though, that metformin has a life-threatening adverse effect and you need to have your kidney and liver functions tested and monitored to make sure you aren't at risk.
Noa,
Wow - thanks for this info - sjb
Posted by sjb on November 28, 2001, at 13:15:17
In reply to Re: depression subtypes and med responses » sjb, posted by Mitch on November 27, 2001, at 23:18:07
> I agree with you about the *expectations* of the patient toward your doctor about this issue. Perhaps when "pdocs" start to commonly be specialists in specific disorders (schizophrenia, bipolar, personality disorders, panic, mixed/atypical dx, etc.) ..as neurologists specialize in epilepsy, parkinsons's, neuropathic pain, etc., will we start to see an up-to-date fully informed pdoc in front of us. AND, if that pdoc can see that we should be seeing a different pdoc instead-there will be no ego/transferance issues to get in the way of a referral.
Amen. My favorite pdoc did exactly that, referred me to someone else. Geez, I miss him. Oh, well. My current doesn't have ego problems either and is referring w/others on recommended treatment places, etc. He's a good guy - I guess I just want a "simple" answer (and a quick one) in a drug.
Posted by Elizabeth on November 28, 2001, at 16:45:55
In reply to Re: depression subtypes and med responses » Elizabeth, posted by jay on November 26, 2001, at 16:40:46
> Actually, I prefer to look at treating symptoms rather than a general Dx.
That often works better. Occasionally the symptom cluster is relevant, though. :-)
> SRI/SNRI's are well documented in causing sleep distrubance, it seems more so than with tricyclics.
Yes. SSRIs and Effexor do very strange things to sleep; although, like the TCAs and MAOIs, they decrease the amount of time spent in REM sleep, they increase REM density in REM sleep. They also increase nighttime awakenings.
Desipramine seems to be making my sleep problems worse, though (FWIW). I may end up going back to Parnate. I talked to a sleep specialist in Boston about my problems; he seemed to think that a good combination would be TCA at night + amphetamine in the daytime. (I never got around to having a sleep study to see exactly what's going on with my sleep problems.)
> I don't know about that, because in 'melancholic' depression, frequent restless sleep can exacerbate anxiety further.
Sure; like I said, "anxiety" without any further qualifiers doesn't differentiate between types of depression.
> 'Atypical' seems to indicate a *lack* of most feeling/things, and I think latching interpersonal sensitivity doesn't make a lot of sense. Again...that's why I say look at and treat symptoms first.
"Rejection sensitivity," as a trait (not just when depressed), is one of the symptoms of atypical depression. The criteria for atypical depression have been extensively studied and well validated. Atypical depressives do often experience lethargy and anxiety. I wouldn't say that they lack feelings, though: by definition a person with atypical depression has reactive mood and does respond affectively to at least some stimuli.
> Early-morning awakenings is one symptom, but frequent wakenings is also another of melancholic depression.
I know; I have both.
> > IMO, the most important distinctive feature of melancholic depression is the total absence of mood-reactivity.
>
> Absence? I have seen many with melacholic depression who have horrific crying spells, massive amounts of anxiety, panic, and experience moods just as *intense* as any depressive I have seen.Well, the first thing I would wonder is what made them "melancholic" in your opinion. But anyway -- that's not mood *reactivity*. Mood reactivity, in this context, means that a person can feel better in response to certain pleasant experiences (such as eating a favorite food). Melancholic depressives are (by definition) not mood-reactive. That doesn't mean they don't have any emotions at all; it means that what they experience isn't liable to make them feel better. (I think that it's probably generally true that their negative feelings also seem to arise from within, rather than being reactions to anything in particular.)
> > There doesn't seem to be any reason to suppose this. I have fairly clear-cut melancholic depression, and I was helped somewhat by several different MAOIs. Desipramine is about as effective as Parnate was; in fact, the main distinction that I notice is that while I never dreamed on Parnate, I have frequent intense dreams on desipramine.
>
> Again, after I have thought about this, it is an example of why we should not only focus on symptoms, but avoid the "this drug is only good for this Dx", etc.Well, then can you rephrase your original thought or question in terms of symptoms rather than categories/subtypes?
> I agree with your last statement in particular, and wonder why a doctor wouldn't give say a med like nortiptyline or desiprmaine to a person experiencing more lethargic symtoms, and even older meds like Doxepin or Clomiprmaine for more extreme anxiety prone folks, and of course a benzo thrown in the mix for anxiety present in both situations.
I'm not sure that clomipramine is an "older" TCA; what it has in common with doxepin is that it's sedating. But anyway, giving a sedating drug isn't always the most effective way to treat anxiety (and just because a drug is stimulating, that doesn't mean that it will help with lethargy).
> > Effexor has been shown to be effective for melancholic depression.
>
> I'd like to see this, in the long run (i.e. 5 years) of Effexor Vs. Nortriptyline. There are some reports of MASSIVE weight gain on some on Effexor, and even though this is true for some on Nortrip, it does have a track record for long-term lack of weight gain, and even loss.I'm not sure what you're getting at here -- yes, weight gain can be a side effect of both of these ADs; how is that relevant?
> Also, I am concerned about the constant need for dose increase with Effexor. This doesn't seem to be the case with Nortrip.
Tolerance or "poop-out" occurs with all types of ADs. Aside from toxicity concerns, though, nortriptyline and amitriptyline seem to have a therapeutic window, becoming less effective (and not just more toxic) if you increase the dose too high.
> I also found Nortrip FAR more activating without massive anxiety than Effexor. It also didn't seem to have some of the emotional 'numbing' effects of Effexor....good sometimes in the short run, but I don't think good in the long run.
I'm not clear what condition you're trying to treat. I'm also a little confused since you seem to be going back and forth between focusing on what helps specific symptoms and focusing on what treats the entire syndrome.
> If i feel better physically and mentally sharp and calm, not having put on 50 pounds and not being able to party and enjoy myself, that sure as hell is no fugging way to go.:-)
So you're saying that gaining weight makes you feel depressed? I gained 50 lbs or so on Nardil, but (for as long as it was working!) I didn't feel sluggish or anything like that. The problem there was that the effect didn't last, not that the drug was making things worse in any way. (Of course, weight gain was not a problem for me when depressed, and once I stopped taking the Nardil and became thoroughly depressed again, I quickly lost the weight!)
> > True melancholic depression is actually pretty rare.
>
> Melancholic symptoms aren't, though, and yes, they can be treated.What do you consider to be "melancholic symptoms?" As I said, I think the most important one is the absense of mood-reactivity. This is what makes melancholic depression distinct, and it's also probably much of the reason why this type of depression tends to be more severe than nonmelancholic depression. And it's unusual: most people who are depressed are able to be cheered up, at least some of the time.
-elizabeth
This is the end of the thread.
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