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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 16 of 16. This is the beginning of the thread.
Posted by david maclean on February 16, 2003, at 17:42:25
This is a long email. Please be patient and please take time to read through. Thank you.
I feel I am coming to the end of all my efforts to sort my head out. The end is approaching because (1) my medical insurance has almost run out and (2) I am weary from the journey.
I am 47 and have had dysthymia for most of my adult life. In addition I have Obsessive Compulsive Personality Disorder (OCPD and not OCD). I have been in good therapy (mainly for the OCPD rattehr than the low mood but the two are interlocked) for 16 months but that finished when the money ran out about 10 months ago. SInce then I have had a relapse.
I am now looking for a few last meds to help out. I have found that using the MAOI moclobemide (not available in the US) really and truly helps with my mood. I noticed that it produced a CLARITY of thought and ENERGY and WAKEFULNESS and lack of low MOOD which I very much welcome. These effects come on quickly within days when I get to a dose of about 450 mg and do not take weeks like SSRIs might. But the last time I tried moclobemide I could not get much above 450 to 600 due to side effects (constricted feeling inside my guts) even though many people feel that high doses of 600 to 1,200 mg are better.
Well, at only 450 to 600 I found the moclobemide lost its efficacy after a several months. Sad. So I feel there is not much left for me to try as I have already tried clompramine and various other tricyclics. I have tried all the SSRIs except for the new escitalopram and had poor results on all of them. Only the SNRI reboxetine also gave me a good effect but its side effects were quite severe (Reynaulds syndrome strangely enough) and really I had to stop.
So what should I take?
I gently starting to try moclobemide once again but the interesting thing is that I very recently read that some MAOIs have amphetamine derivatives. Now holy shit!!! I used to describe moclobemide to my psychiatrists as almost a drug of abuse where I pooped a pill and a day or two later I was feeling energised and good. I never got a glimmer of response. But now I see that I was probably experiencing the stimulant effect..
Can someone help me with 2 questions ... (1) Where can I find out more about MAOIs and their amphetamine like effects as there is little on Google? and (2) is it worth trying a pure stimulant like Ritalin perhaps with or without moclobemide? The effect I got was very worth while and did not remind me of the sort of drug relationship which amphetamine addicts probably have. BTW does ritalin like compunds demonstarte a “poop out” simialr to that which I experienced after a few minths or do they tend to be effective for a long while?
If not a low level amphetamine like Ritalin then would you suggest one of the newer neuroleptics like Clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), sertindole (Serlect) or ziprasidone (Zeldox)?
It is clear than increasing serotonin does not seem to help me. Would buproprion be useful for me?
As I said I am getting desperate. I am running out of time. I have personal crises which need me to address then as soon as possible so I can't wait around for 12 week trials on meds and all that sort of thing.
The only other thing is that I find I am highly functional on benzodiazepine sleeping tablets. I never take a BDZ for more than 3 or 4 nights in a row to avoid addiction. They really do make me very effective the following morning. Maybe anxierty is a major part of my make up and maybe I should address it more directly. I have started taking 1mg Clonazepam but it does not work as well my my old 5mg nitrazepam. Would it be worth looking at an anti-anxierty med like Buspirone which has far less of the addictive and habituation potential?
I am sorry this has been so very long. Thank you for kindly reading this. I look forward to any constructive answers.
Posted by Thomas123 on February 16, 2003, at 20:50:37
In reply to Near the end: What meds can I try? Quick pls!, posted by david maclean on February 16, 2003, at 17:42:25
You say the end is near. You say you need an immediate answer. You say the benzos work for you real well. Take the benzos.
Withdrawing suddenly from benzos is hell on earth but gradual withdrawal is tolerable.
Incidnetally whether Parnate is around I have no idea but I believe a metabolite of Parnate is methamphetame.
Posted by likelife on February 16, 2003, at 23:08:07
In reply to Near the end: What meds can I try? Quick pls!, posted by david maclean on February 16, 2003, at 17:42:25
David,
I've also experienced longstanding dysthymia, overlaid with recurrent major depressive disorder. I've experimented with a number of meds and found that desipramine taken with a small dose of ritalin (30 mg) has worked wonders. Since starting the ritalin, almost 6 months ago, I've had periods of what seem like full remission, from both disorders. I'm not constantly symptom-free, but feel better than I have in 5+ years.
The Ritalin was also very quick acting--I noticed results immediately.
Take care,
Natalie
Posted by missinglynxx on February 17, 2003, at 1:37:06
In reply to Near the end: What meds can I try? Quick pls!, posted by david maclean on February 16, 2003, at 17:42:25
David , that was a very well written critique.
Its a complicated case you have, as is mine. Im taking Nortriptyline (medium doses) with MANY augementing AGENTS.========>
These include NADH, 10mcgs of Cytomel, Low dose Buspar....I DEMAND Of my psychiatrist that Im allergic to SSRIs and have found the Nortripyline to be up to my high standards. Im not cured but 60 percent better GOOD Luck , You will find an answer soon
Posted by david maclean on February 17, 2003, at 9:27:21
In reply to Re: Near the end: What meds can I try? Quick pls! » david maclean, posted by likelife on February 16, 2003, at 23:08:07
> David,
>
> I've also experienced longstanding dysthymia, overlaid with recurrent major
> depressive disorder. I've experimented with a number of meds and found that
> desipramine taken with a small dose of ritalin (30 mg) has worked wonders.
> Since starting the ritalin, almost 6 months ago, I've had periods of what
> seem like full remission, from both disorders. I'm not constantly
> symptom-free, but feel better than I have in 5+ years.
>
> The Ritalin was also very quick acting--I noticed results immediately.
>
> Take care,
> Natalie
Natalie, that is a very encouraging piece of information. Like you, I too have had the odd infrequent major depressive period on top of my dysthymia. My mild personality disorder (OCPD) does not much help solve the mood difficulties.I have two sets of questions to ask about what you have said. Apologies that I have a lot to say but I would appreciate it if you could take a moment to read it through.
FIRSTLY
We do not have desipramine avialable here in the UK. Are there any other members of that class of antidepressant which I could check to see if we can get it here?
SECONDLY
The Ritalin sounds interesting. I know almost nothing about it. Does it wear off ("poop out") after a few months and therefore the dose needs increasing?
Do you get problematic side effects?
If I am not able to get Ritalin from my doc then would other mild stimulants work like Dexedrine (dexamphetamine suphate) or Provigil (modafinil)? I think Ritalin is the med of choice for childhood hyperactivity and so I guess it may in some way actually be qualitatively different to the other two I mentioned. Right?
Importantly, does the improved mood and improved alertness you get from Ritalin come at the expense of a "trough" feeling at some later point. Do you see what I mean? For example if you take 10 strong coffees then you will feel alert but when the alertness wears off then you feel very lethargic. Does anything like this happen with Ritalin?
Finally, can I take a mildy stimulant med like Ritalin with my MAOI moclobemide (UK: Manerix). Moclobemide is a "Reversible MAOI" and not the same as the old generation of MAOIs like phenelzine (Nardil), isocarboxazid (Marplan) or tranylcypromine (US: Parnate, UK: Parstelin) but it is still an MAOI.
Sorry to ask so many questions. Hope someone can advise.
David
Posted by david maclean on February 17, 2003, at 9:40:15
In reply to Re: Near the end: What meds can I try? Quick pls!, posted by Thomas123 on February 16, 2003, at 20:50:37
>
> You say the end is near. You say you need an immediate answer.
> You say the benzos work for you real well. Take the benzos.
>
Yes this is very logical. It's just that I take a benzo (nitrazepam) that is so old and dated and which I believe is not even available in the US any longer. I kind of feel that there must be better replacements, especially as they have a high potential for dependancy after several months. Also they start to wear off and increased doses are needed to maintain any beneficial effect.Buspar has been recommended by an American friend as being very good for anxiety and I was wondering if that might be suitable. However, I really do value the traquillity I get from "following day" effects of the benzo and I do not know if I will get these effects from Buspar. Can anyone advise?
>
> Incidnetally whether Parnate is around I have no idea but I believe a metabolite
> of Parnate is methamphetame.
>
Yes I have heard this but only in passing. I would dearly love to know more.This seems so important to me in understanding why my MAOI works for me. Maybe the MAOI works for me not because it raises serotonin, noradrenaline and dopamine but because it conatins amphetamine type substances.
This will be important as I know my moclobemide will poop out after a few months. Hmmm ... maybe all mild stimulants poop out after a few months.
David
Posted by likelife on February 18, 2003, at 1:01:18
In reply to Re: Near the end: What meds can I try? Quick pls!, posted by david maclean on February 17, 2003, at 9:27:21
David,
Desipramine (Norpramin) is a tricyclic, and is, I believe, a derivative of imipramine (Tofranil)(but don't quote me on this). Other tricyclics include clomipramine (Anafranil, amitriptyline (Elavil), amoxapine (Ascendin), doxepin (Sinequan), and nortriptyline (Pamelor), though regretedly, I don't really know anything about these. I'm told that tricyclics mostly inhibit the reuptake of norepinephrine, and those with fewer side effects include desipramine, amoxapine, and nortriptyline. (Side effects often include dry mouth, sedation, constipation, etc.)
I did need to increase my dose of Ritalin by 10 mg after having taken it for about 4 months, though the increase was only temporary, and I'm back to the lower dose most of the time, except when I feel it might be helpful to have a little more energy (which is something I have not yet shared with my pdoc).
The combination of desipramine and Ritalin did cause what is basically slight tachychardia (rapid heartbeat), but the combination worked so well for me (and so little else has in the past), that my GP prescribed Atenolol (a beta-blocker) in addition. It is slightly annoying to have to take a med to counteract the effects of others--but I haven't had any problems since.
I believe that Ritalin is a milder stimulant than Dexedrine (though I think this is also prescribed for childhood ADHD). Dexedrine also seems to have a higher potential for addiction.
After I had taken the Ritalin for four months, I did notice the "trough" experience you described, at which time my pdoc increased the dose. Since then, I've gone back down to the original dose, without experiencing a similar trough. If I do, it's while I'm sleeping.
According to the PDR Drug Guide for Mental Health Professionals, taking Ritalin with moclobemide causes hypertensive crisis. Generally, Ritalin and MAOIs are contraindicated. The same is true for dexedrine, so I imagine any stimulants may be ruled out.
Hope this helps...let me know how things go,
Natalie
Posted by david maclean on February 18, 2003, at 7:30:26
In reply to Re: Near the end: What meds can I try? Quick pls! » david maclean, posted by likelife on February 18, 2003, at 1:01:18
Natalie, thank you for your message. You have written several points and I have read them all carefully. There is one thing I would like to ask you a bit more about. You wrote this:
> According to the PDR Drug Guide for Mental Health
> Professionals, taking Ritalin with moclobemide
> causes hypertensive crisis. Generally, Ritalin
> and MAOIs are contraindicated. The same is true
> for dexedrine, so I imagine any stimulants may
> be ruled out.
>
> Hope this helps...let me know how things go,
>
> Natalie
>The strange thing is that yesterday I had contacted the medical advice department at Roche who are the manufacturers of Moclobemide. As I am in the UK I contacted their UK department. I might have got more info from elsewheer because we are extraordinarily guarded about what medical information is given to the public - it is quit different to the situation in the US. The lady at Roche whom I spoke to said she was not aware of any interaction between Moclobemide and a stimulant such as Ritalin.
Now that seems to differ from what you have discovered. The Roche medical person also said that she felt she would have known if there was such a link but if she needed to do a search of the medical literature then she would need a request from my doctor. Frankly, I can't see that being an effective route to get this info.
So do you mind if I trouble you again and ask you to quote, as fully as you can find the effort to do so, from the section in the PDR Drug Guide for Mental Health Professionals where it makes reference to this possible interaction.
The purpose is that I would like to assess whether it is one of those interactions which are statistically possible but in practise are very rare and even then are not significantly damaging.
Thank you once again!
Dave
Posted by likelife on February 20, 2003, at 0:02:05
In reply to Re: Near the end: What meds can I try? Quick pls! » likelife, posted by david maclean on February 18, 2003, at 7:30:26
Funny how there's so much conflicting info. out there.
I got the info. from PDR Drug Guide for Mental Health Professionals, under Section 2: Interactions with psychotropic drugs. Under methylphenidate (generic for Ritalin) is listed moclobemide: Concurrent use of methylphenidate and moclobemide may result in hypertensive crisis (headache, palpitation, neck stiffness). The onset is rated as 1, rapid (develops within 24 hours). Severity is 1, contraindicated (the interaction may be life-threatening; concomitant use of the interacting agents is contraindicated). The evidence for this is a 3, fair (available documentation is fair, but pharmacologic considerations lead clinicians to suspect the interaction exists; or, documentation is good for a pharmacologically similar drug).
Hope that helps,
Natalie
Posted by david maclean on February 20, 2003, at 9:32:09
In reply to Re: Near the end: What meds can I try? Quick pls! » david maclean, posted by likelife on February 20, 2003, at 0:02:05
> Funny how there's so much conflicting info. out there.
>
> I got the info. from PDR Drug Guide for Mental Health Professionals, under Section 2: Interactions with psychotropic drugs. Under methylphenidate (generic for Ritalin) is listed moclobemide: Concurrent use of methylphenidate and moclobemide may result in hypertensive crisis (headache, palpitation, neck stiffness). The onset is rated as 1, rapid (develops within 24 hours). Severity is 1, contraindicated (the interaction may be life-threatening; concomitant use of the interacting agents is contraindicated). The evidence for this is a 3, fair (available documentation is fair, but pharmacologic considerations lead clinicians to suspect the interaction exists; or, documentation is good for a pharmacologically similar drug).
>
> Hope that helps,
>
> Natalie
>
Natalie, you are an absoulte star for providing me with that info. Thank you very much indeed! It is much appreciated especially as I intend to pursue the Ritalin for my dysthymia.Maybe the real worry in what you have quoted is not of an interaction per se between moclobemide and Ritalin. But rather than one does something similar to the other and the result may (or may not) be an excess dose of stimulant.
Now I must puzzle over why such a clear warning as the one you have quoted is unknown to the person I spoke to at Roche here in the UK (at a conversational level, at least). I think they are probably not as well informed as they should be. To be fair, they did say that my doc or pharmacist should contact them to get a proper search done ... but if it is in black and white in the US specs then I would have thought they would have known of the warning.
I think I will now go and visit my pharmacist to see if he has info in his drug ref book.
Thank you once again.
Dave
Posted by Dr. Bob on February 20, 2003, at 19:51:45
In reply to Re: Near the end: What meds can I try? Quick pls! » david maclean, posted by likelife on February 20, 2003, at 0:02:05
> I got the info. from PDR Drug Guide for Mental Health Professionals
I'd just like to plug the double double quotes feature:
http://www.dr-bob.org/babble/faq.html#amazon
But I don't mean to be pushy. Did you deliberately not use it to link to Amazon? If so, I'd be interested in why, over at Psycho-Babble Administration:
http://www.dr-bob.org/babble/admin/20020918/msgs/7717.html
Thanks!
Bob
Posted by likelife on February 20, 2003, at 23:51:25
In reply to Re: Near the end: What meds can I try? Quick pls! » likelife, posted by david maclean on February 20, 2003, at 9:32:09
David,
Good luck with your search. I'd like to know how your trial goes, if you do end up taking the Ritalin.
All the best,
Natalie
Posted by likelife on February 20, 2003, at 23:53:39
In reply to Re: double double quotes » likelife, posted by Dr. Bob on February 20, 2003, at 19:51:45
We'll see if this works...
Posted by Dr. Bob on February 21, 2003, at 11:58:22
In reply to here's the link, posted by likelife on February 20, 2003, at 23:53:39
Posted by Lawrence S. on February 22, 2003, at 4:16:51
In reply to Re: Near the end: What meds can I try? Quick pls!, posted by Thomas123 on February 16, 2003, at 20:50:37
Nardil is the only thing that worked for me. You will feel better than you have ever felt in your life. It takes a long time to kick in. Parnate does'nt come close to Nardil but it can help. (just my experience and a lot of other peoples opinion.)
Good luck.
Posted by david maclean on February 22, 2003, at 14:27:21
In reply to Re: Near the end: What meds can I try? Quick pls!, posted by Lawrence S. on February 22, 2003, at 4:16:51
> Nardil is the only thing that worked for me.
> You will feel better than you have ever felt
> in your life. It takes a long time to kick
> in. Parnate does'nt come close to Nardil but
> it can help. (just my experience and a lot of
> other peoples opinion.)
> Good luck.Glad to see Nardil works so well for you! :-)
The dietary regime for a med like Nardil is awkward for me. My MAOI, moclobemide, does not require any dietary precautions so I am going to go along with that for the time being.
Can I ask you if you experienced the Nardil or the Parnate "maxing out" after a while and no longer having a therapeutic effect?
I think I read somewhere that this can easily happen with MAOIs. Is this right?
BTW do you think a large part of the therapeutic effect might have come from the stimulant effects of the metabolites of Nardil?
Dave
This is the end of the thread.
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