![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 15 of 15. This is the beginning of the thread.
Posted by Ame Sans Vie on August 12, 2004, at 10:05:21
I'm about to see my pdoc this afternoon (3:30 Central Time). I spoke with him on the phone just now and he left me with a decision to make -- which antidepressant should I add onto my 12mg Klonopin and 120mg Adderall? He's thinking I should either go with Wellbutrin XL, desipramine, or nortriptyline. Currently, my panic attacks, avoidant behavior, social phobia, agoraphobia, performance anxiety, somatic manifestations of anxiety, insomnia, attention deficit disorder, mild obsessive-compulsive disorder and dysthymia are in complete remission. But that still leaves me with the ever so pleasant endogenous atypical reactive depression -- anhedonia (though that's improved about 40% with the Adderall), complete lack of motivation, hypersomnia, and fatigue. Luckily, the Adderall has stopped my binge-eating.
So any votes for one of the above three? Or other suggestions? Obviously Parnate is out of the question with the Adderall, but I may consider bringing up selegiline as an option. I've tried it before with modest results, but what if I were to take it along with Stalevo (for COMT and dopa-decarboxylase inhibition, and even a little l-dopa)? Then, in theory, supplementing with either phenylalanine or tyrosine would be exponentially more effective due to avoidance of first-pass metabolism in the stomach... just a thought. But getting selegiline *and* Stalevo isn't very likely to happen.
I've given amantadine a try and, though it was a bit helpful, it gave me horribly vivid nightmares that still give me the chills just thinking about them... but what about a dopamine agonist? I mean, Mirapex worked beautifully for me before except that after several weeks or so it began to cause sleep attacks. Perhaps now with the Adderall I can avoid that?
But truth be told, I'd really rather stick with one of the more tried and true -- desipramine, Wellbutrin XL, or nortriptyline. My only question is, as best as you can judge by the list of symptoms I outlined above, which of the three would you all guess would be my best bet?
Thanks so much -- I really hope someone reads this in time! T minus five hours and counting!
~Michael
Posted by King Vultan on August 12, 2004, at 10:22:51
In reply to Somebody! I need advice fast!, posted by Ame Sans Vie on August 12, 2004, at 10:05:21
I guess I would vote for desipramine, as my own experience with nortriptyline was that it was too sedating. Desipramine is definitely more activating and because it works so heavily on norepinephrine, you may find it has a tendency to reduce your need for sleep. It does have a weak histamine blockade that some people are sensitive to, but this is going to generally be overpowered by its NE reuptake blockade. Some people feel nortriptyline is a better antidepressant, and desipramine is better for ADD, but this was certainly not my experience. YMMV.
Todd
Posted by zeugma on August 12, 2004, at 10:27:20
In reply to Somebody! I need advice fast!, posted by Ame Sans Vie on August 12, 2004, at 10:05:21
Hi Ame,
I'm no expert (and wary of the whole 'take this 'cause it worked for me' deal) but given these symptoms:
Currently, my panic attacks, avoidant behavior, social phobia, agoraphobia, performance anxiety, somatic manifestations of anxiety, insomnia, attention deficit disorder, mild obsessive-compulsive disorder and dysthymia are in complete remission. But that still leaves me with the ever so pleasant endogenous atypical reactive depression -- anhedonia (though that's improved about 40% with the Adderall), complete lack of motivation, hypersomnia, and fatigue. Luckily, the Adderall has stopped my binge-eating.>
I would say that your pdoc's recommedations of Wellbutrin XL, desipramine, or nortriptyline are in order, but given that your panic attacks and anxiety are in remission, I would go with the TCA's as they are also antipanic agents. Both desipramine and nortriptyline can be anxiogenic but to less degree, and in descending order of anxiogenicity, than Wellbutrin. Nortriptyline would also have an anti-insomnia effect, unlike desipramine. OTOH you mention binge-eating, and nortriptyline can have mixed effects in this regard, while desipramine is more likely to lower appetite.
None of these meds is likely to induce anhedonia, or worsen ADHD symptoms.
curious to see what others say.
-z
Posted by alesta on August 12, 2004, at 10:43:04
In reply to Somebody! I need advice fast!, posted by Ame Sans Vie on August 12, 2004, at 10:05:21
Hi, Ame! such urgency!:) i'm not sure which is best, but my vote is definitely for trying wellbutrin first. it can affect people differently so there's no way to predict if it's *the* best or not, but concerning side effects it definitely is; i wouldn't go with the tricyclics unless you have to. just my 2 cents.....hope somebody else responds......
Posted by alesta on August 12, 2004, at 11:12:28
In reply to Somebody! I need advice fast!, posted by Ame Sans Vie on August 12, 2004, at 10:05:21
i would listen to these guys.....wellbutrin is prescribed for panic disorders yet people report that it causes anxiety....i'm so confused. having never taken wellbutrin i can't say either way...if you take my advice and your anxiety increases i'm going to feel really bad, and i only responded b/c i thought no one else had. i think i change my vote.
Posted by Ame Sans Vie on August 12, 2004, at 12:06:43
In reply to Re: Somebody! I need advice fast!, posted by King Vultan on August 12, 2004, at 10:22:51
> I guess I would vote for desipramine, as my own experience with nortriptyline was that it was too sedating. Desipramine is definitely more activating and because it works so heavily on norepinephrine, you may find it has a tendency to reduce your need for sleep.
I was sort of leaning toward desipramine as well... I certainly don't want to take anything that is likely to sedate me (i.e., nortriptyline) as I have enough trouble staying awake as is. I can't remember ever having a medication-provoked panic attack, so I think I'd be safe with Wellbutrin (especially with 12mg of clonazepam on board each day). But I remember the past few times I tried it I couldn't get through the first two weeks solely because of that dry mouth which drove me crazy. I know there's that cholinergic medication Salgan that causes saliva to be secreted and it's often used in cases like those, but I simply can't afford *another* medication.
However, desipramine does worry me a bit because I've heard of more than one person experiencing terribly painful inability to urinate that lasted several days, due to the anticholinergia. I went through that once with Gabitril, and I don't think I'd dare take that gamble again!
Damn, this is a tough decision...
> It does have a weak histamine blockade that some people are sensitive to, but this is going to generally be overpowered by its NE reuptake blockade.
My brain doesn't know the meaning of "antihistamine", lol. I guess I'm just a complete screw up -- 200mg of Benadryl and I'm wired. <shrug>
>Some people feel nortriptyline is a better antidepressant, and desipramine is better for ADD, but this was certainly not my experience. YMMV.
Thanks a bunch for your input! I'll just keep pondering and researching for the next three hours I suppose, lol.
~Michael
Posted by Ame Sans Vie on August 12, 2004, at 12:09:55
In reply to Re: Somebody! I need advice fast! » Ame Sans Vie, posted by zeugma on August 12, 2004, at 10:27:20
> Hi Ame,
Hiya. :-)
> I would say that your pdoc's recommedations of Wellbutrin XL, desipramine, or nortriptyline are in order, but given that your panic attacks and anxiety are in remission, I would go with the TCA's as they are also antipanic agents. Both desipramine and nortriptyline can be anxiogenic but to less degree, and in descending order of anxiogenicity, than Wellbutrin. Nortriptyline would also have an anti-insomnia effect, unlike desipramine. OTOH you mention binge-eating, and nortriptyline can have mixed effects in this regard, while desipramine is more likely to lower appetite.
Well, I'm so confused about the whole thing right now I'm sure I'll just pick a medication's name out of a hat as I pull up to the doctor's office, lol.
~Michael
Posted by Ame Sans Vie on August 12, 2004, at 12:17:41
In reply to Re: Somebody! I need advice fast!, posted by alesta on August 12, 2004, at 11:12:28
>Hi, Ame!
Hi there!
> such urgency!:)
You bet! My head hurts from thinking, lol.
> i'm not sure which is best, but my vote is definitely for trying wellbutrin first. it can affect people differently so there's no way to predict if it's *the* best or not, but concerning side effects it definitely is; i wouldn't go with the tricyclics unless you have to. just my 2 cents.....hope somebody else responds......
<sigh> I still just don't know... they all sound like good ideas, and, let's face it, I'm not going to pick a winner on the first try just by analyzing the drugs' subjective effects. I'm just gonna have to try them one at a time... doesn't matter much what order I suppose.
> i would listen to these guys.....wellbutrin is prescribed for panic disorders yet people report that it causes anxiety....i'm so confused.
Actually, I've never heard of Wellbutrin being prescribed for panic disorder... I could be wrong of course. But I believe it's generally reserved for certain types of depressives, ADDers and recovering stimulant addicts. Practically every doctor I've seen wouldn't even consider Wellbutrin because of the potential to provoke anxiety.
> having never taken wellbutrin i can't say either way...if you take my advice and your anxiety increases i'm going to feel really bad, and i only responded b/c i thought no one else had. i think i change my vote.
lol, if I go on the Wellbutrin, it's definitely my fault alone if I end up miserable. And now that I've really gotten to thinking about these three drugs, I think I really am starting to lean much more toward an Eldepryl + Stalevo + DL-phenylalanine combination. I'll be sure to keep you updated, whatever happens!
~Michael
Posted by Sad Panda on August 12, 2004, at 18:01:53
In reply to Somebody! I need advice fast!, posted by Ame Sans Vie on August 12, 2004, at 10:05:21
Hi Michael,
I like Nort myself & I find it anxiolytic. Desipramine is a potent NE reuptake inhibitor with the least side effects of any TCA. Nortriptyline is also a potent NE reuptake inhibitor, but it's toned down because it adds 5-HT2A antagonism which can be anxiolytic & does improve sleep & counters most SSRI side effects, downside is it does have more A1 & M1 blockade than Desipramine, it also is a modest H1 blocker.
Cheers,
Panda.
Posted by Ame Sans Vie on August 12, 2004, at 20:51:02
In reply to Re: Somebody! I need advice fast! » Ame Sans Vie, posted by Sad Panda on August 12, 2004, at 18:01:53
> Hi Michael,
>
> I like Nort myself & I find it anxiolytic. Desipramine is a potent NE reuptake inhibitor with the least side effects of any TCA. Nortriptyline is also a potent NE reuptake inhibitor, but it's toned down because it adds 5-HT2A antagonism which can be anxiolytic & does improve sleep & counters most SSRI side effects, downside is it does have more A1 & M1 blockade than Desipramine, it also is a modest H1 blocker.Thanks a bunch for your opinion! So, from what you've said I'm drawing the conclusion that you've tried both desipramine and nortriptyline... could I trouble you to go any deeper into the subjective differences between the two drugs? What *did* each help with?...What *didn't* each help? Sorry, I'm just really wanting to become very knowledge on this subject in case the time comes again that I must weigh nortriptyline as an option.
My pdoc became ill and had to leave the office, so he referred me to a general practitioner friend of his. I figured I'd just go for the desipramine (and *why* I'll explain in a moment <g>) and so she wrote up a script for 180 x 100mg tablets, with one refill, lol (talk about overkill -- thank goodness I haven't experienced suicidal ideation in several years). But hey, if it works well at least I have plenty on hand. About six months plenty to be exact, lol.
~Why I went with desipramine:
I am constantly coming across the following quote in various places on the web, and it has me intrigued. Maybe I'll be able to cut back on the Adderall? ....
"Amphetamines may enhance the activity of tricyclic or sympathomimetic agents; d-amphetamine with desipramine or protriptyline and possibly other tricyclics cause striking and sustained increases in the concentration of d-amphetamine in the brain; cardiovascular effects can be potentiated."
I had taken 30mg Adderall two hours prior to taking my first two desipramine; the peak of the drug's effect was waning, but within fifteen minutes of taking the desipramine, I felt that nice amphetamine "kick" all over again. I'm *definitely* going to try decreasing my dose of Adderall to 15 or 20mg four times daily starting tomorrow.
~Michael
Posted by Sad Panda on August 13, 2004, at 3:31:51
In reply to Re: Somebody! I need advice fast! » Sad Panda, posted by Ame Sans Vie on August 12, 2004, at 20:51:02
> > Hi Michael,
> >
> > I like Nort myself & I find it anxiolytic. Desipramine is a potent NE reuptake inhibitor with the least side effects of any TCA. Nortriptyline is also a potent NE reuptake inhibitor, but it's toned down because it adds 5-HT2A antagonism which can be anxiolytic & does improve sleep & counters most SSRI side effects, downside is it does have more A1 & M1 blockade than Desipramine, it also is a modest H1 blocker.
>
> Thanks a bunch for your opinion! So, from what you've said I'm drawing the conclusion that you've tried both desipramine and nortriptyline... could I trouble you to go any deeper into the subjective differences between the two drugs? What *did* each help with?...What *didn't* each help? Sorry, I'm just really wanting to become very knowledge on this subject in case the time comes again that I must weigh nortriptyline as an option.
>
> My pdoc became ill and had to leave the office, so he referred me to a general practitioner friend of his. I figured I'd just go for the desipramine (and *why* I'll explain in a moment <g>) and so she wrote up a script for 180 x 100mg tablets, with one refill, lol (talk about overkill -- thank goodness I haven't experienced suicidal ideation in several years). But hey, if it works well at least I have plenty on hand. About six months plenty to be exact, lol.
>
> ~Why I went with desipramine:
>
> I am constantly coming across the following quote in various places on the web, and it has me intrigued. Maybe I'll be able to cut back on the Adderall? ....
>
> "Amphetamines may enhance the activity of tricyclic or sympathomimetic agents; d-amphetamine with desipramine or protriptyline and possibly other tricyclics cause striking and sustained increases in the concentration of d-amphetamine in the brain; cardiovascular effects can be potentiated."
>
> I had taken 30mg Adderall two hours prior to taking my first two desipramine; the peak of the drug's effect was waning, but within fifteen minutes of taking the desipramine, I felt that nice amphetamine "kick" all over again. I'm *definitely* going to try decreasing my dose of Adderall to 15 or 20mg four times daily starting tomorrow.
>
> ~MichaelHi Michael,
I haven't tried Desipramine. I chose Nort because I need help with sleep & it is the metabolite of Amitriptyline, an AD that has the highest efficacy of all reuptake inhibitors. I believe Zeugma would have the best info on this because he is ADHD like you & is on Nort. Desipramine is the most potent NE reuptake inhibitor with the least side effects, but if you have insomnia and/or anxiety and/or are taking an SSRI, then Nort is probably the better choice.
Cheers,
Panda.
Posted by zeugma on August 13, 2004, at 5:26:22
In reply to Re: Somebody! I need advice fast! » Ame Sans Vie, posted by Sad Panda on August 13, 2004, at 3:31:51
> > > Hi Michael,
> > >
> > > I like Nort myself & I find it anxiolytic. Desipramine is a potent NE reuptake inhibitor with the least side effects of any TCA. Nortriptyline is also a potent NE reuptake inhibitor, but it's toned down because it adds 5-HT2A antagonism which can be anxiolytic & does improve sleep & counters most SSRI side effects, downside is it does have more A1 & M1 blockade than Desipramine, it also is a modest H1 blocker.
> >
> > Thanks a bunch for your opinion! So, from what you've said I'm drawing the conclusion that you've tried both desipramine and nortriptyline... could I trouble you to go any deeper into the subjective differences between the two drugs? What *did* each help with?...What *didn't* each help? Sorry, I'm just really wanting to become very knowledge on this subject in case the time comes again that I must weigh nortriptyline as an option.
> >
> > My pdoc became ill and had to leave the office, so he referred me to a general practitioner friend of his. I figured I'd just go for the desipramine (and *why* I'll explain in a moment <g>) and so she wrote up a script for 180 x 100mg tablets, with one refill, lol (talk about overkill -- thank goodness I haven't experienced suicidal ideation in several years). But hey, if it works well at least I have plenty on hand. About six months plenty to be exact, lol.
> >
> > ~Why I went with desipramine:
> >
> > I am constantly coming across the following quote in various places on the web, and it has me intrigued. Maybe I'll be able to cut back on the Adderall? ....
> >
> > "Amphetamines may enhance the activity of tricyclic or sympathomimetic agents; d-amphetamine with desipramine or protriptyline and possibly other tricyclics cause striking and sustained increases in the concentration of d-amphetamine in the brain; cardiovascular effects can be potentiated."
> >
> > I had taken 30mg Adderall two hours prior to taking my first two desipramine; the peak of the drug's effect was waning, but within fifteen minutes of taking the desipramine, I felt that nice amphetamine "kick" all over again. I'm *definitely* going to try decreasing my dose of Adderall to 15 or 20mg four times daily starting tomorrow.
> >
> > ~Michael
>
> Hi Michael,
>
> I haven't tried Desipramine. I chose Nort because I need help with sleep & it is the metabolite of Amitriptyline, an AD that has the highest efficacy of all reuptake inhibitors. I believe Zeugma would have the best info on this because he is ADHD like you & is on Nort. Desipramine is the most potent NE reuptake inhibitor with the least side effects, but if you have insomnia and/or anxiety and/or are taking an SSRI, then Nort is probably the better choice.
>
> Cheers,
> Panda.
>
>
>
>
Hi Panda and Ame,I've never tried desipramine either, but I researched it extensively because of its efficacy in ADHD. The consensus seemed to be that it worked better for this condition than NOR, presumably because of less antihistaminic interference and/or greater affinity for the NE transporter. I do have substantial experience with Strattera, whose profile seemed almost identical to desipramine's (in fact I believe that it was reports of DMI's efficacy that spurred Lilly to develop atomoxetine for ADHD). Strat worked well at first, but in a very non-stimulant-like manner (i.e. it seemed to 'force' me to pay attention, without increasing energy at all- a peculiar effect, but at the time it seemed great). It turns out that Strat's major metabolite, 4-hydroxyatomoxetine, is a kappa opioid partial agonist- probably responsible for the dysphoria and fatigue so many have experienced on it! Significantly, it was NOT Lilly's lab team that discovered this effect.
The potentiation of amphetamine's effects, good and bad, probably makes it a wise idea to lower the Adderall dosage. While on the subject of Adderall, do you think you could compare the subjective effects of Adderall with Ritalin? Ritalin LA seems to work well, so far, much better than Provigil. From an abstract in Pub med, Ritalin has more pharmacokinetic interactions with TCA's, while amphetamine has more pharmacodynamic interactions (the 'potentiation' factor). My dr. will probably want me to have a plasma level taken for NOR because of this.
And just to share one other bit of arcana- desipramine has a linear dose-response curve, but one study showed that its metabolite, 2-hydroxydesipramine, has a curvilinear one! The complexities of these drugs are mind-boggling- it's no wonder people have such differing responses to them. I suppose it's a miracle that they work at all.
-z
Posted by Ken5440 on August 13, 2004, at 12:40:14
In reply to Re: Somebody! I need advice fast! » Sad Panda, posted by Ame Sans Vie on August 12, 2004, at 20:51:02
I know that this is a day late, but I guess it will not hurt.
Over the years I have taken many, many AD's, including Wellbutrin, Amitriptyline, Imipramine, and Nortriptyline. Tricyclics had a far greater number and more troubling side effects than Wellbutrin. I found Amitriptyline to be the most effective of the TC's but weight gain, rapid pulse, tremors, and blurred vision were some of the side effects.
Wellbutrin gave me a "wired" feeling for quite some time and I had to take Prozac along with it. That side effect has disappeared, but it does increase alertness and can prevent sleep.
Posted by starlight on August 14, 2004, at 10:33:43
In reply to Re: Somebody! I need advice fast!, posted by alesta on August 12, 2004, at 11:12:28
I found wellbutrin to cause me agitation and irritation. starlight
Posted by paulbwell on August 15, 2004, at 20:00:50
In reply to Somebody! I need advice fast!, posted by Ame Sans Vie on August 12, 2004, at 10:05:21
AME SANS VIE!
If thats your biggest problem in life, you don't know how good you have it.
Go with Desoxyn for *most* of your 'mental' problems. You are lucky you have access to it.
Good Health
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.