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Dr. Bob is Robert Hsiung, MD,
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Posted by MBAVON on December 15, 2004, at 17:38:29
I wonder if anybody out there has some suggestions as how I can obtain 100% remission from treatment resistant recurrent depression. I've been depressed on and off for 14 years. I had full remission of symptoms from around 1995 -2001. I was on a combination of Wellbutrin XL and Effexor XR ( 450mgs and 225mgs respectively) and Klonopin on an as need basis. In 2001 I experienced my 3rd major episode and am currently still having symptoms. I have been on every class of drugs including an MAOI..which I am currently on...Parnate ( up to 60 mgs)currently on 40mgs due to side effects ( insomnia especially and anxiety). I am also taking Klonopin on a daily basis..apprx. between .75mgs and 1 mg daily. I feel I've reached a level of about 65-70 % remission .I have been on Parnate since August. I am unhappy with the remission leevel and I told my doctor no sense being on the dietary restrictions if I still have to live with the depression. Does anyone have any ideas or suggestions and/or have been in a similar situation. The doctor wanted to add Provigil but I was afraid of it intesifying insomnia and anxiety. I was thinking of asking the dooctor to maybe re-try Wellbutrin and replace the Effexor with Cymbalta. Any responses and or suggestions and experience would greatly be appreciated. The only thing I won't consider is ECT. By the way I am also in CBT but both my doctor and therapist feel I have a very biological and genetically based problem because things are going very well in my life and the depression sort of gradually came out of nowhere. I appreciate any help.
Posted by King Vultan on December 15, 2004, at 20:06:22
In reply to Treatment Resistant ( sorry a little long ), posted by MBAVON on December 15, 2004, at 17:38:29
> I wonder if anybody out there has some suggestions as how I can obtain 100% remission from treatment resistant recurrent depression. I've been depressed on and off for 14 years. I had full remission of symptoms from around 1995 -2001. I was on a combination of Wellbutrin XL and Effexor XR ( 450mgs and 225mgs respectively) and Klonopin on an as need basis. In 2001 I experienced my 3rd major episode and am currently still having symptoms. I have been on every class of drugs including an MAOI..which I am currently on...Parnate ( up to 60 mgs)currently on 40mgs due to side effects ( insomnia especially and anxiety). I am also taking Klonopin on a daily basis..apprx. between .75mgs and 1 mg daily. I feel I've reached a level of about 65-70 % remission .I have been on Parnate since August. I am unhappy with the remission leevel and I told my doctor no sense being on the dietary restrictions if I still have to live with the depression. Does anyone have any ideas or suggestions and/or have been in a similar situation. The doctor wanted to add Provigil but I was afraid of it intesifying insomnia and anxiety. I was thinking of asking the dooctor to maybe re-try Wellbutrin and replace the Effexor with Cymbalta. Any responses and or suggestions and experience would greatly be appreciated. The only thing I won't consider is ECT. By the way I am also in CBT but both my doctor and therapist feel I have a very biological and genetically based problem because things are going very well in my life and the depression sort of gradually came out of nowhere. I appreciate any help.
I am on 60 mg Parnate, and while I appear to have achieved a somewhat better remission than you have, I am not quite where I want to be in a few areas. I am also suffering from severe insomnia from the Parnate and have finally come up with a sleep med scheme that is reasonably effective; however, my anxiety levels are apparently quite a bit lower than yours are.What I intend to ask my pdoc about at my next appointment is adding a low dose of an atypical antipsychotic that is selective for blockading serotonin-2A receptors (I have a paper that suggests 0.5-1.0 mg/day Risperdal). There is some persuasive evidence that this can have a synergistic effect in augmenting drugs that increase serotonin transmission, of which Parnate would be one example. Drugs that blockade the serotonin-2A receptor will also tend to help with sleep, as stimulation of this receptor causes insomnia in some people (I am someone who suffers particularly bad insomnia on SSRIs and Effexor, so it makes sense to try in my case).
My own experience with Parnate has been that there was a significant improvement in a number of areas going from 50 to 60 mg/day. While 60 mg/day is ostensibly the maximum as indicated in the Physician's Desk Reference, taking 70 or 80 mg/day is not that uncommon and IMO is not an imprudent amount for individuals who don't fully respond at lower dosages. If you want to take full advantage of this drug, I feel you really owe it to yourself to work with your doctor in finding some sleep med or combination thereof that will allow you to take a higher dosage.
One other option you might want to consider if you haven't already tried it is Nardil, which IMO is a better med for anxiety than is Parnate. The insomnia does not generally seem to be as bad on Nardil (It was still terrible for me because any drug that increases serotonin transmission will give me insomnia), but Nardil is not nearly as dopaminergic as Parnate and is a much poorer med if you have ADD type symptoms as I do. Nardil also has more side effects in general than does Parnate.
Todd
Posted by cybercafe on December 15, 2004, at 21:19:56
In reply to Re: Treatment Resistant ( sorry a little long ), posted by King Vultan on December 15, 2004, at 20:06:22
> > I wonder if anybody out there has some suggestions as how I can obtain 100% remission from treatment resistant recurrent depression. I've been depressed on and off for 14 years. I had full remission of symptoms from around 1995 -2001. I was on a combination of Wellbutrin XL and Effexor XR ( 450mgs and 225mgs respectively) and Klonopin on an as need basis. In 2001 I experienced my 3rd major episode and am currently still having symptoms. I have been on every class of drugs including an MAOI..which I am currently on...Parnate ( up to 60 mgs)currently on 40mgs due to side effects ( insomnia especially and anxiety). I am also taking Klonopin on a daily basis..apprx. between .75mgs and 1 mg daily. I feel I've reached a level of about 65-70 % remission .I have been on Parnate since August. I am unhappy with the remission leevel and I told my doctor no sense being on the dietary restrictions if I still have to live with the depression. Does anyone have any ideas or suggestions and/or have been in a similar situation. The doctor wanted to add Provigil but I was afraid of it intesifying insomnia and anxiety. I was thinking of asking the dooctor to maybe re-try Wellbutrin and replace the Effexor with Cymbalta. Any responses and or suggestions and experience would greatly be appreciated. The only thing I won't consider is ECT. By the way I am also in CBT but both my doctor and therapist feel I have a very biological and genetically based problem because things are going very well in my life and the depression sort of gradually came out of nowhere. I appreciate any help.
>
>
> I am on 60 mg Parnate, and while I appear to have achieved a somewhat better remission than you have, I am not quite where I want to be in a few areas. I am also suffering from severe insomnia from the Parnate and have finally come up with a sleep med scheme that is reasonably effective; however, my anxiety levels are apparently quite a bit lower than yours are.
>
> What I intend to ask my pdoc about at my next appointment is adding a low dose of an atypical antipsychotic that is selective for blockading serotonin-2A receptors (I have a paper that suggests 0.5-1.0 mg/day Risperdal). There is some persuasive evidence that this can have a synergistic effect in augmenting drugs that increase serotonin transmission, of which Parnate would be one example. Drugs that blockade the serotonin-2A receptor will also tend to help with sleep, as stimulation of this receptor causes insomnia in some people (I am someone who suffers particularly bad insomnia on SSRIs and Effexor, so it makes sense to try in my case).
>
> My own experience with Parnate has been that there was a significant improvement in a number of areas going from 50 to 60 mg/day. While 60 mg/day is ostensibly the maximum as indicated in the Physician's Desk Reference, taking 70 or 80 mg/day is not that uncommon and IMO is not an imprudent amount for individuals who don't fully respond at lower dosages. If you want to take full advantage of this drug, I feel you really owe it to yourself to work with your doctor in finding some sleep med or combination thereof that will allow you to take a higher dosage.
>
> One other option you might want to consider if you haven't already tried it is Nardil, which IMO is a better med for anxiety than is Parnate. The insomnia does not generally seem to be as bad on Nardil (It was still terrible for me because any drug that increases serotonin transmission will give me insomnia), but Nardil is not nearly as dopaminergic as Parnate and is a much poorer med if you have ADD type symptoms as I do. Nardil also has more side effects in general than does Parnate.
>
> Toddi added low dose abilify (got rid of insomnia) and ritalin (for ADD, boredom, depression?)
Posted by denise1904 on December 16, 2004, at 4:11:11
In reply to Treatment Resistant ( sorry a little long ), posted by MBAVON on December 15, 2004, at 17:38:29
Hi,
Can't really offer you any advice but just wanted to say that your situation sounds very much like my own. I became depressed again in June 2001 and like you it came out of nowhere, everything was going really well in my life (unles of course I'm in denial which I'm sure a psychotherapist would have me believe). Since then I went through hell for two years trying to find a drug that would take me out of hell and the last year or so I've been about 50% better on 40mg of Seroxat, however I still have some somatic symptoms of the depression and I tend to tire very easily in the evening. For instance I'm supposed to be going to a christmas lunch this afternoon, most people will carry on partying into the night but there's no way I can do that, I'll just have my meal, two bottles of budweiser and leave because I know my limits.
Anyway, like you and a lot of other people on this board I'm still searching.
Can I ask you if you had stopped taking your effexor, wellbutrin etc prior to 2001 when you got depressed again or did the medication just poop out?
Denise
Posted by ed_uk on December 16, 2004, at 6:49:57
In reply to Re: To MBAVON, posted by denise1904 on December 16, 2004, at 4:11:11
Hi,
King Vultan gave some good advice. Another drug that you could consider adding is Surmontil. Surmontil is a tricyclic antidepressant which does not appear to interact with MAOIs. It is especially good for insomnia and it could also relieve your anxiety and depression. If you were treated with Surmontil, you might be able to increase your dose of Parnate, this could help to relieve your depression.
Regards,
Ed.
Posted by MBAVON on December 16, 2004, at 14:41:53
In reply to Re: Surmontil, posted by ed_uk on December 16, 2004, at 6:49:57
I don't think Surmontil is available in the US. Even if it is, I doubt my doctor will go for a TCA. I am taking some Restoril which helps with sleep. In the last couple of days, I've actually felt better on 40mgs of Parnate.
Posted by MBAVON on December 16, 2004, at 14:43:11
In reply to Re: To MBAVON, posted by denise1904 on December 16, 2004, at 4:11:11
I was still on Wellbutrin and effexor when they pooped out.
Posted by MBAVON on December 16, 2004, at 14:44:56
In reply to Re: Treatment Resistant ( sorry a little long ), posted by cybercafe on December 15, 2004, at 21:19:56
I really don't think Nardil is for me. I think I'd rather try reinstituting Wellbutrin XL with Cymbalta.
Posted by ed_uk on December 16, 2004, at 15:35:17
In reply to Treatment Resistant ( sorry a little long ), posted by MBAVON on December 15, 2004, at 17:38:29
Hi,
Unless it has very recently been discontinued, Surmontil is available in the US. No one should be seen as treatment resistant until they've tried a few different tricyclics. I currently take a tricyclic and it is more effective than any of the other antidepressants that I've tried!
Best Wishes,
Ed.
Posted by Larry Hoover on December 16, 2004, at 16:08:16
In reply to Re: Surmontil » ed_uk, posted by MBAVON on December 16, 2004, at 14:41:53
> I don't think Surmontil is available in the US. Even if it is, I doubt my doctor will go for a TCA. I am taking some Restoril which helps with sleep. In the last couple of days, I've actually felt better on 40mgs of Parnate.
Yes, trimipramine is available in the US. I use 25 mg each night, and it really helps me sleep. I also use Restoril, 30 mg. They're a good combination.
Lar
Posted by MBAVON on December 16, 2004, at 18:20:38
In reply to Re: Surmontil » MBAVON, posted by Larry Hoover on December 16, 2004, at 16:08:16
Well thank you..I'll have to see what my doctor thinks. I was on tricyclics Nortrptylene(spelling ?)and desipramine 14 years ago and the dry mouth was so bad I couldn't contine. I work in a job in which I speak all day long and I just couldn't tolerate it. Plus both never really seemed to lift me out of depression. Who knows now though..maybe I would be able to tolerate something if I took it overnight. I have a question about the Restoril. About how long before bedtime should it be taken. It helped me sleep but it didn't seem like it let me fall asleep.
Posted by Larry Hoover on December 16, 2004, at 18:27:49
In reply to Re: Surmontil » Larry Hoover, posted by MBAVON on December 16, 2004, at 18:20:38
> Well thank you..I'll have to see what my doctor thinks.
25 mg trimipramine that I take is the lowest possible dose, without splitting pills. The therapeutic (for depression) dose is 200 mg.
> I was on tricyclics Nortrptylene(spelling ?)and desipramine 14 years ago and the dry mouth was so bad I couldn't contine. I work in a job in which I speak all day long and I just couldn't tolerate it. Plus both never really seemed to lift me out of depression. Who knows now though..maybe I would be able to tolerate something if I took it overnight. I have a question about the Restoril. About how long before bedtime should it be taken. It helped me sleep but it didn't seem like it let me fall asleep.
I find that taking the trimipramine one hour before retiring, and the temazepam a half hour before, works best for me.
Lar
Posted by ed_uk on December 17, 2004, at 4:22:56
In reply to Re: Surmontil » MBAVON, posted by Larry Hoover on December 16, 2004, at 18:27:49
Hi,
You'd need to take a very low dose of Surmontil to avoid dry mouth. We have 10mg pills in England!
Ed.
Posted by Larry Hoover on December 17, 2004, at 9:23:04
In reply to Re: Surmontil, posted by ed_uk on December 17, 2004, at 4:22:56
> Hi,
>
> You'd need to take a very low dose of Surmontil to avoid dry mouth. We have 10mg pills in England!
>
> Ed.I had overnight dry mouth for about a week, but I don't even get that any more. 50 mg started to produce the classic tricyclic side effects, but 25 was very mild, in that regard. Like I said, overnight dry mouth for a week, and then nada.
Lar
Posted by ed_uk on December 17, 2004, at 9:35:54
In reply to Re: Surmontil » MBAVON, posted by Larry Hoover on December 16, 2004, at 18:27:49
Hi Lar,
Since MBAVON had a really bad dry mouth on nortriptyline and desipramine, I expect trimipramine might be worse because it is more anticholinergic. Don't you have the 10mg tabs?
Ed.
Posted by Larry Hoover on December 17, 2004, at 12:12:25
In reply to Re: Surmontil » Larry Hoover, posted by ed_uk on December 17, 2004, at 9:35:54
> Hi Lar,
>
> Since MBAVON had a really bad dry mouth on nortriptyline and desipramine, I expect trimipramine might be worse because it is more anticholinergic. Don't you have the 10mg tabs?
>
> Ed.Our doses are 12.5, 25, 50 mg etc. I was unaware of the 12.5 size, until you asked. That's Canadian, and includes generics.
In the U.S., Surmontil brand starts at 25 mg. That's not to say generics might have different doses.
I get severe anticholinergic drug effects, such that my pdoc refused to prescribe even the lowest dose to me. My family physician is more open-minded.
Lar
Posted by ed_uk on December 17, 2004, at 12:40:01
In reply to Re: Surmontil » ed_uk, posted by Larry Hoover on December 17, 2004, at 12:12:25
Hi Lar,
12.5 mg sounds like a good place to start! Oddly, we don't seem to have a generic trimipramine in the UK.
Ed.
Posted by fachad on December 17, 2004, at 23:11:25
In reply to Re: Surmontil » ed_uk, posted by MBAVON on December 16, 2004, at 14:41:53
Surmontil (trimipramine) IS available in the US. I took it for a while a few years back.
It is still on-patent (not available as a generic), which is rare for a TCA.
It is not a typical TCA. It does not block the re-uptake of NE or 5-HT. It has weak DA blocking properties. It is a truly unique med.
> I don't think Surmontil is available in the US. Even if it is, I doubt my doctor will go for a TCA. I am taking some Restoril which helps with sleep. In the last couple of days, I've actually felt better on 40mgs of Parnate.
Posted by steve3211 on December 18, 2004, at 18:42:17
In reply to Treatment Resistant ( sorry a little long ), posted by MBAVON on December 15, 2004, at 17:38:29
I think we have a very similar situation. I had my first episode of major depression at the age of 19 for about 6 months then recovered and went on my merry way. At 26 another one which I also got over after about 6 months and completely went into remission. These were both brought on by changes in life style. At 31 I moved oversees and fell into a really bad depression for about a year so much so that I moved back to the states. I have been suffering with it on and off since then. I never took a/d's until this last year and feel that they have helped. I am currently on 5 mg of lexapro every day at 6 pm with xanax as needed (almost never). I also take fish oil and magnesium and a really good soft gel mult vitamin. I also quit drinking. This last year has been the best in a long time although even as I write this I am in a small slump (back somewhat depressed and anxious) which I think is due to the holidays. I am somewhat successful with a lovely family and don't have the life circumstances to explain this. I really believe we train our brains into this. When I was younger I recovered easier and was able to put it behind me. Now it has become chronic and as I am older more difficult to overcome. It is my honest belief that the longer you can go depression free then the more likely you are to stay depression free especially as you age. It is a real bastard to go 4 or 5 months feeling good and then feel depressed again for no discernible reason. Very frustrating. Sorry to ramble on.
Best to you - Steve
Posted by KaraS on December 19, 2004, at 14:58:03
In reply to Re: Surmontil, posted by ed_uk on December 17, 2004, at 4:22:56
Why is it better for sleep than say, doxepin or maprotiline? It's more anticholinergic so it has more side effects, right? Is it less antihistaminic?
This is the end of the thread.
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