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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 30. This is the beginning of the thread.
Posted by SLS on March 3, 2006, at 7:32:07
I guess this seems like an obvious statement to make.
Which ones work most often? How often?
Which ones work best? How well?
Which ones have the most favorable side effect profiles? What are these side effects and how severe are they?
The answers to these questions are less obvious. Is it a cop-out to simply say that it depends on the person and their individual biology and psychosocial matrix?
Sounds good to me.
- Scott
Posted by linkadge on March 3, 2006, at 7:44:56
In reply to Antidepressants don't work except for when they do, posted by SLS on March 3, 2006, at 7:32:07
I guess the reason that people ask such questions is to try and reduce the time they need to feel better.
If drug A works in %90 of patients but
drug B works in %20then it makes sence to try drug A first. Unless there were additional factors.
So when people ask what is the best antidepressant, they are just kind of trying to get an idea of what helps and what doesn't.
If somebody asked me what was better, moclobemide or nardil. I'd say Nardil, because it has a better record of sucess.
Linkadge
Posted by TylerJ on March 3, 2006, at 10:29:33
In reply to Antidepressants don't work except for when they do, posted by SLS on March 3, 2006, at 7:32:07
> I guess this seems like an obvious statement to make.
>
> Which ones work most often? How often?
>
> Which ones work best? How well?
>
> Which ones have the most favorable side effect profiles? What are these side effects and how severe are they?
>
> The answers to these questions are less obvious. Is it a cop-out to simply say that it depends on the person and their individual biology and psychosocial matrix?
>
> Sounds good to me.
>
>
> - ScottYou're right Scott...I totally agree!
Tyler
Posted by Racer on March 3, 2006, at 13:25:28
In reply to Antidepressants don't work except for when they do, posted by SLS on March 3, 2006, at 7:32:07
Sorry -- can't resist...
Yes, what you've said is completely true. I agree entirely. But I'm gonna add my thoughts on why...
Seems to me that psychiatry is different from other areas of medicine because it's much more subjective. Just like you questioning your response to -- was it mifepristone? -- after seeing the reduction in your HAM-D scores? There are no blood tests that can be done to diagnose bipolar or depression, it's all based on a clinical picture, and there's a lot of wiggle room within that. (Like the doctors now saying that there is no such thing as co-morbid depression and anxiety, those two symptoms together are ALWAYS bipolar.)
I think we'll someday find out that depression, for example, is a cluster of probably unrelated conditions with a similar set of symptoms. And that that's why some people respond to Drug A, and others don't.
Also, as you say, psychosocial factors play a large role, as well. If we all had a great social support network around us, supporting and encouraging us, I'd bet we'd mostly respond a whole lot more quickly than if we had to struggle along, and try to pay all our bills on inadequate resources due to the economic effects of our depression/bipolar/etc. This is certainly one area where you can't separate nature and nurture.
OK. Done now. You can now return to your regularly scheduled programming...
Posted by Chairman_MAO on March 3, 2006, at 13:31:51
In reply to Antidepressants don't work except for when they do, posted by SLS on March 3, 2006, at 7:32:07
Simply because it is a trivial fact that there are a wide variety of differences among people's psychobiological makeup does not rule out the possibility that there are some drugs classified as "antidepressants" that do not [usually] elevate mood in any commonly accepted sense of the term, thus betraying the patient's trust.
In order for any system of classification to make sense, people must agree on certain fundamental propositions. If everyone's reality is so subjective that this center does not hold, then there is no justification for the existence of psychiatry as a discipline.
Can't have it both ways, I don't think.
Posted by Chairman_MAO on March 3, 2006, at 13:39:25
In reply to Re: Antidepressants don't work except for when they do, posted by linkadge on March 3, 2006, at 7:44:56
This debate is couched in psychiatry's own bad-faith ontological quandaries. Namely, different drugs have different qualitative effects. Depression is more symptomatology; it is part of the human condition. Elimination of symtpoms as in a classical medical illness does not adequately describe any actions of any drug's real-world effects.
Moreover, medicine on a whole, one can argue, is needlessly and myopically focused on palliatives which eliminate symptomatology but do not address the core problems. For instance, chronic dehydration indubitably a root cause of many degenerative diseases, yet the one of the most glaring deficits in any hospital--especially geriatric care centers--is adequate hydration of patients.
Posted by Chairman_MAO on March 3, 2006, at 13:40:29
In reply to Re: Antidepressants don't work except for when the » linkadge, posted by Chairman_MAO on March 3, 2006, at 13:39:25
I should have said "more _THAN_ symptomatology". Sorry for the clutter.
Posted by SLS on March 3, 2006, at 14:36:12
In reply to Re: Antidepressants don't work except for when the » SLS, posted by Chairman_MAO on March 3, 2006, at 13:31:51
Hi.
> Simply because it is a trivial fact that there are a wide variety of differences among people's psychobiological makeup...
I don't agree that this is a trivial fact. I don't know too many facts that are.
> ...does not rule out the possibility that there are some drugs classified as "antidepressants"
Possibility? Any facts you'd like to offer? Let's name names.
> that do not [usually] elevate mood in any commonly accepted sense of the term,
Perhaps we should define the term "mood" so that there are no common misunderstandings.
> thus betraying the patient's trust.
I think the betrayal lies in the lack of facts offered patients by their physicians. Perhaps it is these physicians whom consider some facts too trivial to burden their patients with, thus fostering urealistic expectations.
> In order for any system of classification to make sense, people must agree on certain fundamental propositions.
Which propositions would you consider appropriate to proclaim?
> If everyone's reality is so subjective
There are commonalities in the perception of depression amongst individuals. Even the ability to interpret facial expressions is skewed in a similar fashion intraindividually. These things are observable and measurable.
> that this center does not hold, then there is no justification for the existence of psychiatry as a discipline.
If you haven't already done so, it might be fruitful for you to expose yourself to NIMH research and speak directly to the researchers there or to those of the major universities - even if only, and especially, as a patient. It is extremely enlightening to come to realize how enlightened *they* are and how progressive is their current research. Perhaps you haven't yet encountered the right doctors or medical institutions to have the same confidence in them that I have. On the other hand, I have met and been treated by some of the worst and unenlightened psychiatrists since my adventure began 30 years ago. It only takes one bad apple to spoil one's taste for an entire species if one allows it to be that way.
> Can't have it both ways, I don't think.
I don't understand what you are saying here. What are the two ways you refer to?
- Scott
Posted by Chairman_MAO on March 3, 2006, at 15:53:57
In reply to Re: Antidepressants don't work except for when the » Chairman_MAO, posted by SLS on March 3, 2006, at 14:36:12
I am already late leaving my apartment, otherwise I would respond in more detail. But I have to stop putting off going outside otherwise I will never be able to do it.
By trivial I meant "commonly understood", not "unimportant".
I do not wish to come off as antagonistic, I am sorry if I did. I am very agitated/anxious/depressed right now and do not know what to do. The doctor I have now _IS_ one of the top research psychopharmacologists at UMDNJ I think--at least of the ones that practice. i was referred to him after being labelled "treatment-resistant". I am sure you know how that is.
And this guy is without a doubt highly competent, especially relative to many psychiatrists out there. It is nice to have someone for a doctor that actually knows way more than I do about the drugs that I am taking. I know the reason he will not combine nardil + dexedrine has to do with lawsuits. He came here from columbia (the country, not the university) in 1997 and had to do his residency all over in the US in order to practice here. He has been in practice for 35 years. I do not blame him for being scared to do something that is conventionally considered unthinkable, but in reality probably OK. The people who would be trying to yank away his license--and reputation and livelihood--should I get hurt and sue are not bright enough to understand the reasoning involved in the combination.
It still infuriates me to no end, because there is exactly ONE antidepressant that really works for me long-term: Nardil. I also need d-amphetamine to focus enough to get anything done in the workforce--at least until I can find a job that I dont need to take it to do.
Posted by linkadge on March 3, 2006, at 16:07:00
In reply to Re: Antidepressants don't work except for when the » Chairman_MAO, posted by SLS on March 3, 2006, at 14:36:12
I honestly don't think we have come anywhere. We are still using the exact same techniques to treat depression as we were 40 years ago. In addition we lack any conlusive evidence whatsoever that these are the mechanisms involved in the etiology of depression.
What does this modern research amount to?
In addition, we are uncovering solid evidence that links depressive disorders to low activity of the serotonin transporter (not to bring up old dirt). Many recent studies are currently baffling scientists because they suggest that depression is actually more common in people who have less acitivity of the serotonin transporter ie people with the (SS) varient of the serotonin transporter, a condition we are effectively reproducing with SSRI's. We have a drug called tianeptine that is as effective as SSRI's yet it works the opposite, leaving scientists reverting back to the old biochemistry kickstart theory of antidepressant action. It's great to marvel, but I still contend that we are clueless.
I see our attempts as pathetic as the assumption that alzheimers is a disease cause by low acetycholine.
Linkadge
Posted by linkadge on March 3, 2006, at 16:09:18
In reply to Re: Antidepressants don't work except for when the » SLS, posted by Chairman_MAO on March 3, 2006, at 15:53:57
Are you currently taking Nardil ?
Linkadge
Posted by Racer on March 3, 2006, at 17:57:45
In reply to Re: Antidepressants don't work except for when the, posted by linkadge on March 3, 2006, at 16:07:00
> I honestly don't think we have come anywhere. We are still using the exact same techniques to treat depression as we were 40 years ago. In addition we lack any conlusive evidence whatsoever that these are the mechanisms involved in the etiology of depression.
>
> > I see our attempts as pathetic as the assumption that alzheimers is a disease cause by low acetycholine.
>
> Linkadge
>Link, I left some of your post, to show what I'm responding to.
Don't lose sight of the fact that every step we take leads us somewhere. I agree that we don't know what actually causes depression, nor why exactly certain drugs work for certain people, and certainly not why those same drugs don't work for other people. But it's not bad not to know something -- what's bad is giving up because you don't have the answer right now.
Sorry -- your view seems so bleak, to me, and I wish there were a way to show you a more hopeful perspective. Obviously, I ain't got the "How to" on that, but the desire is there. Give 'em a break -- most of them mean well, and really do want to help.
Posted by linkadge on March 3, 2006, at 21:14:19
In reply to Re: Antidepressants don't work except for when the » linkadge, posted by Racer on March 3, 2006, at 17:57:45
"Give 'em a break -- most of them mean well, and really do want to help."
Sorry, are you referring to people or to drugs ?
No, my only contention is that the drugs get an accurate representation. Information is what people need. The more information, the better. Like I said, I am not against anybody getting better, I am not trying to prevent that.
I see the meds from a different angle. From a destructive angle. Even a lot of people here, have experienced the destructive abilities of these medications, but they will still cling to their magical powers, well because most of us don't have alternatives.
Again, I don't want to sound like a mean person, but there will be people who will agree with me later in their lives, when the meds have had time to take a toll. It creeps up on you over the years, and you look in the mirror and say, OMG what the f*ck have I don't to myself. I was fine, and if I had just left well enough alone...
You have to realize that even people with the best intentions can do dammage, even when they mean the best. That is why it is always best to take care of yourself, to the best of your ability. Cause nobody knows you like yourself, and you're the only one who has to live with the decisions that are chosen for you.
Just my oppinion.
Linkadge
Posted by Phillipa on March 3, 2006, at 21:28:18
In reply to Re: Antidepressants don't work except for when the, posted by linkadge on March 3, 2006, at 21:14:19
I think Scott said it the best. We have to have hope. Love Phillipa
Posted by cecilia on March 4, 2006, at 2:27:14
In reply to My opinion (to which you're all entitled), posted by Racer on March 3, 2006, at 13:25:28
What doctors say that comorbid anxiety and depression are always bipolar? My pdoc said the exact opposite, that depression and anxiety are basically the same thing. I certainly have both, and no signs of being bipolar. Cecilia
Posted by SLS on March 4, 2006, at 8:13:29
In reply to Re: Antidepressants don't work except for when the » SLS, posted by Chairman_MAO on March 3, 2006, at 15:53:57
> I also need d-amphetamine to focus enough to get anything done in the workforce--at least until I can find a job that I dont need to take it to do.
Have you thought about adding desipramine instead? It might help increase activity in the left DLPFC like Strattera. It has been one of the tools used to treat ADD in the past. The only two side effects that were troublesome for me when using this combination were postural hypotension and delayed micturition. Of course there are remedies for these things, fludrocortisone and bethanechol respectively, but these effects can resolve with time on their own. My advice is to titrate the desipramine very slowly so as not to trigger these side effects so severely in the first place. Also, if the antidepressant effect of Nardil is somehow incomplete, an effective augmentor might improve libido.
I avoided mentioning nortriptyline because I think it might be too serotonergic. Atomoxetine might resolve your condition, but I know of no examples of people combining it with an MAOI to want to go so far as to recommend it.
Regarding the UMDNJ psychiatric department, I have worked with only one of their doctors. I found him competent, but didn't spend enough time with him to be able to get a good "feel" for him. He wrote up an interesting report on the use of Keppra (levetiracetam) for treating rapid-cycling bipolar disorder and some stuff on epilepsy. I wish I could have gone back to him with another Keppra success story. It does help a bit, but not enough to consider my reaction to it as being an antidepressant response.
- Scott
Posted by SLS on March 4, 2006, at 9:01:45
In reply to Re: Antidepressants don't work except for when the, posted by linkadge on March 3, 2006, at 16:07:00
> I honestly don't think we have come anywhere.
That's too bad. You might glean more hope to realize how intense and diverse is the work being performed in the field of psychiatry. Wait. You do realize this. With as much reading and understanding as you demonstrate, I am surprised you don't recognize this work as being true progress. Digging, digging, digging. They are still digging. They need more time to locate the buried treasures of understanding.
> We are still using the exact same techniques to treat depression as we were 40 years ago.
This is not true. rTMS didn't exist 40 years ago. Neither did SSRIs, Wellbutrin, and other drugs that have served to rescue those people whom were non-responders to TCAs and MAOIs. I served willingly as a guinea pig during this formative era that began around 1980. I agree that the pace of discovery in clinical therapeutics has been painfully slow. Rome was not built in a day - trite, but true. Some of these guys are working their *sses off.
> In addition we lack any conlusive evidence whatsoever that these are the mechanisms involved in the etiology of depression.
That's why there is such diversity in the targets of current investigation. Until the mystery is unravelled, we gotta go with what works, despite a lack of understanding of how it works. That's why animal drug screening protocols are so important.
> What does this modern research amount to?More people are getting well. Just not you - yet.
> In addition, we are uncovering solid evidence that links depressive disorders to low activity of the serotonin transporter (not to bring up old dirt). Many recent studies are currently baffling scientists because they suggest that depression is actually more common in people who have less acitivity of the serotonin transporter ie people with the (SS) varient of the serotonin transporter, a condition we are effectively reproducing with SSRI's.
I think it is the compensatory re-regulation of the synapse or circuitry that is the key, not the acute actions of the drugs that precipitate it. That's why a drug like tianeptine can work, in my opinion.
> We have a drug called tianeptine that is as effective as SSRI's yet it works the opposite,
Ah. You beat me to it. People investigating brain disorders need to think multidimensionally, not just linearly. Tianeptine might do "just the opposite" acutely, but the resulting compensatory mechanisms might yield an equilibrium similar to that produced by SSRIs. Research cannot be linear either. Pure research does not follow a path set up by theory or proposed destination. You never know where you will stumble upon a clue or an answer to a question that was never asked.
> leaving scientists reverting back to the old biochemistry kickstart theory of antidepressant action. It's great to marvel, but I still contend that we are clueless.
With respect, I offer the possibility that both you and I are clueless as to the volume and sophistication of investigation and theory synthesis going on currently in the field of neuroscience.
> I see our attempts as pathetic as the assumption that alzheimers is a disease cause by low acetycholine.I am under the impression that it is defective ACh neurotransmission that is the ultimate expression of the disease. However, this observation has never duped researchers into concluding that the neural synapse is the primary site of disease induction. But then again, the abnormal tissue morphology is obvious in DAT. Not so much in MDD. With MDD, it might be gene activity that will eventually elucidate the primary sites of disease expression. We are only just now developing the technology to accomplish this. I think this is where many people lose perspective on the rate of discovery. We can only observe what our current technology allows us to. The rate of biological discovery is thus tied to the rate of technological advances. Let's give our researchers some credit for using creatively what little they have to work with.
- Scott
Posted by SLS on March 4, 2006, at 9:20:44
In reply to Question for Racer, posted by cecilia on March 4, 2006, at 2:27:14
> What doctors say that comorbid anxiety and depression are always bipolar? My pdoc said the exact opposite, that depression and anxiety are basically the same thing. I certainly have both, and no signs of being bipolar. Cecilia
Your doctor is more right than those that state that anxiety and unipolar depression are mutually exclusive. The fact is, that many cases of anxiety resolve using the same drugs used to treat depression. There might be some commonalities between the biologies of depression and anxiety. Some people think that they are different expressions of the same disorder.
Sometimes, medical people, like real people :-), are very polar in their thinking - "all or nothing", "either or". It is possible that anxiety as a symptom of a cluster of depressive symptoms is statistically more prevalent in bipolar disorder, but it seems that it does present as a symptom of unipolar depression as well. In addition, anxiety as a symptom of depression is conceptually different from having anxiety be an expression of an anxiety disorder comorbid with a depressive disorder. Besides - even if there is no abnormal biological substrate for the overrepresentation of anxiety, just being asked to perform a task while severely depressed can produce anxiety as a reaction.
To conceptualize psychiatric disorders in a way that yields effective therapeutics often requires multidimensional thinking and problem-solving.
- Scott
Posted by linkadge on March 4, 2006, at 9:24:38
In reply to Re: Antidepressants don't work except for when the » linkadge, posted by SLS on March 4, 2006, at 9:01:45
I'm not saying that its not potentially promising work, but at the present it hasn't amounted to a whole lot.
Breakthoughs discoveries do occur, but how many years before we have the technology to implement them ?Like, I said, I am Doubting Thomas, I'll be impressed by modern science when I see....
(thousands of ways to finish that sentence)Linkadge
Posted by SLS on March 4, 2006, at 9:38:12
In reply to Re: Antidepressants don't work except for when the, posted by linkadge on March 4, 2006, at 9:24:38
>
> I'm not saying that its not potentially promising work, but at the present it hasn't amounted to a whole lot.I agree with you when it comes to the application of clinical psychiatry.
> Breakthoughs discoveries do occur, but how many years before we have the technology to implement them?
I know. It doesn't seem as if anything is to be imminently available that is very different from what we have already. Maybe agomelatine? rTMS?
> Like, I said, I am Doubting Thomas, I'll be impressed by modern science when I see....
> (thousands of ways to finish that sentence)We were born just a bit too early in the course of human history, it seems. You are substantially younger than me. I hope that they find something for you before you reach my age - not that I am all that ancient! You still have time on your side.
- Scott
Posted by pseudoname on March 4, 2006, at 10:38:46
In reply to Antidepressants don't work except for when they do, posted by SLS on March 3, 2006, at 7:32:07
> Antidepressants don't work except for when they do
Another psych med aphorism: “Everything works for somebody; nothing works for everybody.”
I take the first part to mean that for every odd, off-off-label medication, there is *somebody* somewhere it has helped.
The more hopeful interpretation is that for each depressed person, there is *some* drug somewhere that will help her. I don't know if that’s true, but based on my recent success with buprenorphine, I encourage people to act as if it is. Find a good creative pdoc and try try try.
Posted by Racer on March 4, 2006, at 14:06:33
In reply to Question for Racer, posted by cecilia on March 4, 2006, at 2:27:14
> What doctors say that comorbid anxiety and depression are always bipolar? My pdoc said the exact opposite, that depression and anxiety are basically the same thing. I certainly have both, and no signs of being bipolar. Cecilia
LoL! That's more my view of it. I know that I suffer depression, and I know that it is often triggered by unremitting anxiety. I've often gone through periods when I know that, if my anxiety could just be brought under control, I would not sink into the depression. (Of course, so far, nothing has brought the anxiety under control. Pray you're never without insurance or other resources when you start to slide. Or that your county has good mental health care if you do find yourself there.)
The thinking seems to be the new trend. With all the new bipolar dxs, BP III, BP IV, etc, some doctors are saying, "Well, the irritibilty, and anxiety, those are really a different expression of hypomania. So, if someone is anxious and doesn't respond to antidepressant treatment, it's important to rule out bipolar..." So far so good, but you know how some people like to find cheat sheets? Some doctors like to say, "Well, in that case, I'll just assume bipolar until proven otherwise." And we all know how easy it is to find the symptoms you're looking for, right?
I don't agree with it. I don't think that someone who sees me 1/2 an hour a month is going to get much sense of whether I'm anxious and depressed, or expressing hypomania another way. My T says, unequivocally, that I am NOT bipolar. Not even willing to discuss the matter, because she says it simply does not fit me. And, since talking to my T, my new pdoc doesn't seem to say it anymore, either.
Then again, thank you anxiety -- I am finding that I question it myself every time I have trouble sleeping... lol
Hope that's an answer. I didn't sleep very well last night. :-}
Posted by linkadge on March 4, 2006, at 14:26:38
In reply to Re: Antidepressants don't work except for when the, posted by SLS on March 4, 2006, at 9:38:12
I wish the same for you, ie I hope you see the relief you deserve.
Linkadge
Posted by linkadge on March 4, 2006, at 14:29:25
In reply to Everything works for somebody... » SLS, posted by pseudoname on March 4, 2006, at 10:38:46
I'm not trying to be pessimistic so that people will give up. I just sometimes think that curbing ones enthusiasm about a particular treatment can lead to a more realistic expectation, and a more steady outcome.
Linkadge
Posted by SLS on March 4, 2006, at 14:33:35
In reply to Everything works for somebody... » SLS, posted by pseudoname on March 4, 2006, at 10:38:46
> The more hopeful interpretation is that for each depressed person, there is *some* drug somewhere that will help her. I don't know if that’s true, but based on my recent success with buprenorphine, I encourage people to act as if it is. Find a good creative pdoc and try try try.I think I'll bring up buprenorphine with my doctor at some point. I need to introduce him to the idea first and let him dance with it for a little while. Still, I don't know if he'll go along with it.
If you wouldn't mind answering a few questions...
How would you describe your depression?
Does the buprenorphine alleviate all of the symptoms entirely?
How many times a day do you have to take it and at what dosage?
What other medications do you take?
Thanks.
- Scott
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