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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 55 to 79 of 97. Go back in thread:
Posted by WeeWilly on April 9, 2006, at 20:30:22
In reply to Re: I get frightened when I read this sort of thing, posted by linkadge on April 9, 2006, at 11:31:36
> I don't think its a matter of being "smarter" than your doctor. When you're dealing with something like a mental health issue, its not always about right and wrong, it can be a matter of what works better and what works worse.
>
> Sure, it can set your mind at ease to think that all of the doctors decisions take place on a wavelength two steps above the average patient, but most of it is trial and error.
>
> My doctor told me it was ok to take lithium and parnate together. When the pharmacy called him back questioning the decision, he recanted !
>
> Thinking you're better than your doctor probably won't get you very far, but as far as do I "trust" my doctor, the answer would have to be: How could anybody fully trust their doctor? Many of these sorts of medical decisions always cary a degree of uncertainty and risk.
>
> You've got to think for yourself. I think it is foolishly to blindly trust every decision a doctor makes for you, under the guise of "oh they know what they're doing"
>
>
> LinkadgeLinkadge,
I can't understand why your doctor recanted on the use of Lithium with Parnate. Lithium is the first line of augmentation when Parnate is not sufficient on its own. Is there something in your individual case that makes it prohibitive?
Thanks. Best wishes
Posted by Squiggles on April 9, 2006, at 20:48:05
In reply to Parnate is often augmented with Lithium » linkadge, posted by WeeWilly on April 9, 2006, at 20:30:22
Have you tried checking a drug interaction
chart? Or perhaps going to Dr. Preskorn's
site of drug compatibilities or incompatibilities,
or Dr. Steven Stah's "Basic Psychopharmacology"?That might supplement your knowledge;
Squiggles
Posted by Caedmon on April 9, 2006, at 20:48:47
In reply to Parnate is often augmented with Lithium » linkadge, posted by WeeWilly on April 9, 2006, at 20:30:22
I'm curious to know too. Stephen Stahl's "Essential Pharmacology" lists Lithium as an augmenter for Parnate. I know because I'm looking at the page right now.
All I can think of is that they might synergistically lower the seizure threshold in people who are susceptible. <shrug> What is contraindicated about Li?
- C
Posted by SLS on April 9, 2006, at 21:01:50
In reply to Re: Parnate is often augmented with Lithium, posted by Caedmon on April 9, 2006, at 20:48:47
I always thought that Parnate + lithium was a particularly good combination.
What's the problem? Serotonin syndrome?
There have been reports of serotonin syndrome occuring with combinations of lithium and SRIs. It seems to be relatively rare, though.
- Scott
Posted by gardenergirl on April 9, 2006, at 21:25:45
In reply to Re: Please be civil » gardenergirl, posted by Squiggles on April 9, 2006, at 14:01:49
> I only said that because Dr. Bob
> kept kicking him out when he posted
> racist remarks here.Squiggles,
I've read some of the archives, so I'm aware of what you refer to. That said, civility guidelines here do not leave room for characterizing another's posts in a way that could lead others to feel accused. I asked you to be civil before, so now I am blocking you for a week. Dr. Bob has oversight over deputy decisions, and he may view this differently.Follow-ups regarding these issues, as well as replies to the above post, should be posted to Admin. and should of course themselves be civil.
Regards,
gg acting as deputy for Dr. Bob
Posted by gardenergirl on April 9, 2006, at 21:27:18
In reply to Re: Blind Faith In A P Doc » gardenergirl, posted by Phillipa on April 9, 2006, at 17:41:38
Phillipa,
The team I refer to is your doctor and you. I'm sorry your pdoc is not more receptive to your input. And yes, I'm quite lucky that I have a good working relationship with my doctors.gg
Posted by gardenergirl on April 9, 2006, at 21:30:12
In reply to Re: Blind Faith In A P Doc » gardenergirl, posted by linkadge on April 9, 2006, at 14:54:18
> With such a large population sample, (i.e. in Lilly), one would expect to see the same proportion of depressed people as one would in the general population. (Unless working for Lilly was a significanly less depressing job than the average american job :) )
I'm not sure I can agree with that assumption. There is a significant proportion of persons with depression who are not working. So I think applying general population numbers to a subset that has a higher proportion of persons who are currently working may not be the best way to gauge incidence of depression in this subset.
gg
>
Posted by gardenergirl on April 9, 2006, at 21:33:28
In reply to Re: Team work » linkadge, posted by Squiggles on April 9, 2006, at 14:30:00
> > To work as a team with your doctor, generally you need more than 5 minautes every 2 months.
> >
> > LinkadgeI absolutely agree, and I do not think that seeing a patient for such a limited time is a sound medical practice.
>
> And more than one doctor - no offense gg;
> SquigglesI'm not sure I understand. A team can consist of two: you and your doctor. And no offense taken. My team consists of my pdoc, my T, and my GP. I suppose you could add my marriage counselor to the team, as a consultant, too. I'm at the center, coordinating all of the above. That part can be difficult and frustrating at times, but since I'm the common denominator, I think it pretty much has to be me.
I guess some could have a case manager coordinating. And I realize IRL things do not always work as they could or should.
gg
>
Posted by Racer on April 9, 2006, at 21:37:33
In reply to Re: Blind Faith In A P Doc, posted by cecilia on April 9, 2006, at 19:20:19
I agree absolutely that far too many pdocs assume everything has been checked out physically, and don't bother to do it themselves. These days, they're checking thyroid more often, but that isn't necessarily enough. I think there should be a protocol that pdocs require a full physical before they start psychotropic drugs.
And I'll make sure it happens when I take over the world, which I can't do this coming week, but I'll let you know about the week after... ;-)
Posted by Phillipa on April 9, 2006, at 21:40:08
In reply to Re: Blind Faith In A P Doc » linkadge, posted by gardenergirl on April 9, 2006, at 21:30:12
When I was working I wasn't depressed. I only had anxiety treated with a benzo's and a few drink to settle down after a 3-ll shift daily. When I stopped work and drinking due to a high TSH and and started AD's that's when I became depressed so I can no longer work. I told my interenist the other day that I have lost l0 years to ad's that don't work and many pdocs. So I think I will start drinking again. I'd rather have l0 years of a quality life where I could be happy and laugh and work to this stuff. He only looked at me funny as I need no prescription for beer. And me the obedient pt hasen't had a beer in l0 years. So which is better to all of you? Love Phillipa
Posted by Racer on April 9, 2006, at 21:52:08
In reply to Re: Blind Faith In A P Doc, posted by cecilia on April 9, 2006, at 19:20:19
This thread is more than a bit upsetting to me, on several levels. For those of you who know a little more about my history, or have read the archives, you'll expect that discussions of bad pdocs bring examples to my mind that still have the power to upset me. For that reason alone, I think after these observations I had best leave this thread alone.
I don't think anyone who comes here takes what their doctors say on any sort of "blind" faith. I think the purpose of this board is education, as well as support, and participation in this site generally makes us informed consumers. (Didn't GG already say this?) And I think that being an informed consumer of psychiatric care is in our best interests. Doctors are not perfect, and not all pdocs are very good at their jobs. (Again -- I know just a bit about bad pdocs.)
That said, no matter how much I learn from this site and the reading it leads me to elsewhere, I am not the best person to choose a treatment plan for myself. Especially when I most need one. I very much doubt that I'm unique in that, either. Depression and anxiety affect our ability to make optimal decisions for our own care, and they affect it negatively. Someone who is deeply depressed is probably not in a great place to choose the best medication to address it, and is probably not going to be very tolerant of start up effects. Thus, the pdoc, monitoring which of those start up effects are most likely to be transient, and which justify stopping a medication.
After trying a number of drugs, many of us will be able to make some predictions. That still doesn't mean that we know best about what medications we should take, and it certainly doesn't speak to whether or not we can combine medications successfully. It doesn't mean that we should be trying to do the doctor's job. And it certainly doesn't mean that we should change medications without a doctor's supervision.
I am certainly not advocating "blind faith" in anyone except Ginger Baker. And I hardly believe that all pdocs are good doctors. But I do think that we'd be wise to focus on working with a pdoc successfully, rather than trying to direct our treatment ourselves.
Posted by Phillipa on April 9, 2006, at 22:02:06
In reply to Re: Blind Faith In A P Doc » gardenergirl, posted by Phillipa on April 9, 2006, at 21:40:08
Sorry don't have time to read the achives. Love Phillipa
Posted by rvanson on April 9, 2006, at 22:13:53
In reply to More ranting about doctors, posted by cecilia on April 9, 2006, at 5:32:39
> Plus another pet peeve-so many docs supplement their already hefty incomes via the drug reps. When Cymbalta 1st came out I couldn't believe how many people writing in here who had never been on ANY antidepressant before had been started by their docs on Cymbalta. I mean, where's the common sense, when new drugs come out you try them for your multiple failure patients--I'll be lining up for Emsam; but you don't risk trying a brand new drug on someone who's never tried any drug, you give them one of the tried and true ones, like Celexa or Zoloft, first. Unless you're getting paid under the table (or are just stupid). Cecilia
The "brand" of "medicine" (and I use that word loosely) being practiced by doctors these days is simply incredible or should I say, non-credible.My own Pdoc had drug company sales people all over the place until enough of us left or complained right around the time Cymbalta came out as well.
If it happens agains with Emsam, I needless to say wont be back in his office again.
Posted by mattw84 on April 9, 2006, at 22:17:53
In reply to Blind Faith In A P Doc, posted by Phillipa on April 9, 2006, at 0:48:45
Why do we trust our doctors to such a great extent. This a great question you have posed. Could it be that they have the piece of paper that we don't, that says that they know more about how the body works than we? Possibly. . . Yet that is a fair argument against it, that we simply know our bodies better than they possibly could.
The difference being, that we know our symptoms, but it takes expertise to know what is causing it. Granted some of us believe that we have been through the hoops so many times that we just know it better by experience.
Often times we will request drugs, or specific treatments. This is insulting to a doctor, in any field. To imply that you have the solution and they weren't capable of coming to it. Other times it is likely just a great difference of opinion.
Bottom line, any good and caring doctor will be willing to see your point of view. If this is not the case then they have no business taking peoples lives into their hands. The point of a doctor-patient relationship is not for one person to run the show, if the patient runs the show who knows what could come of it. I don't think that is a chance any physician is willing to take. A balanced partnership, or team effort is what makes both parties satisfied. Unless the doctor has a "god" complex (which many do develop) you will find that more often than not, doctors are very open to suggestion. Just remember, that you are entitled to your opinion, but more importanly the doctor is entitled to his or hers as well. That is what they get paid for.
No doctor can force anyone to take a medication, or do anything for that matter. You are paying them, but it isn't for them to do everything you want them to do. Rather you are paying for them to help you, the opions on what course of action is necessary to help you may be different but clearly the goal is the same. Fighting a doctors opinion is more often than not counter productive. It will get you farther away from what you want, and leave you stuck with a half *ssed solution that only leaves you more pissed off about the situation. The key is to work with your doctor, not against. Otherwise you are just wasting time and money. Just my two cents.
Regards,
Matt
Posted by rvanson on April 9, 2006, at 22:28:15
In reply to Blind Faith In A P Doc, posted by Phillipa on April 9, 2006, at 0:48:45
> What I don't understand is so many come here to learn about others and their experiences with meds and combos ect. But in the end it seems like everyone thinks their pdoc is like a person to look up to and does whatever he says even though you know your own body better tnan anyone. Why do you spend time here and then do anything he tells you to do. It makes no sense to me you have a mind and a brain . Oh I understand if someone is psychotic or can't maked decisions for themselves but i think the decision to take a med is up to you the patient who pays their bill. Love Phillipa<
There are good Pdocs and bad Pdocs.
If you are your doctor don't "fit" as a team or talks down to you, you need to find another one.
Life is too short and there are lots of doctors willing to try a new med or whatever you might want, if the one you have now won't.
Posted by Phillipa on April 9, 2006, at 22:32:09
In reply to Re: Blind Faith In A P Doc, posted by mattw84 on April 9, 2006, at 22:17:53
Matt that's the key partnership. I have had good referrals to excellent medical care in my area. Where it falls short is in the pdoc area. And I don't think a medical doctor maybe surgeons have the God complex. The others especially the ER docs are very compassionate and want what is best for you. Now something must be wrong in this area as the pdocs won't and I say won't work with your medical doctor and have trashed info my medical doctor has sent to him. And this is a large practice and oh the God sydrome is very previlent here. only the pdocs. Do you think a single pdoc is better than a large practice? Love Phillipa
Posted by Phillipa on April 9, 2006, at 23:14:03
In reply to Last thing I should say on this thread, posted by Racer on April 9, 2006, at 21:52:08
Racer I'm sorry it's upsetting and I haven't had time to go through the archives. I will google Racer when I can and then maybe I will understand better. you're right I don't know your history. Love Phillipa
Posted by Racer on April 10, 2006, at 1:11:58
In reply to Re: Last thing I should say on this thread » Racer, posted by Phillipa on April 9, 2006, at 23:14:03
Posted by linkadge on April 10, 2006, at 12:40:51
In reply to Re: Blind Faith In A P Doc » linkadge, posted by gardenergirl on April 9, 2006, at 21:30:12
I think this study took that into account. Ie, it was considering the percentage of people in the workforce that you would expect to see on an SSRI.
Linkadge
Posted by linkadge on April 10, 2006, at 12:49:36
In reply to Re: Parnate is often augmented with Lithium, posted by SLS on April 9, 2006, at 21:01:50
While some doctors choose to augment a MAOI with lithium it I think it has generally been done so with distinct caution. Some reactions have been similar to MAOI-SSRI combinations. Ie serotonin syndrome / seizures.
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http://www.cpa-apc.org/Publications/Archives/CJP/2003/august/bauer.asp
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Effects of Lithium on the 5-HT System in Animals
There is consistent evidence from animal studies that lithium enhances 5-HTergic responsiveness by actions on turnover and release (40–42). Grahame-Smith and Green reported that an increase in 5-HT transmission, produced by enhancing the function of 5-HT neurons, could be demonstrated behaviourally by the appearance of “5-HT syndrome” in rats after short-term application of lithium (43). In their study, the combination of lithium and MAOIs produced a behavioural overactivity syndrome in rats that was indistinguishable from the overactivity evoked by MAOIs and tryptophan. This lithium-induced overactivity syndrome was blocked by prior administration of an inhibitor of 5-HT synthesis (43). Lithium administration was also shown to augment 5-HT release in the rats’ dorsal hippocampus (44) and to enhance 5-HT synthesis (45). Further, short-term administration of lithium also augmented the efficacy of electrically stimulating the ascending 5-HT pathway that suppresses firing of postsynaptic neurons in rats’ dorsal hippocampus (38)After adding 450mg lithium to parnate I experienced severe sweating, shivvering, diareah, confusion, etc. I should have gone to the hospital. I think I passed out, and came to (alive luckily)
Linkadge
Posted by Caedmon on April 10, 2006, at 14:20:35
In reply to Re: Parnate is often augmented with Lithium, posted by linkadge on April 10, 2006, at 12:49:36
Hi Link,
I can understand the need for caution but my understanding is that Li acts somewhat paradoxically on 5HT. I also believe that the combination is not uncommonly used.
I just find it an interesting circumstance that your pharmacist freaked out about it like that, and that you had such a negative reaction to the combination. I haven't heard of such a thing before.
Yes, I should think that all augmentation strategies for MAOIs should be done cautiously (450mg Li is probably a bit much in my view).
______________
Am J Psychiatry. 1988 Feb;145(2):249-50.
The combination of lithium carbonate and an MAOI in refractory depressions.Fein S, Paz V, Rao N, LaGrassa J.
Department of Psychiatry, Brookdale Hospital Medical Center, Brooklyn, NY 11212.
Lithium combined with phenelzine alleviated the symptoms of four severely depressed patients. Previously, all four patients had failed to respond to tricyclic antidepressants, and three had not responded to monoamine oxidase inhibitors.
____________
Am J Psychiatry. 1985 May;142(5):619-23.
Efficacy of lithium-tranylcypromine treatment in refractory depression.Price LH, Charney DS, Heninger GR.
Twelve inpatients with major depression refractory to at least two controlled antidepressant trials had tranylcypromine added to ongoing lithium treatment. Eleven patients showed reliable improvement in nurses' depression ratings compared with a prior trial of lithium added to an antidepressant that was not a monoamine oxidase inhibitor (MAOI). Eight patients were blindly judged much or very much improved, and all 12 patients improved sufficiently to be discharged. Preclinical studies of conjointly administered lithium and MAOIs suggest that central serotonergic pathways may mediate this robust clinical effect.
Posted by linkadge on April 10, 2006, at 15:24:19
In reply to Re: Parnate is often augmented with Lithium, posted by Caedmon on April 10, 2006, at 14:20:35
That study doesn't comment on the doses of the drugs used. Lithium is a 5-ht1b autoreceptor antagonist. It causes a release of serotonin in certain parts of the brain.
With less MAO-A to metaboloize it, the serotonin can accumulated to toxic levels leading to serotonin syndrome.
The pharmacy (shoppers drug mart) is geared with an interaction checker. This is a potential interaction. I'm sure you can find studies that suggest that certain populations respond to SSRI + MAOI combinations, but that doesn't negate the fact that there is a potential for interaciton.
I'm not saying never do it, I am just saying be carefull.
I guess the point I was trying to make was that my doctor was unaware that there was a *potential* for interaction. When the pharmacy questioned him he checked his books and decided not to go through with the combination.
Posted by linkadge on April 10, 2006, at 15:26:59
In reply to Re: Parnate is often augmented with Lithium, posted by linkadge on April 10, 2006, at 15:24:19
On two different ocasions, when I was hospitalized, there were inpatients with me who were there. One had a seizure from a Nardil Lithium combination (she was in a coma) and the other was hospitalized from serotonin syndrome due to a marplan, lithium combination.
Linkadge
Posted by gardenergirl on April 10, 2006, at 15:32:04
In reply to Re: Blind Faith In A P Doc » gardenergirl, posted by linkadge on April 10, 2006, at 12:40:51
Thanks for clarifying that. Not having seen the study, it was hard to interpret the statement.
Take care,
gg
Posted by Caedmon on April 10, 2006, at 16:04:40
In reply to Re: Parnate is often augmented with Lithium, posted by linkadge on April 10, 2006, at 15:26:59
It's just that, I couldn't find any case reports on PubMed re: MAOI + Li and negative interactions. I would expect this (semi-common) augmentation strategy would have at least one case report of seizure or serotonin toxicity associated with it in the literature, considering that you and at least two others who you know have experienced problems with it. Surely there would be something, but I can't find any. I may have entered the wrong search parameters. (Or I completely missed it, which is also possible.) Anyone have better skills than me, can find something?
It is good to know about nonetheless. I wonder about the MAOI + Lamictal combination having a small possibility of serotonin interactions as well, since it acts lightly on 5HT3 as well as some sigma opioid junk?
- C
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