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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 18 of 18. This is the beginning of the thread.
Posted by gmb on June 17, 2006, at 8:02:41
I wrote a note a few months ago about how happy I was to have achieved a steady, happy state. (I wrote it under a different username that I can't seem to use any more.) I'd started with an ADHD diagnosis and started Ritalin. It helped at first, but my moods went up and down with the dose. I started at 15mg per day, finally going to 90mg. I was angry a lot, especially coming off the medication in the evening. Back to the doc.
Hmmm, it looks like it was depression as well, just like I'd suspected. I started Cymbalta at 20 mg, going to 40mg daily, with smaller amounts of Ritalin. Everything went great except for the sexual side effects. Back to the doc.
How about dropping to 20mg of Cymbalta? Not effective. OK, let's add Wellbutrin at 100mg, moving to 300mg, keeping Cymbalta and Ritalin at 20mg and 20mg daily. This seemed to work, but it was never as good as the higher Cymbalta dose.
Four months ago, I made a huge career change. I gave up half of my salary to have more free time with my family. Depression returned intermittently along with periods of intense anxiety. The doc said it was to be expected and it would settle down.
But, it hasn't. The past two weeks have been horrible. I contacted the doc by e-mail, letting him know that things are bad. I admitted that I'd been using alcohol to cut the fears. I didn't like to admit that, and he didn't like it at all either, and I don't blame him. He told me to stop the alcohol and keep a diary of my feelings and desires to drink. I've done that.
The past two weeks have included periods of extreme dread, suicide ideation, inability to focus at work, killer headaches all day long, anger, etc.
I'm just not even sure what to think about where I should go next from a medication perspective. I'm not the doc, but something isn't right. I know that it makes no sense to take three meds daily and still feel this way. I don't want to go back to the sexual side effects. Benzos worry me because I'm a long distance runner and they can't possibly do anything but hurt me there, I'd think. Buspar seems to have a low success rate.
I already gain weight easily, despite my running, so something like Remeron worries me as well.
Other SSRIs worry me (and my wife) because of sexual side effects.
Any thoughts from the wealth of experience out there? I might go back into therapy as well for a while. The doc seems to think this is all a temporary or minor setback, still related to the job change. He's the pro, but I think that I'm past the worry about the change. It's been great, we're doing OK on less money, and yet, I feel like crap. Will it just resolve on its own in another month or two?
If I'm going to feel this bad, I see no reason to continue to pay for three meds. I may as well save the money and feel bad on my own.
GMB
Posted by fca on June 17, 2006, at 13:21:14
In reply to I thought I was OK, but apparently not, posted by gmb on June 17, 2006, at 8:02:41
How much and how long are you running? Before my most recent crash I was increasing my running with out realizing it--clearly I was running away from my anxiety, fears and depression. I have run everyday except five for over 30 years so I know how important running is--BTW--I can almost assure you that alcohol is more of a problem for running than a benzo--do you run recreationally or competetively--I have no simple solutions--I am sure others more experienced will chime in--take Care fca
Posted by Phillipa on June 17, 2006, at 14:09:54
In reply to Re: I thought I was OK, but apparently not, posted by fca on June 17, 2006, at 13:21:14
Benzos don't cause wt gain. Love Phillipa I ran with Jim Fixx once in Westport CT. So now you know I am old not running anymore bike riding.
Posted by gmb on June 17, 2006, at 17:54:46
In reply to Re: I thought I was OK, but apparently not, posted by fca on June 17, 2006, at 13:21:14
> How much and how long are you running?
When I answer this, people will know that I've got some sort of mental problems!!!
I'm a reformed, ex-road runner who now races trail ultramarathons. I try to run at least one 100 mile trail race every summer and a few other races in the 50K-100K range. Next weekend, I'll be in CA, pacing a runner in the Western States 100 miler. A pacer runs with a competitor late in a race to keep them company, provide a safety element, and to provide advice. That race next weekend is the ultramarathon world's equivalent of the Boston Marathon. Well, for the US at least. There are a couple really big deal races in South Africa as well.
Three weeks after that, I'll be running in a 100 mile race in Vermont.
I know it sounds crazy, but it's something I really love. To me, the mental aspect is what is most interesting. You have to find a way to keep your body moving when your brain is getting all these signals telling it to quit. You do have to know when to quit, if necessary, but you also have to know when to simply ignore the tiredness and pain and just keep going. I've been doing this for a long time, running for 20+ years and ultras for 12+.
The think that prompted me to finally get some psychiatric help was when I finished the toughest 100 in the US two years ago, something I'd dreamed about for years, and I simply felt empty afterward. There was no joy at all in something that had been a goal for years - something I loved.
Sorry for the long rambling response. I don't think I'm running away from anything, and I do think the exercise helps me mentally. But, who knows?
gmb
Posted by gmb on June 17, 2006, at 18:00:48
In reply to Re: I thought I was OK, but apparently not, posted by Phillipa on June 17, 2006, at 14:09:54
> Benzos don't cause wt gain.
I was more worried about benzos from a motivation and coordination perspective. I don't really need to find excuses to skip runs and I don't want to fall down more often than I already do on trail runs.
I've taken valium twice in my life and I remember feeling a bit off in my coordination. Although, one of those times I'd also had percocet with it, as I was heading out the door for a minor surgical procedure that starts with a V. My wife was driving and I no longer cared what part of my body they were going to be cutting.
Remeron was the drug that really concerned me from the weight gain perspective. That is where I probably would have started on ADs, rather than Cymbalta, if I wasn't a runner and concerned about my weight. At least, that's what the doc told me he might have done.
Thanks for the responses.
Posted by fca on June 17, 2006, at 18:58:43
In reply to Re: I thought I was OK, but apparently not, posted by gmb on June 17, 2006, at 18:00:48
I don't think you are nuts at all--I have always aspired to do ultramarathons--my most ambitious undertakings have been triathalons (1 mile swim, 50 bike and 10 mile run)--I also have done many centuries on my bike. Now my running (pre-geriatric shuffling) is by time 50 minutes every week day and 70-90 each weekend day plus a modest bike ride in the evening.
As a life long runner/biker I will tell you that you need to critically examine the amount of exercise you are doing to better assess you depression and anxiety--you know and I know that one of the first symptoms of overtraining is lethargy, depression, anxiety, difficulty sleeping etc. I would never suggest you give up running--I firmly believe it has been instrumental in keeping me together for the last 37 years (I am 64). But if I was a physician and putting you on a medication program I would want you to reduce (substantially moderate) you running for at least 12-16 weeks. I am totally making this up but I would put a limit of 25-30 miles per week with at least two days of rest or very easy jogging.
Let's face it--traditional treatment protocols simple are not tested and used on persons who are stressing their body the way you are--I certainly do not think running is the problem but it has to be a significant clinical challenge to figure out a medication program for you. Who knows what is happening to your neurotransmitters let alone other chemistry under those sustained conditions. I would be very interested in knowing what you do and how you progress--my best wishes and hopes for you fca
Posted by gmb on June 18, 2006, at 8:12:18
In reply to Re: I thought I was OK, but apparently not, posted by fca on June 17, 2006, at 18:58:43
>you know and I know that one of the first
>symptoms of overtraining is lethargy,
>depression, anxiety, difficulty sleeping etc. II certainly recognize the physical symptoms when I'm overtraining, but don't know that I'd recognize the mental side of things as well these days. When you mix in the roller coaster of the past two years, the lines aren't so clear any more. And given my family history ( my mother's story is beyond sad - untreated depression and GAD for decades - well, I could write a novel on that one ) and my own history, it might be even more difficult. Even though I finally sought some help at age 42, I can look back and see depressive issues back into my late teens, and I know that I've used alcohol and exercise and other activities over the years as treatment for the way I felt. Some of it was probably appropriate and some of it not.
>But if I was a physician and putting you on a
>medication program I would want you to reduce
>(substantially moderate) you running for at
>least 12-16 weeks. I am totally making this up
>but I would put a limit of 25-30 miles per week
>with at least two days of rest or very easy >jogging.Here's an old joke among physical therapists:
Q: How do you get rid of a patient that you don't like treating if he's a runner?
A: Tell him not to run and he'll go somewhere else.
I do tend to take two rest days per week, and at the peak of my training, I might do a really easy run on those two days, 3-5 slow miles. But, I manage to cram 60-80 miles into the other five days. If a doctor asked me to run only 25-30 miles per week in the winter, I'd say OK. At this time of the year, I'd probably look for another doc.
Although, the truth is I've got a great doc. I was very lucky to become a patient of his. He treats lots of very sick inpatients at a learning hospital, he's on faculty at the med school, he does a lot with tele-medicine, and he turned down two friends of mine because he simply couldn't take on more patients. I don't know how I managed to sneak into his practice. He is accessible by e-mail all the time and even though I've told him to bill for appointments for some of our e-mail or phone calls, he hasn't done that.
> Let's face it--traditional treatment protocols
>simple are not tested and used on persons who
>are stressing their body the way you are--IAgreed. There are about 2000 people in the US that finish a 100 mile race each year. It's such a small fringe sport that very little has been studied.
One thing that is obvious in the ultrarunning community is a history of obsessive behavior, substance abuse, failed marriages, etc. Many of us are running away from something and/or self-medicating through exercise. I think that we like to think that this is a more benign type of obsessive behavior, but it's not that way for everyone.
Speaking of which, it's time for me to go run before the heat gets any worse.
Again, thanks for your thoughts.
GMB
Posted by Caedmon on June 18, 2006, at 10:55:17
In reply to I thought I was OK, but apparently not, posted by gmb on June 17, 2006, at 8:02:41
I'm just throwing out some ideas here, maybe they are bad but maybe they are worth looking into:
Perhaps you could try the higher dose of Cymbalta again along with 300mg of Wellbutrin?
Or you could try an SSRI. There are various antidotes to sexual side effects which may work. Buspar sometimes helps sexual dysfunction. You might have your sex hormones tested on an SSRI - a doc might try testosterone or a drug that combats prolactin.
Lyrica seems to have some success treating anxiety, perhaps it wouldn't impact your sports performance? It's an idea. Also Neurontin, which is a similar drug.
I take benzos and I run and lift weights. But I am not competitive. I suspect alcohol has more adverse effects on performance (and maybe weight?) than SSRIs or benzos generally would.
Therapy is worth looking into. If you have a hunch that it would help, then I would go with that hunch.
- Chris
Posted by fca on June 18, 2006, at 10:57:59
In reply to Re: I thought I was OK, but apparently not, posted by gmb on June 18, 2006, at 8:12:18
I am so glad you have a great doc--I am also lucky with my pdoc (totally accessible) and I am fortunate to see one of the best CBT therapsists in the country (talk about pressure to improve). I do totally understand your responses--I would never quit running (well I might if I could substitute biking) but the sheer simplicity and elegance of running make it almost irreplacable. I really want to offer some sage advice but with the doc you have I can not think of anything to say. I always described my daily running as a positive addiction/obsession which I do truly think it is--but as I got older I also realized there were other pure obsessive streams in my thinking that were causing unnecessary pain and depression. May be a sit down with a really good cbt might be helpful. For some reason I feel a great deal of empathy for youyr discomfort (perhaps it is to close to home). I wish you the best and please keep us posted--If I have any brainstorms I will post them for what they are worth. I run a large community mental health center and I will pick some of the docs brains--with never a mention regarding the possibility of reducing your running program. Stay in touch fca
Posted by fca on June 21, 2006, at 17:20:10
In reply to Re: I thought I was OK, but apparently not, posted by fca on June 18, 2006, at 10:57:59
I spoke with my favorite pdoc today about you--obviously a brief summary--she has never treated an untra-distance runner but has seen a number of marathoners. Bottom line, she would not be particularly concerned with your running unless you were on certain drugs where specific blood level were extremeluy important--she said she would generally approach it as if the distance running was one aspect of your life and would not feel a need to ask you to reduce it. So you have my mea culpa--best wishes on you running and finding that right mix for you
Posted by Donna Louise on June 22, 2006, at 6:47:09
In reply to Re: I thought I was OK, but apparently not, posted by gmb on June 18, 2006, at 8:12:18
Well, small world, even on the net. I ride horses in distance events and although I haven't done the Tevis or the one in Vermont, I know how exhausting it is to just ride a horse 100 miles. The mental confusion at the end is really amazing. I am also dizzy for days. And I just riding. Wow, you guys have always amazed me.
As a recovering alchohol and drug addict, I find that I need alot of adrenaline type stimulation, a living on the edge if you will. It satisfies a need that keeps me from seeking satisfaction in other less satisfactory ways. I used to run a little too, I wish I could get remotivated.
Oh, the little klonopin I take does not effect in any way my motivation or coordination, it makes is one of the things in the aresenal that makes my life possible. And for me, I need a certain level of serotonin for some remission and when I was taking cymbalta, I needed at least 40mg. I have MMD and generalized anxiety disorder.donna
Posted by fca on June 22, 2006, at 13:10:34
In reply to Re: I thought I was OK, but apparently not » gmb, posted by Donna Louise on June 22, 2006, at 6:47:09
I completely agree about small doses of klonopin--I notice no lack of motivation or coordination--it does make things just a bit easier--I seriously doubt if it would impair running--if you can handle a horse on Klonopin I am relatively sure one can handle their feet. fca
Posted by Dr. Bob on June 22, 2006, at 23:33:55
In reply to I thought I was OK, but apparently not, posted by gmb on June 17, 2006, at 8:02:41
> (I wrote it under a different username that I can't seem to use any more.)
A different username 5 letters long? :-)
Bob
Posted by dmlvt on June 29, 2006, at 9:03:15
In reply to Re: I thought I was OK, but apparently not, posted by fca on June 21, 2006, at 17:20:10
> and would not feel a need to ask you to reduce
> it. So you have my mea culpa--best wishes on
> you running and finding that right mix for youNo "mea culpa" is necessary here. I asked for advice and all of it is worth considering. In general, I do feel that the running is a positive overall.
Right now, any time that I am by myself, from a mental rather than physical perspective, I seem to start getting anxious and things just go downhill quickly. Flying twice within the last week was especially bad. The only "alone time" where I feel OK these days is when I'm running. If I'm feeling bad and I start running, I feel better within 10 minutes of starting the run.
dmlvt
Posted by dmlvt on June 29, 2006, at 9:09:20
In reply to Re: I thought I was OK, but apparently not » gmb, posted by Donna Louise on June 22, 2006, at 6:47:09
> or the one in Vermont
The one in VT is great because the horses are on the course at the same time as the runners. I really enjoy sharing the trail with them.
> I know how exhausting it is to just ride a
> horse 100 miles.I always wonder what the horses think about it!
> Oh, the little klonopin I take does not effect
> in any way my motivation or coordination, it
> makes is one of the things in the aresenal
> that makes my life possible. And for me, I
> need a certain level of serotonin for some
> remission and when I was taking cymbalta, I
> needed at least 40mg. I have MMD and
> generalized anxiety disorder.Thanks for those thoughts. I have been put back up to 40mg of the Cymbalta and I've dropped the Wellbutrin to 100mg. The goal is to get me stabilized now and worry about any side effects later.
The doc seems reluctant to try Xanax or Klonopin right now. I would love to try one of them just once when I'm feeling really bad to see if it makes a difference. If not, I'd be glad to just wait out all of this right now. Maybe I will need to go to 60mg of Cymbalta eventually. But, the negative feelings I'm being hit with these days seem to be more anxiety than depression. I understand the reluctance to start anyone on a benzo, but I've had some really, really bad days recently and I don't think the pdoc really understands how bad they've been.
Again, thanks for the thoughts.
In just 16 days, I'll be out there with the horses for 100 miles in the mountains of Vermont.
dml
Posted by dmlvt on June 29, 2006, at 9:10:23
In reply to Re: different username » gmb, posted by Dr. Bob on June 22, 2006, at 23:33:55
> A different username 5 letters long? :-)
Yes, obviously. Seeing that you switched the thread to my other username, you clearly got it right. Thanks.
dml
Posted by Donna Louise on June 29, 2006, at 11:21:07
In reply to Re: I thought I was OK, but apparently not » Donna Louise, posted by dmlvt on June 29, 2006, at 9:09:20
> > or the one in Vermont
> The one in VT is great because the horses are on the course at the same time as the runners. I really enjoy sharing the trail with them.
>
>
> > I know how exhausting it is to just ride a
> > horse 100 miles.
>
> I always wonder what the horses think about it!
>
> > Oh, the little klonopin I take does not effect
> > in any way my motivation or coordination, it
> > makes is one of the things in the aresenal
> > that makes my life possible. And for me, I
> > need a certain level of serotonin for some
> > remission and when I was taking cymbalta, I
> > needed at least 40mg. I have MMD and
> > generalized anxiety disorder.
>
> Thanks for those thoughts. I have been put back up to 40mg of the Cymbalta and I've dropped the Wellbutrin to 100mg. The goal is to get me stabilized now and worry about any side effects later.
>
> The doc seems reluctant to try Xanax or Klonopin right now. I would love to try one of them just once when I'm feeling really bad to see if it makes a difference. If not, I'd be glad to just wait out all of this right now. Maybe I will need to go to 60mg of Cymbalta eventually. But, the negative feelings I'm being hit with these days seem to be more anxiety than depression. I understand the reluctance to start anyone on a benzo, but I've had some really, really bad days recently and I don't think the pdoc really understands how bad they've been.
>
> Again, thanks for the thoughts.
>
> In just 16 days, I'll be out there with the horses for 100 miles in the mountains of Vermont.
>
>
> dmlYou lucky dog. Going to Vermont. I did the 3 day 100 there last year (horses only) and loved the area. Say hi to the Rojecks for me. Donna from Altoona, Fl.
I was more afraid to take a benzo than my pdoc was to prescribe it to me. I was afraid I would get addicted because of my past history. But not so, just take them as prescribed. Anymore than that puts me in a place that feels non-therapeutic.
i have managed to pull a hip flexor muscle that is now bothering me even to walk. don't feel it at the time but I do the next day. I can tell how much it helps my mental health to run when I am not able to, even though it is nothing compared to you guys. At least it doesn't bother me to ride. Or I would truly lose my mind.donna
Posted by Phillipa on June 29, 2006, at 20:41:17
In reply to Re: I thought I was OK, but apparently not » fca, posted by dmlvt on June 29, 2006, at 9:03:15
That's how I felt when I could run. Now that I can't I riding my bike but it's not the same. Nothing like the runner's high. Love Phillipa
This is the end of the thread.
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