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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 25. This is the beginning of the thread.
Posted by jealibeanz on July 12, 2006, at 20:18:50
OK, so I've got to update my doctor (family practioner, DO) on how I'm doing... not so well with the insomnia, anxiety, and depression. Actually, very badly.
My Lunesta, which I once loved has progressively stopped helping since I moved 2 months ago. I sleep 3 hours a night at best. I'm very stressed and have a full day of school and work, so this is making life very difficult, physically, emotionally and academically. I've used Ambien CR before and expericed nightmares, hallucinations, and sleepwalking. Yes, I believe some of the crazy stories on TV. So, I wonder what the next approach will be. I NEED sleep! Deperately, it's not helping my already fragile emotional state. I liked Lunesta because I never felt "drugged" yet it was strong enough to work fully every night for the entire night. What are some other good options?
My Xanax isn't fully covering the anxiety. I take .25 mg 3 times a day. I'd really like to increase and hope he's OK with that.
The depression is not good... at all. I'm really unhappy, negative, tearful hopeless, don't care about life. I don't want to mention this. I'd really like to try an antidepressant (no SSRI/SNRI!). I think I need one (but what?). I just am praying and can find a few meds that can get me back on track and in a positive frame of mind. It's gonna be a rough existence to continue with this way a feel right now.
Posted by Phillipa on July 12, 2006, at 22:26:03
In reply to My new list of symptoms for my doc, posted by jealibeanz on July 12, 2006, at 20:18:50
You've already tried EMSAM haven't you? Or am I mistaken. Love Phillipa
Posted by jealibeanz on July 13, 2006, at 10:52:49
In reply to Re: My new list of symptoms for my doc » jealibeanz, posted by Phillipa on July 12, 2006, at 22:26:03
No, I haven't. I've just been thinking about it personally. My doctor doesn't even know about the depression right now. He initially put me on Paxil, the Buspar, the Wellbutrin, then Klonopin for anxiety years ago. His PA put me on Klonopin for anxiety, which induced crying spells/depression, so he put me on Effexor. My doctor recently put me on Xanax for anxiety. I guess he doesn't really know how much of an issue depression is for me, this it's hugely anxiety. I suppose I tend to forget that he doesn't understand if I don't tell him. (I also hadn't seen him in years, so it's understandable that we hadn't had the closest relationship for a time. The depression/anxiety comes and goes, so it's hard for me to consistently present symtoms anyway)
Posted by jealibeanz on July 13, 2006, at 21:53:33
In reply to Re: My new list of symptoms for my doc, posted by jealibeanz on July 13, 2006, at 10:52:49
I wonder if stopping my Strattra would help. I know it caused insomnia when I first began taking it, even though I'd been on lunesta successfully for 5 months at the time. I only have mild ADD. (I think most of the severe symptoms are caused by the anxiety/depression, I can probably manage the ADD by willpower and work ethic if my other illnesses are uncontrol. Unfortunately they are not.) So I may be OK, but am in an intense grad program right now so hesistate a little to D/C.
I know it gave me so energy during the day, I definitely appreciated that when I first started. I don't notice it now, but would surely miss it if I were to crash! I have classes sometimes up to 10 hours are day straight! No time for rest. All waking hours are spent studying. So I need energy, which I am lacking due to the fact that I don't sleep. So maybe it would be a trade off. Drop the Straterra, sleep at night, be refreshing, just not extra energized from medicated during the day.
I also worry that I'd sink into major depression since I'm at a pretty bad state right now and the Strattera is known as an off label antidepressant, a NE reuptake inhibitor, sorta like Wellbutrin without the DA reuptake and tiny bit of SE reuptake nobody talks about and Effexor without the SE reuptake. The funny thing is take both Effexor and Wellbutrin caused me to gain weight rapidly, killed my appetite, and caused apathy. Straterra lessens my appetite, but no weight gain or appetite. I guess my body doesnt mind NE reuptake, but doesn't like SE or DA reuptake. I also gained with Paxil and Buspar.
Here's more detail on my past drug's metabolism:Wellbutrin (gained 20 lbs in 4 months)
DA reuptake inhibition +
NE increase
ACh(n) antagonistBuspar (2 lbs/wk)
5-HT1a full agonist (pre)
5-HT1a partial agonist (post)
DA2 partial agonist
* 1-PP metabolite:
NE-alpha2 antagonistPaxil (2lbs/wk)
SSRI
5-HT reuptake inhibition +++
ACh(m) antagonistEffexor- gained quickly 20lbs, in 6 wks! this gives some clue that probably all of these receptors are the likely culprits for me!
SNRI
5-HT reuptake inhibition +++
NE reuptake inhibition ++
DA reuptake inhibition +Current:
Strattera:
NE reuptake inhibition +++
-no major side effectsLunesta:
BZD, GABA receptor agonistXanax- Current, 2 months (.75 mg total daily); provides OK anxiety relief, need a higher dosage to be fully efftive
BZD agonist
5-HT release ... this is like serotonin, meaning a liklihood to gain weight? I have had some struggle lately despite my best efforts. Has anyone else experienced this? I know some people move less, but I work out a tonnn, in the AM before taking it. Then I have a busy day, so no opportunity to lie on the couch all day.Based on my current past history, what would be a good next line of treatment for the anxiety/depression/ADD/insomnia?! (alot, I know). I'm willing to leave the ADD untreated. As far as anxeity depression meds go, I'm completely against weight gain as a side effect. I don't like apathy, but I think that goes along with whatever causes weight gain. For insomnia... I hate Ambien! Made my crazy and feel drugged. I need something that's effective, yet doesn't cause me to sleepwalk and hallucinate.
Posted by Phillipa on July 13, 2006, at 22:32:24
In reply to Re: My new list of symptoms for my doc, posted by jealibeanz on July 13, 2006, at 21:53:33
I hope you wrote this all down for your doc but I have a feeling you know a ton more than he does. Good luck How long before your out of classes. Love Phillipa
Posted by jealibeanz on July 14, 2006, at 0:06:49
In reply to Re: My new list of symptoms for my doc » jealibeanz, posted by Phillipa on July 13, 2006, at 22:32:24
I've got a month of classes and 5 weeks til my appointment. Anyone have suggestions as far as meds go?
Posted by jealibeanz on July 14, 2006, at 0:13:15
In reply to Re: My new list of symptoms for my doc » jealibeanz, posted by Phillipa on July 13, 2006, at 22:32:24
Is 3 x .25 mg Xanax even considered a therapeutic dosage for an adult? Seems like a child's amount, at best.
Posted by Phillipa on July 14, 2006, at 20:05:45
In reply to Re: My new list of symptoms for my doc, posted by jealibeanz on July 14, 2006, at 0:13:15
It's not very strong I always took at least 2mg a day. With maybe .5 of klonopin. Love Phillipa
Posted by jealibeanz on July 14, 2006, at 21:27:13
In reply to Re: My new list of symptoms for my doc » jealibeanz, posted by Phillipa on July 14, 2006, at 20:05:45
I didn't think so, especially considering I'm not taking any other antidepressant or antianxiety medications. I called my doc today and left a message, hopefully he'll agree!
Posted by circusboy on July 14, 2006, at 21:32:34
In reply to My new list of symptoms for my doc, posted by jealibeanz on July 12, 2006, at 20:18:50
> OK, so I've got to update my doctor (family practioner, DO) on how I'm doing... not so well with the insomnia, anxiety, and depression. Actually, very badly.
>I've never experienced that kind of insomnia that wasn't clearly caused by circumstances (starting a new job, etc.). However, I've got the anxeity/depression thing covered.
Have you considered the possibility that the Strattera may be causing the depression directly? Over the last few months I've been experimenting with the stuff, and found that it does push me into a hole... I start feeling vaguely hopeless, like almost nothing is worth doing, much less smiling about. I'll actually feel a sort of weight on my face, like it would take an extraordinary effort to smile. When it gets really bad I'll withdraw from friends and coworkers, thinking I've got nothing worthwhile to add to their lives.
Still, Strattera is powerfully effective for my particular brand of concentration problems/executive dysfunction type stuff...so much better that Ritalin (which I still take as well). I'm trying again at 25mg twice a day (down from 40mg twice a day) and hoping.
Anyway, search for (especially) zeguma's posts on Strattera. She had an initially wonderful response and then came crashing down. Just like me, and perhaps you as well.
A possible substitute and an excellent antidepressant -- if you can tolerate it, which I couldn't -- is desipramine. It was probably the most effective and balanced AD I've ever taken. Unfortunately it gave me that classic sort of TCA insomnia: a sort of "Tell-Tale Heart" without the terror to make it interesting.
-cb
Posted by jealibeanz on July 14, 2006, at 22:54:27
In reply to Re: My new list of symptoms for my doc, posted by circusboy on July 14, 2006, at 21:32:34
Hmmm... well, I've gone through bouts of depression for a few years now, since a was a teenager. I don't think Straterra is causing it. My last was last fall, which I probably didn't fully recover from. The depression returned a couple months after I quit Effexor, claiming that I felt better, because I did. I wasn't going to take it any longer because of the side effects. The insomnia has been for the past year, but has been controlled by the Lunesta. Recently, I moved and started and a very difficult grad school program. Yes, it is partially caused by outside factors. Still, I need medication to relieve symptoms because I have not been able to treat it "naturally" and lack of sleep is a horrible thing to deal with.
Posted by nickguy on July 17, 2006, at 12:47:40
In reply to Re: My new list of symptoms for my doc, posted by jealibeanz on July 14, 2006, at 22:54:27
I would also say try a TCA. Nortriptyln if you take it at night can be good in helping you sleep. The only problem for me, (I take desipramine) is that the side effects can sort of mimic anxiety. i.e- dry mouth, shaking...
Desipramine is used for a.d.d and depression. It's sometimes used for people on cocaine withdrawal, because it can be quite stimulating. I don't think weight gain is an issue but I can't say for sure.
With the xanax, could you skip using it a few times here and there so that at other times you could take 2?Although, If it's not working and you tell your doctor that, I think he would probably prescribe a higher dose since he's prescribed it at all.
The other option is the MAOI's which are hard to get and are kind of a hassle with all the restrictions. But if you've tried many other options than going with an MAOI might be a good idea.
There's many other combinations and alternative options so know that something will work for you eventually. If your not happy with your doctor, than write all your history down and go see a new one. I really stress this because I wasted too much time and money on a guy who didn't do anything for me, and now I have a psychiatrist who is willing to try pretty much anything.
Posted by jealibeanz on July 17, 2006, at 17:07:56
In reply to Re: My new list of symptoms for my doc, posted by nickguy on July 17, 2006, at 12:47:40
I'm pretty sure I don't want a tricyclic, tend to cause weight gain, right, along with other side effects. I had enough problems with that aspect of SSRI's, even the "weight loss drug", Wellbutrin, and Effexor.
I've gone to a psychiatrist. I thought he would help. He gave me absolutely nothing and send me on my way, basically "fired" me on the spot! Saying that I won't respond to meds since any depression/anxiety wasn't caused by a traumatic situation, such as a death. Who's heard of such a thing. I later found out that it was a state facility and they're terrible, no kidding!
I sought out two other GP's. They both dismissed me. So I went back to my own family doctor. The reason why I didn't want to see him in the first place was that it almost felt too personal since he knows me, my family, and I interned there, but I realize this may be to my benefit. It's a little awkward with people you know, but he's willing to help because he knows me. I've never actually seriously persued other AD's with him. I just stopped taking them when I grew too tired of the side effects and didn't come back (no rechecks!) other than for sinus problems, ect.
The Paxil/Buspar/Wellbutrin were all consecutive with him. That was one episode. I eventually quit the meds. I came back one year later and got Klonopin + Adderall. My psychologist thought that was a horrible terrible idea and convinced me never to take them again. Me, being young and uneducated on the matter, believed that he was right. So, that ended that med trial.
Two years later I was having anxiety and my doc's PA gave me Klonopin + Adderall, which I took for several days and it through me into a major, deep, dark depression. I stopped, went back, and he put me on Effexor. I had brief moments of happiness when I decided to do my own titration (oops! haha, I now know I shouldn't have experimented). After 6 weeks I quit due to major apathy, extreme nausea (couldn't eat a thing, yet...) and an extra 20 lbs. I told my PA I felt fine (no longer going through crying spells) basically because I wasn't about to be put on another SSRI or Cymbalta (his other suggestion, but thought I'd have similar response).
I know my PA probably wouldn't have been comfortable even suggesting an MAOI/TCA/ or some other more "radical" alternative. I don't bleme him! PA's don't need to go down that road, not "safe". My doc probably would at least consider or talk about it with me if I asked. (he actually said something about prescription weight loss drugs when I complained of difficulties losing the SSRI weight gain, but said I wasn't thaaat heavy to require them, however it was his suggestion, not mine!) I just feel awkard bringing up 1. depression and 2. medications suggestions, because I hate sounding like one of those people who researched online and wants tp self-prescribe and tell the doc what to do.
How common is it for GP's to prescribe anything other than SSRI's these days? Are MAOI's or TCA's the next line of treatment. I keeping getting drawn toward EMSAM, for my own reasons, I feel an MAOI would treat my type of anxiety/depression (and it has fewer side effects than oral meds, and hopefulllly no weight issues). Plus, since it's new, GP's like to give out the latest and greatest drugs. But if the drug reps haven't visited, which I doubt, then it wouldn't be so likely.
Posted by nickguy on July 17, 2006, at 17:49:58
In reply to Re: My new list of symptoms for my doc, posted by jealibeanz on July 17, 2006, at 17:07:56
It seems like trying to get the meds you want is a pain in the *ss. I really reccomend trying different pyschiatrists if your not confident in your doctor, and especially if he's not willing to consider things that you have researched and want to try. Doctors can ocassionally be a-holes who think they know everything and take offense at your suggesting different meds. Even if you get a vague vibe of this nature, find somebody new.
My old pyschiatrist would never let me talk, and thought that I was bi-polar just from the very fact that my grandmother was bi-polar. I never had any mania, even of a bi-p 2 nature. So he treated me with basically all mood stabilizers and anti convuslants. None of them worked even remotely. For my social anxiety, he gave me gabitril. It didn't do anything, and when I went to see him he said "oh i didn't think that would work anyway." Why'd ya prescribe it for me than jackass? He refused benzos to me because I drink. He refused maoi's and all other antidepressants because he thought they would make me manic, because of his bi polar theory. I never switched for 6 months because I thought it would be too much of a hassle.
SInce i've switched to a different guy who is very friendly, listens to me, and is very intelligent, I've started a TCA (which I wanted to experiment with) and we're discussing maoi's in the future if this doesn't work out. We're also discussing stimulants for depression which my old doc would never even consider. I take ativan and inderal as needed for anxiety and it's made a big difference in my quality of life. It's also reassuring that he is willing to go down many different roads until I feel better.Well, nobody needed to hear that story but I just think it's really important to get a good pyschiatrist who you trust, feel is knowledable, is friendly and willing to listen, and respects your knowledge and will do whatever it takes to get you feeling better.
Posted by Phillipa on July 17, 2006, at 20:37:20
In reply to Re: My new list of symptoms for my doc, posted by jealibeanz on July 17, 2006, at 17:07:56
I don't respond to my meds either and I'd been waiting for EMSAM and the results of others. To me the idea of a patch you can take off and not a pill appeals to me. If the drug works well maybe docs won't be hesitant to prescribe it. But first the price has to come down. Love Phillipa
Posted by jealibeanz on July 17, 2006, at 20:53:58
In reply to getting a good psychiatrist, posted by nickguy on July 17, 2006, at 17:49:58
I've never brought up alternatives with my doc. I don't know where he usually goes after SSRI's/SNRI's/Wellbutrin are not tolerated/beneficial. For all I know, he does have some other AD that he uses when all else fails. But I just don't know how he handles such cases. I'm afraid to ask due to fear of rejection.
Again, bringing up the topic of depression is hard, but it's even more difficult when you're unsure he can do much for you. (after all, even if he were willing to prescribe every med under the sun, I don't know one will work.) If say, I'd had luck with Zoloft in the past with him, and were going through depression again, I'd have no problem saying ummm I think I may need to go back on Zoloft. But that's not my situation. I have lists of drugs I don't want, and they of course, are the meds he'd prefer to use.
Actually, I feel I have a better chance of getting a different medication from him than from anyone else in the world, especially anyone I have easy access to. I've seen so many close minded docs. He is not one of them. He's very caring and compassionate.
Even if he is listening to me thinking "this girl's crazy, can't be helped by meds, and wayyy too drug-seeking" (like others have basically either said blatantly to my face, or partially said and the other part implied...) he doesn't show it. I feel important to him (medically and personally), even though his visits are short, as the practice is extreeemely overbooked. He has listened to ideas in the past.
The one thing he turned down years ago was Topamax, to offset the SSRI weight gain, no big deal. He said they weren't sure that the potential benefits outweighed the risk for major side effects. That's a respectable decision, as I think I was really stretching it to propose the idea.
I asked him for the combo of Klonopin + Adderall (got that idea from this forum). Back then, I had nooo clue what a benzo was, let alone had enough knowledge to understand why it may work and why a stimulant also may help social anxiety/general anxiety (wasn't experiencing a depressive episode at the time).
He isn't afraid of prescribing medications. I'm on Lunesta right now, and have been since last fall. Many docs wouldn't even let Lunesta go that long, for fear of dependence, but at least it's a lower scheduled drug. Quality of life is enhanced when one sleeps. Thank god he and his PA recognize that. I don't like the idea of taking sleeping meds, but not sleeping is just not an option!
He's giving me daily Xanax right now for an indefinite time period. Actually, he just increased the dosage today after I left a message with his nurse asking him to consider the idea. He never spoke to me, just did it. He never scheduled a recheck, just told me to call from college and he'll write it every month. Right now he realizes that the Xanax is helping me get through a major stepping stone in life. Ideally, he and I agreed I'd be able to stop, but that's not in consideration right now.
So, that's pretty gutsy for a family practitioner! I think he also trusts *me* and would not do so for everyone who walks into his office, or else he'd be in some trouble with the DEA.
But, he is willing to help me out. I just wish I could read his mind to know what he'd say if I brought up the depression and opposition toward all reuptake inhibitors. Next time I see him, in August, it's for a physical, so I will have him working at a slower pace with more attention. I also just can't find the words... It's hard when you already feel volunerable.
Posted by jealibeanz on July 17, 2006, at 21:01:25
In reply to Re: My new list of symptoms for my doc » jealibeanz, posted by Phillipa on July 17, 2006, at 20:37:20
I don't have a problem with cost. I have wonderfullly low copays on everything. I just am unsure of what the medical community thinks of the medication at the moment.
Posted by nickguy on July 18, 2006, at 16:39:14
In reply to Re: getting a good psychiatrist, posted by jealibeanz on July 17, 2006, at 20:53:58
"Again, bringing up the topic of depression is hard, but it's even more difficult when you're unsure he can do much for you. (after all, even if he were willing to prescribe every med under the sun, I don't know one will work.) If say, I'd had luck with Zoloft in the past with him, and were going through depression again, I'd have no problem saying ummm I think I may need to go back on Zoloft. But that's not my situation. I have lists of drugs I don't want, and they of course, are the meds he'd prefer to use."
As you obviously know, meds for depression or anxiety are on a trial and error basis. You'll never know what works without trying them. If you've been on a bunch of meds that havent worked, thats where doctors can start to get creative and try different kinds of combos and augmenting anti-depressants. If your unsure if he can do anything for you, like you said, than what's the point of seeing him?
There are AD's out there that don't cause weight gain and are worth a shot. I don't think many doctors are going to prescribe EMSAM or other maoi's, stimulants and such until all the other options are exhausted. What do you take at the moment (besides xanax) ?
Posted by jealibeanz on July 18, 2006, at 17:36:34
In reply to Re: getting a good psychiatrist, posted by nickguy on July 18, 2006, at 16:39:14
I currently take Strattera, 60 mg. Although I don't think my concentration problems are due to ADHD as much as the anxiety/depression. When you say "they are AD's which don't cause weight gain", which are you referring to? Neither Buspar, Effexor, and especialllly Wellbutrin are "supposed" to cause weight gain, however, something involved in their mechanisms cause this side effect, at a large rate, with my body. (I know it was the meds. I was a competitive athlete, working out twice a day, eating very healthily.) I'm not sure he'd go for a stimulant right now since I had a terrible time with Adderall.
Posted by nickguy on July 19, 2006, at 19:52:49
In reply to Re: getting a good psychiatrist, posted by jealibeanz on July 18, 2006, at 17:36:34
thats pretty weird that you exercised and ate well and yet STILL gained weight on AD"s that ARE NOT supposed to have weight side effects. I don't understand how that's possible, because food is what gives us weight, and exercise burns excess fat. Maybe those AD's do something to your digestive system?
Maybe you could try an AD along with an appetite suppressant.
Posted by jealibeanz on July 19, 2006, at 20:30:59
In reply to Re: getting a good psychiatrist, posted by nickguy on July 19, 2006, at 19:52:49
This isn't uncommon. Many people gain weight from medications. Some more than others. I happen to be in the category of those who gain large amounts for no apparent reason, other than a change in medication. All of the metabolic pathways and mechanisms of AD's are not understood, therefore the weight gain cannot be clearly understood in those who are surely not violating the calories in vs. calories out rule.
I think my body takes this to the extreme. Appetite suppressants would not help or be healthy. I had to force myself to put some fuel in my body at least 3 times a day, but it ended up being mainly veggies, salads, because no food would sit well in my stomach and I was never hungry. I barely ate a few bites of food throughout the day, and all healthy, fresh, lowfat, during the period when I took Effexor. It made me that nauseous. Yet, I was still very very active, with large amounts of exercising daily like I always had, plus a very full day's worth of classes, internship, work, and more.
There may be some byproduct of the drug's metabolism, a major drug-induced alteration of my own body's metabolism, or a combination of the two that causes this to occur. All I know is that any medication with even the slightest bit of serotonin reuptake inhibition (Wellbutrin has a little) causes a major disruption in my own body. Straterra, on the other hand, is only a NE reuptake inhibitor and does not cause this side effect with me.
So, my point is that I definitely know that SSRI's/SNRI's do this to me. Maybe I don't need serotonin, at least not in that method of delivery. That's why I'm interested in EMSAM. At lower doses there's no serotonin involved. If that doesn't help, bumping up to the largest patch gets serotonin into play, and I could see if that helps.
Posted by nickguy on July 20, 2006, at 12:30:49
In reply to Re: getting a good psychiatrist, posted by jealibeanz on July 19, 2006, at 20:30:59
yes some medications can cause weight gain, it's just strange because those that you mentioned (wellbutrin for example) usually don't. What about a norepinephrine uptaker like desipramine?
Posted by jealibeanz on July 20, 2006, at 19:29:22
In reply to Re: getting a good psychiatrist, posted by nickguy on July 20, 2006, at 12:30:49
Yeah, it is a rare side effect with Wellbutrin, yet does occur with some individuals. Is desipramine at all like Straterra, which I am currently taking? How common is it?
Posted by nickguy on July 20, 2006, at 20:18:25
In reply to Re: getting a good psychiatrist, posted by jealibeanz on July 20, 2006, at 19:29:22
desipramine is a stimulating anti depressant. It's used sometimes for people in cocaine withdrawal. I think it's mode of action is different than strattera, but I'm not sure. Desipramine also effects dopamine.
Posted by jealibeanz on July 20, 2006, at 20:27:09
In reply to Re: getting a good psychiatrist, posted by nickguy on July 20, 2006, at 20:18:25
Yes, the mechanism is different since one is a reuptake inhibitor and one is not. My question is, how do these didderences manifest themselves in the patient?
This is the end of the thread.
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