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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 11 of 11. This is the beginning of the thread.
Posted by Galen on October 23, 2007, at 3:07:21
I'm posting for a friend. She is severely depressed and suicidal -- at times she is literally obsessed with suicide.
She has now agreed to make an appointment with a psychopharm. Her family doctor has had her on Prozac for six months. However, my friend was not comfortable telling that doc about her preoccupation with suicide. Prozac hasn't helped and may be making things worse.
I've been exploring posts on this site and others. Can't help but notice many of the posters here are well-informed about psych drugs. I'm NOT asking anybody to play shrink: we'll see what the psychopharm says. But a preview of the drugs typically prescribed for atypical depression with severe suicidal ideation would be very helpful. Success stories would be helpful too.
There's a good 2002 post about Remeron for suicidal ideation. Is that still considered a good choice in this situation? Can anyone suggest any other good candidates? I appreciate any info (especially technical info) on the drugs or drug combos likely to be prescribed.
Based on what I've seen so far, seems like Remeron or an MAOI or maybe trazadone plus an SSRI are likely candidates. Comments or suggestions anyone?
P.S. I hope to show your responses to my friend, so please try to keep it upbeat and optimistic -- though of course truthful. TIA
Posted by Racer on October 23, 2007, at 9:27:42
In reply to Severe depression and suicidal ideation., posted by Galen on October 23, 2007, at 3:07:21
Welcome to Babble.
For someone who is experiencing suicidal ideation, I wouldn't expect to see any MAOIs nor TCAs prescribed on an outpatient basis, unless someone else can dispense them. And MAOIs are rarely considered before the newer medications have been explored pretty thoroughly. They may work well for many people, but they are also the Big Guns of antidepressants -- and sometimes you don't need to get out the 4 gauge when you're going after prairie dogs.
I'd be interested in knowing more about your friend's symptoms, but I'd say Seroquel, or maybe Risperdal, to help with some of the suicidal thinking and anxiety. If the Prozac has provided any benefit at all, I'd think about trying another SSRI, or maybe an SNRI, like Cymbalta. If the Prozac has done nothing, then Remeron, or maybe Wellbutrin, depending on energy and anxiety.
That's my thinking. I'll be interested in what others have to say.
Posted by Squiggles on October 23, 2007, at 9:57:32
In reply to Re: Severe depression and suicidal ideation. » Galen, posted by Racer on October 23, 2007, at 9:27:42
From what i've read of Dr. Healy's warnings
about SSRIs and short-term stimulating antidepressants, there is a higher risk for suicide if the person is really in that state. Prozac, and
other SSRIs might stimulate the person towards acting out the deep depression, at least until stabilization, which is after the fact.The big guns probably work, but as Racer said it is important to know the patient's condition.
If you want to know what stopped me from suicide,
it was lithium. But you probably already know that and it is for bipolars, presumably.Squiggles
Posted by Phillipa on October 23, 2007, at 11:54:49
In reply to Re: Severe depression and suicidal ideation., posted by Squiggles on October 23, 2007, at 9:57:32
Not first hand info but I see a lot of good responses to zyprexa to stop suicidal ideation. I have a friend who found this to be true. Also despite what you may read I've heard a lot of people neighbors included do great on effexor xr stronger med. Has serotonin first and then norepenephine combined in it. Good luck there is an answer. Phillipa
Posted by tecknohed on October 23, 2007, at 12:05:26
In reply to Severe depression and suicidal ideation., posted by Galen on October 23, 2007, at 3:07:21
I'm a fan of MAOIs, but as others have said they are usually reserved for multiple failed attemps with other meds. Nardil in particular has (for me) a calming & 'optimistic' effect right from the start, long before it really kicks in. But they are particularly dangerous in overdose.
SSRIs ARE NOT all the same. Your friend may do alot better on citalopram, escitalopram or paroxetine, which I've found alot more calming. Compared to these three, fluoxetine (Prozac) & sertraline seem more activating.
A short course of clonazepam (or possibly another benzo), whilst your friend is waiting for the antidepressant to begin working may also be helpfull. From http://en.wikipedia.org/wiki/Clonazepam :
"Clonazepam appears to also have a secondary effect on the neurotransmitter serotonin.[8] It has shown itself to be highly effective as a short-term (3 weeks) adjunct to SSRI treatment in obsessive-compulsive disorder and clinical depression in reducing SSRI side effects with the combination being superior to SSRI treatment alone in a study funded by the manufacturers of clonazepam, Hoffman LaRoche Inc.[9] Similar results have been found with some other anxiety disorders, but the role of the serotonergic effects enhancing the action of the SSRI treatment remains unclear in these cases due to clonazepam's primary anxiolytic mechanism of action."
I'm also wondering if your friend my have comorbid OCD with the depression, possibly explaining her 'obsession' with suicide. What do others think? The SSRIs I mentioned above may be especially good for this.
Finally, although you (nor your friend) probably wont want to here this, she may be safer in hospital until she responds effectively enough to a med.
I wish you & your friend luck in your search for an effective remedy.
Posted by sometimesblue on October 23, 2007, at 15:09:07
In reply to Severe depression and suicidal ideation., posted by Galen on October 23, 2007, at 3:07:21
You may want to google "suicide ideation" and see what other posters have said or had experience with.
Good luck, I hope your friend find the help she needs.
-SB
Posted by Netch on October 23, 2007, at 15:32:24
In reply to Severe depression and suicidal ideation., posted by Galen on October 23, 2007, at 3:07:21
Are you sure she is not bipolar or mixed state?
Lithium is the most effective treatment to prevent suicide. Can be combined with ADs or mood stabilizers
/Netch
Posted by bleauberry on October 23, 2007, at 19:29:29
In reply to Severe depression and suicidal ideation., posted by Galen on October 23, 2007, at 3:07:21
First off, make sure you have drawn plans to prevent suicide. Keep a close eye and close contact. The hospital is the worst place to be, so do all you can do to avoid a trip to the emergency room. Worst case scenario, a hospital stay would at least save one's life.
For meds, it is so hard to predict. I saw zyprexa mentioned, and I agree with that one. Especially in combo with prozac. Good combo usually. Benzos were mentioned. Could at least sedate the patient for a while. Some like xanax actually do have some pronounced antidepressant effects to them. The others too, though I've heard it more with xanax. Benzos can worsen depression too though, so it's a careful balance with low dose and short term in mind. Lithium was mentioned. That could help but I'm not well schooled on it.
Prozac does not look like the one to stay with. On pubmed there was a meta analysis of all antidepressants to see if there were any that were superior to the others. Overall, lexapro turned out superior. Surprise, prozac was actually the least effective. The differences between them all were not huge however, and there is no way to predict who will respond best to what drug. I'm just saying if we have to roll the dice and go for the best odds of success, then lexapro came up tops in the meta analysis. Some people do terrible on lexapro, some great. The results of the study were overall, not on an individual basis.
A good psychiatrist or doctor will be needed in the short term. Longterm however, I think it is extremely important to hunt down a really good integrative doctor (one who does natural and conventional medicine) and get some testing done to find out where this vicious depression is coming from. It could be thyroid, adrenal, heavy metals, allergy or intolerance to something, or a chronic infection (yeast, bacteria, fungal, viral) that is spewing toxins in the blood. All of these things wreak total havoc on the brain. I have come to my own conclusion over the years that the primary hidden cause of depression that is overlooked 99% of the time is heavy metals. Too much lead. Too much mercury. Only with a book called Amalgam Illness can you understand why these things are overlooked, misdiagnosed, and treated improperly. And why so many people on the best psychiatric meds, herbs, and supplements never get well until the metals are dealt with.
But control of symptoms should be an achievable goal in the short term, no matter what the cause of the depression. Just a matter of the right meds and/or supplements to counteract whatever is awry.
This might sound strange, but a reduction of prozac dose could actually help. Personally I would not keep taking a medication where I am feeling suicidal despite it. For all I know, it could be the medication doing it. Been there done that.
First order of business...protect the patient and speed up the time to get to a doctor. Seeing one today or tomorrow would be best. Suicidal ideation is risky and could be carried out at any moment.
Posted by Questionmark on October 24, 2007, at 0:47:32
In reply to Severe depression and suicidal ideation., posted by Galen on October 23, 2007, at 3:07:21
I used to think about and fantasize, more or less, about suicide all the time. The only THING (drug or otherwise) that changed this was Nardil. This is actually sad imo, but it's a fact.
First of all, she needs to know that sometimes these stupid drugs can make her feel much worse-- temporarily or semi-continually. SSRIs in particular can cause horrible depression during the startup or quitting periods, but since the depression doesn't start right away people don't realize it's due to or exacerbated by the SSRI and feel hopeless. Try to remember that.
But... I personally don't think Zyprexa or any antipsychotic is a good idea at all unless she is schizophrenic or otherwise psychotic (EVEN if she has OCD!). I don't think benzos are a good idea unless she has Some kind of anxiety contributing to her depression or has a very restless activated depression. Benzos can aggravate depression big time, especially in certain people. None of this crap will likely be of any help. But wait...
Severe depression needs a good, knowledgeable, compassionate doctor and, ideally, therapist. I totally understand her not wanting to tell her pdoc or therapist about her suicidal ideation b/c they very well might throw her into a mental institution for a time (which could be helpful or extremely detrimental) and tell her parents. But hopefully she could-- and should-- at least tell her docs/therapists that she is terribly depressed, etc. and needs more help while still lying about feeling suicidal.
(Some would disagree but i would almost encourage lying about that if one didn't want to risk losing the time etc to being involuntarily confined to a hospital [and i'm not saying that b/c i've ever been-- i've always lied myself]. I would of course, however, say that you should tell them about your suicidal thoughts etc before actually going through w/ ending your life.)
But she needs to find a *good* knowledgeable psychiatrist who will treat her depression aggressively and with whatever unique drugs or combinations will help. Screw Prozac. If it's not helping she needs something else. And screw (w/ caveats) combinations like Wellbutrin and SSRI, or SSRI plus antipsychotic, or SSRI plus dull mood stabilizer (although I agree that lithium could be helpful). OK not necessarily but probably, unless her *individual makeup* seems to be needing that sort of combo. But if she is going to stay on an SSRI and Prozac is not helping her much, she is going to need something else, NOT just a different SSRI: maybe a benzo if she has too much anxiety; maybe a good stimulating catecholaminergic drug if she feels to zombified. Maybe a drug that acts on opioid receptors in some way would be ideal, I don't know, but you would be hard pressed to get prescribed that. My suggestion: get on an MAOI. Nardil if you have anxious and/or serotonin-deficient-like depression (so to speak); Parnate if you have lethargic, anhedonic depression. Nardil first probably. It may be the greatest truest antidepressant medication in existence. It has some significant side effects (all drugs do). It requires a few diet and drug restriction. It changes you (?). But it often works, and when it does it works miraculously.
I have much more i want to say and clarify but i can't write a book in this post. Sorry i've rambled so much already. But there are ways to feel... not in intense suffering.
Tell her I wish her luck. And, at least to some extent, I really sympathize.
The world loses far too many good people to suicide.
Posted by tecknohed on October 24, 2007, at 4:59:03
In reply to Re: Severe depression and suicidal ideation., posted by Questionmark on October 24, 2007, at 0:47:32
I share the same view as you about Nardil. My only concern would be the danger of overdose if the person is suicidal.
Of course to avoid this someone could 'hold onto' the Nardil for her, keeping it in a safe place where she cann't find/have access to it. Then meet with her EVERYDAY to give her her daily supply, untill she becomes responsive to it. Hopefully she wouldn't feel too patronized by this.
Posted by Maxime on October 24, 2007, at 21:21:45
In reply to Re: Severe depression and suicidal ideation. » Galen, posted by sometimesblue on October 23, 2007, at 15:09:07
Sometimes Zyprexa can knock the depression out of you. Maybe she could take that until the crisis is over, and then start anti-depressants.
You should contract with her. Contract that if she feels like she is going to harm herself that she will call you or go to the ER.
I am where your friend is right now. I have so much empathy for her.
You are a good friend to help her like this, but I am sure she would do the same for you.
You might want to give her some numbers for suicide hotlines.
maxime
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