![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 49. This is the beginning of the thread.
Posted by Questionmark on November 6, 2007, at 2:42:33
Sorry for the exclamation. I just get frustrated when thinking about SSRIs.
But I don't agree (as someone said in a thread above in recent post) that the apathy/numbness from SSRIs only occurs if/when the SSRI isn't working properly. In my opinion, it seems like a time-dependent inevitability. How much time is not certain, but not much.
For me (and i would assume many/most others), when I initially increase my serotonin transmission, I feel ... almost how we should feel all the time, or most of the time. I feel wonderful. Not beaming with pleasure, or even euphoric at all as with stimulants, but... good. Bright; happy; sociable; energized, to some extent;... and still protected (numb) from intense emotional pain, and even numb to certain of those longing and pleasure feelings. And so maybe even it is not "natural", or real. Who knows what it is to feel natural?! But it feels about as close to being happily alive as anything can, without feeling like a DRUG. If only i could sustain that state, i would probably stay on an SSRI indefinitely(while looking for various things to relieve the cognitive and sexual side effects), and would probably actually enjoy life. But alas, that state is not sustainable, which is why I am NOT on an SSRI (I am on Nardil). As various 5-HT2(?) receptors are continuously agonized with serotonin longer and longer, dopamine transmission is inhibited further and further (or how I crudely understand it) until one's reward system becomes all but shut down. The grandest pleasures become mild at best. And motivation is anything but strong. Yes the pain is nearly eradicated too-- nothing is a "big deal." You are a walking, talking zombie. But eventually the one source of pain that does arise is the pain of not being able to feel! It's not terrible, as severe depression is terrible, but it's not good. And it can logically lead to one wondering why they're bothering to live at all (which in my opinion is one of the two primary reasons SSRIs sometimes or potentially lead to increased suicides, and NOT because it "gives depressives the energy" to do it, as the Psychiatric-Pharmaceutical complex so often suggests).
... And then words don't come to you quite as easily, and your experiences become lost in a fog of hazy memory, and... you can't understand why you're on the damn drug anymore! And so you get off. And then after about a week-- oh my goodness!-- you feel alive and your emotions come flooding back and you cry at every sad commercial, but overall you feel good, maybe even great. And this lasts for another 7 to 30 days or so (depending on the dropped drug's half life). And you think you've overcome your depression. You think it's finally gone and you don't need to be dependent on those freaking drugs anymore and you will be able to lead a relatively more or less OK and normal life. And then one day shortly thereafter... all those familiar thoughts and feelings about yourself and humanity and the world and life come flooding back. And you are covered in blackness. (This is the other primary reason SSRIs can sometimes or potentially increase suicidal ideation, and suicide). Then, if you're lucky, you manage to drag yourself to a psychiatrist, and he or she explains that you have relapsed into depression as a result of discontinuing your antidepressant medication. (This is true, partially. It's also true that your body and brain have become physiochemically dependent on the presence of a very powerful drug, your serotonin [and other] receptors having had adapted and altered their sensitivity and quantity to the point that without said drug your central nervous system will be so out of balance that its only function will be to produce a perpetual state of paralyzing despair. .....
So of course you get back on the drug and feel amazing (comparatively at least) for a day or two or three, and the whole cycle continues.
.
This is a gross overgeneralization-- of course-- but one that I think holds a lot of truth.
Of course, even with a miracle drug like Nardil you have the same problems, but the numbness and apathy are not as bad, and it's more effective at helping you feel good. Weird-- and after all that i just had a thought about going back on an SSRI (and drinking coffee every day) (mostly because of the convenience-- 1x daily as opposed to 2 or preferably 3 or even 4 times daily with Nardil-- and the at least perception of significantly less social stigma attached to the all-too-common SSRIs). But no. When I think about it logically I know it wouldn't be nearly as good as Nardil-- even with daily caffeine, or even with daily caffeine and a low-dose benzo, or even with benzo and selegeline and whatever else you want to throw in there.
Maybe one day they'll create a drug or class of drugs that eradicates depression (and etc.) without changing too much else-- and one that doesn't lose effectiveness. Until then, good luck, and there's always Nardil.
P.S. I should have been asleep hours ago. Once again. Damn you, PsychoBabble. Damn you.
(No i'm just kidding i love this site so much more than i hate it. Ooh, kind of like Nardil.)
Posted by War-Face on November 6, 2007, at 10:55:51
In reply to SSRI Apathy- This is the *True* SSRI response!, posted by Questionmark on November 6, 2007, at 2:42:33
That is almost exactly my experience with SSRIs. Well said.
Posted by Phillipa on November 6, 2007, at 11:48:57
In reply to Re: SSRI Apathy- This is the *True* SSRI response!, posted by War-Face on November 6, 2007, at 10:55:51
Why am I the only person they seem to do the opposite to reve me up and then horrible side effects. So I stay at a low dose and suffer and try and work through it with diversion and the reamains of my nightly valium. Phillipa
Posted by Bob on November 6, 2007, at 11:53:24
In reply to SSRI Apathy- This is the *True* SSRI response!, posted by Questionmark on November 6, 2007, at 2:42:33
I too have experienced this unfortunate cycle. Sadly, long term effects of drugs are not payed attention to much in the medical and pharma communties. STAR*D is the only study I've seen which has even touched on the dismaying effects of long term AD use, and that has hardly even scratched the surface. Currently, drug studies only seem to provide information on what occurs in the first few months at most.
Honestly, I don't know how this will ever change.
Posted by Dinah on November 6, 2007, at 12:12:44
In reply to SSRI Apathy- This is the *True* SSRI response!, posted by Questionmark on November 6, 2007, at 2:42:33
This is my favorite link on the topic:
http://www.geocities.com/ss06470/index.htm
I haven't read it for a while, so I should temper my endorsement to only the portion that points out that the way it works in very dissimilar conditions is similar.
Posted by rgb on November 6, 2007, at 12:25:44
In reply to SSRI Apathy- This is the *True* SSRI response!, posted by Questionmark on November 6, 2007, at 2:42:33
Sorry to hear that you had difficult experiences with them.
But what makes you think that your experience is a "inevitability" (unless you were only talking about how they affect /you/ there)?
I've been on sertraline for half a year and it's still working fine. Though I agree that the beginning was the best (I had some really nice feelings starting on day 3, but as you say, not the stimulant-kind euphoria, actually it slightly reminded me of 5-HT2A agonists :) A major advantage over dopamine euphoria is that there is zero desire to redose.).
Maybe the apathy will slowly creep up on me, but for now I will stick with the sertraline and see how it affects me /personally/.
I do have /some/ dampened emotions (mostly negative ones are dampened, I was pretty anhedonic at base-line anyway). I don't think this is necessarily bad. It doesn't mean that one is a zombie, it's not so black and white. It might merely make the negative emotions manageable. There is more to life than emotionality; I for one like the fact that it seems to enable me to think beyond my negative feelings, look at outside things.
Motivation still seems to be somewhat increased.
I do try to counteract the dampening with caffeine (I don't have to watch the dose for anxiety reasons anymore :)) and nicotine gum though. Not sure whether it's doing anything in the long-run when you are tolerant though.
Regards,
rgb
Posted by rgb on November 6, 2007, at 12:29:55
In reply to you have a point, but I think it's not so bad. » Questionmark, posted by rgb on November 6, 2007, at 12:25:44
p.s.: I do find MAOIs interesting, but since sertraline works for me so far, I don't want to bother with MAOI interactions. Also, noone seems to want to prescribe the "irreversible" and nonselective ones, which look most promising to me.
Posted by linkadge on November 6, 2007, at 12:53:39
In reply to p.s. about MAOIs, posted by rgb on November 6, 2007, at 12:29:55
Thats what bothers me about the arguments used int the "war" against marijuanna.
Opponents incessantly harp on about how it can cause amotivational syndrome, and how this is particularly damaging to youth.
You hear it on Dr. Phil. They pay off some youth to talk about how he had no motivation on marijuanna.
They then proceed to prescribe youth drugs like paxil for anxiety and depression.
Anyhone who I have talked to about the differences in apathy between the two substances indicate that SSRI apathy is like MJ amotivation syndrome times 10.
Anyhow, I'm done ranting.
Linkadge
Posted by War-Face on November 6, 2007, at 15:56:38
In reply to Re: p.s. about MAOIs, posted by linkadge on November 6, 2007, at 12:53:39
Interesting comparison with marijuana and ssri's. I found Lexapro to have a kind of similar amotivational action to marijuana.
I found Prozac, on the other hand, to be extremely motivating (probably from NE boosting properties), although after prolonged use, it did leave me feeling dumb and forgetful and tired, in a way similar to the well-articulated cycle of SSRI use above.
Posted by mike lynch on November 7, 2007, at 15:37:39
In reply to SSRI Apathy- This is the *True* SSRI response!, posted by Questionmark on November 6, 2007, at 2:42:33
I go through this cycle too. I am off all drugs now but I just feel flat.
Posted by bleauberry on November 7, 2007, at 18:35:25
In reply to SSRI Apathy- This is the *True* SSRI response!, posted by Questionmark on November 6, 2007, at 2:42:33
Yeah, well said. I think maybe that is why certain drugs go well with SSRIs (the drugs vary from person to person of course), such as zyprexa, remeron, wellbutrin, provigil, ritalin...they tweek the norepinephrine or dopamine circuits in a way to partnership with the tweeked serotonin circuits and cut back on that apathy numbness stuff. I experienced that ssri partnership good feeling with zyprexa added to prozac, or adrafinil/provigil added to prozac.
Posted by rskontos on November 8, 2007, at 11:56:04
In reply to SSRI Apathy- This is the *True* SSRI response!, posted by Questionmark on November 6, 2007, at 2:42:33
I am glad you wrote this thread because I started Lex a little over a month ago and I never felt that bright happy sociable energized feeling. I feel slightly not so anxious but I will still have a panic attack and I am still depressed so I guess it isnt' working. I have no desire to do anything I push myself and I have had more thoughts of suicide than ever so I am guessing this one is bad. I believe with my issues ssri's aren't right. I think it is time to taper off. I am not sure what to go to next but thanks for this thread to alert me all is definitely not right with this med. Sometimes it takes a large rock to fall on me to wake me up in my present state. Thanks for being that cyber rock ! rk
Posted by bart on November 9, 2007, at 10:26:30
In reply to SSRI Apathy- This is the *True* SSRI response!, posted by Questionmark on November 6, 2007, at 2:42:33
wow!!!! the words in your post took the words right out of my mouth. I'm glad others are noticing this stuff so I don't feel so isolated
Posted by Questionmark on November 11, 2007, at 21:26:46
In reply to Re: SSRI Apathy- This is the *True* SSRI response! » Questionmark, posted by Dinah on November 6, 2007, at 12:12:44
I appreciate the comments.
I do want to say, just to be clear, that i think SSRIs can be very useful in many situations. I just think that patients and doctors need to be more aware of their (SSRI's) limitations, and understand that the general SSRI effect is to a large extent what is both good and bad about them.
Ah shoot i'll just reply to each post individually.
Posted by Questionmark on November 11, 2007, at 21:30:27
In reply to Re: SSRI Apathy- This is the *True* SSRI response! » War-Face, posted by Phillipa on November 6, 2007, at 11:48:57
These are also common side effects of SSRIs, but not as common in my opinion as the flattening of affect. But if i remember correctly i thought you had Bipolar, which could (and does) change the dynamic of SSRI effects quite significantly.
> Why am I the only person they seem to do the opposite to reve me up and then horrible side effects. So I stay at a low dose and suffer and try and work through it with diversion and the reamains of my nightly valium. Phillipa
Posted by Questionmark on November 11, 2007, at 21:45:48
In reply to Re: SSRI Apathy- This is the *True* SSRI response! » Questionmark, posted by Bob on November 6, 2007, at 11:53:24
"Currently, drug studies only seem to provide information on what occurs in the first few months at most." Yes this is so often completely true is it not? This is one of the aspects of psychiatric research that i think is most ridiculous. I mean come ON, many people need to be on these drugs for many months if not years, especially after they become somewhat more or less dependent on them (and subsequently oftentimes severely dependent on them). And similarly we have so -- ***so little*** knowledge about the long-term consequences (i.e., potential adverse even irreversible? long-term effects) of taking various psychiatric drugs.
It is ridiculous. It is shameful. It is absurd.
And only time (if that) will tell what the long-term consequences of drugging a generation of children with stimulants are. [Again stimulants also *may* be quite beneficial overall for many children as well as adults, but certainly not to the extent that we have taken it, i strongly believe].> I too have experienced this unfortunate cycle. Sadly, long term effects of drugs are not payed attention to much in the medical and pharma communties. STAR*D is the only study I've seen which has even touched on the dismaying effects of long term AD use, and that has hardly even scratched the surface. Currently, drug studies only seem to provide information on what occurs in the first few months at most.
>
> Honestly, I don't know how this will ever change.
Posted by Questionmark on November 11, 2007, at 22:08:13
In reply to you have a point, but I think it's not so bad. » Questionmark, posted by rgb on November 6, 2007, at 12:25:44
I'm basically of the opinion that, given enough time, eventually an SSRI will begin to exert the zombie effect, so to speak. Maybe that's pessimistic; maybe it's wrong. It could very well be for some people. But it's how i feel about it. I hope your positive response to sertraline continues.
And i don't mean one becomes completely like a zombie, like it is black and white. Of course there are variations on the scale. Also, if it is only "making the negative emotions more manageable," that is not what I'm talking about. I'm specifically referring to a condition in which both positive and negative emotions are dampened.
P.S. That was a great if simple point about the difference between strictly serotonergically derived happiness or well-being and "dopamine euphoria"-- that there "is zero desire to redose" with the former. I never really thought about it in those terms (that i remember), but it's completely true and a good way to describe the difference. Strange actually, too.P.P.S. In your second post you stated the following:
"I do find MAOIs interesting, but since sertraline works for me so far, I don't want to bother with MAOI interactions. Also, noone seems to want to prescribe the "irreversible" and nonselective ones, which look most promising to me."
First, if an SSRI is working for you, then ***by ALL MEANS*** stay on it before trying to get onto an MAOI. I would actually try to talk you out of getting on an MAOI. Absolutely. But for people in whom they're not working, especially if severely depressed or "debilitated" (or if having certain comorbid anxiety disorders), my stance is stop freaking struggling with that same class of drugs and try an MAOI.
And yes, you also will find that trying to find someone to prescribe you an MAOI can be a freaking chore in itself-- which is ridiculous, unfortunate, and unnecessary, in my opinion.> Sorry to hear that you had difficult experiences with them.
>
> But what makes you think that your experience is a "inevitability" (unless you were only talking about how they affect /you/ there)?
>
> I've been on sertraline for half a year and it's still working fine. Though I agree that the beginning was the best (I had some really nice feelings starting on day 3, but as you say, not the stimulant-kind euphoria, actually it slightly reminded me of 5-HT2A agonists :) A major advantage over dopamine euphoria is that there is zero desire to redose.).
>
> Maybe the apathy will slowly creep up on me, but for now I will stick with the sertraline and see how it affects me /personally/.
>
> I do have /some/ dampened emotions (mostly negative ones are dampened, I was pretty anhedonic at base-line anyway). I don't think this is necessarily bad. It doesn't mean that one is a zombie, it's not so black and white. It might merely make the negative emotions manageable. There is more to life than emotionality; I for one like the fact that it seems to enable me to think beyond my negative feelings, look at outside things.
>
> Motivation still seems to be somewhat increased.
>
> I do try to counteract the dampening with caffeine (I don't have to watch the dose for anxiety reasons anymore :)) and nicotine gum though. Not sure whether it's doing anything in the long-run when you are tolerant though.
>
> Regards,
> rgb
Posted by Questionmark on November 11, 2007, at 22:21:01
In reply to Re: SSRI Apathy- This is the *True* SSRI response! » Questionmark, posted by Dinah on November 6, 2007, at 12:12:44
Post Preface: So sorry if i'm posting too many consecutive posts at once! I now feel stupid. But i just wanted to respond to each reply post individually cuz -- well because i did.
_____________________________________________That *is* a great link, and I'm glad you posted it so I can read it again and bookmark it. It's brilliant.... Or maybe not that brilliant but so refreshingly logical and common-sensical in an industry of such a frustratingly appalling lack of logic and common sense. (Oh, many highly intelligent people, but grossly lacking in logic for some reason, and with an overabundance of hubris-- and probably a great deal of corruption, ultimately, involved as well.)
I was actually just going to read a bit of that and then ended up reading the whole article/page(?).
I totally agree with so much in that article (or whatever it should be called). Many great and important points.
> This is my favorite link on the topic:
>
> http://www.geocities.com/ss06470/index.htm
>
> I haven't read it for a while, so I should temper my endorsement to only the portion that points out that the way it works in very dissimilar conditions is similar.
Posted by Questionmark on November 11, 2007, at 22:44:17
In reply to Re: p.s. about MAOIs, posted by linkadge on November 6, 2007, at 12:53:39
Oh i could go on about marijuana and the hypocrisy of our government and legal system and the medical profession, and psychiatry in particular, in regards to it, for hours.
And this is coming from someone who does not use marijuana anymore and who more or less HATES the high from it.
But i'll restrain my comments to .
I will say that I think I am *personally* more demotivated and lazy from marijuana than SSRIs. Yeah almost definitely. And i also think the latter are better antidepressants than cannabis, for me. That said, I do believe there are many who are the opposite in both respects. And cannabis also has many other beneficial as well as medicinal properties (and actually increases sex drive in the short term, and is not nearly as detrimental to it as SSRIs in the long term). But of course SSRIs are treated as the diamonds of psychiatric drugs while marijuana is treated as ... well, feces... at best.
And don't even get me started on comparisons and differences of alcohol vs. marijuana. I'll just get incredibly angry.
And again I do not use marijuana but i do drink.
> Thats what bothers me about the arguments used int the "war" against marijuanna.
>
> Opponents incessantly harp on about how it can cause amotivational syndrome, and how this is particularly damaging to youth.
>
> You hear it on Dr. Phil. They pay off some youth to talk about how he had no motivation on marijuanna.
>
> They then proceed to prescribe youth drugs like paxil for anxiety and depression.
>
> Anyhone who I have talked to about the differences in apathy between the two substances indicate that SSRI apathy is like MJ amotivation syndrome times 10.
>
> Anyhow, I'm done ranting.
>
> Linkadge
Posted by Questionmark on November 11, 2007, at 23:00:11
In reply to Re: SSRI Apathy- This is the *True* SSRI Questionm, posted by rskontos on November 8, 2007, at 11:56:04
I'm so glad to be helpful, if it hopefully turns out to be the case that i was.
It's possible that you're not on a high enough (or low enough?) dose of Lexapro, but that's doubtful seeing as how most psychiatrists tend to over-prescribe (dosage wise) than under-, in my opinion. It's also possible that you just need something else along with it (also doubtful from sounds of things)-- but i really do not know, of course. And, as you said, it's quite possible you just need to get off it and on to something else altogether. Regardless there are many options, so don't lose hope.
And remember there will never be a perfect drug, but there almost definitely is SOMEthing that will be good enough to give you the ability to live your life and to be happy that you are living it.
> I am glad you wrote this thread because I started Lex a little over a month ago and I never felt that bright happy sociable energized feeling. I feel slightly not so anxious but I will still have a panic attack and I am still depressed so I guess it isnt' working. I have no desire to do anything I push myself and I have had more thoughts of suicide than ever so I am guessing this one is bad. I believe with my issues ssri's aren't right. I think it is time to taper off. I am not sure what to go to next but thanks for this thread to alert me all is definitely not right with this med. Sometimes it takes a large rock to fall on me to wake me up in my present state. Thanks for being that cyber rock ! rk
Posted by rskontos on November 12, 2007, at 10:23:56
In reply to Re: SSRI Apathy- This is the *True* SSRI Questionm » rskontos, posted by Questionmark on November 11, 2007, at 23:00:11
Again, thanks Questionmark, I am going back to the doctor this week. I went ahead and lowered the dosage to begin a taper. My T said for my dx Ad's aren't always very effective. I rarely tell her about the suicide issues. I know I should but I don't. I feel a little better on less. No side effects from less, not so tired. Maybe I will stay a while and see what happens. Again thanks, rk
Posted by Phillipa on November 12, 2007, at 18:19:19
In reply to Re: SSRI Apathy- This is the *True* SSRI response!, posted by Questionmark on November 11, 2007, at 21:30:27
No not bipolar MDD with anxiety. That's my official diagnosis thanks for the response. Phillipa
Posted by circusboy on November 13, 2007, at 15:15:02
In reply to Re: p.s. about MAOIs » linkadge, posted by War-Face on November 6, 2007, at 15:56:38
> I found Prozac, on the other hand, to be extremely motivating (probably from NE boosting properties), although after prolonged use, it did leave me feeling dumb and forgetful and tired, in a way similar to the well-articulated cycle of SSRI use above.
>Wanted to chime in and say I've had very similar experiences with Prozac. Pretty good in the short term, then the not-insignificant cognitive deficits start to move in. Also, the Prozac-induced anxiety (5-HT2C agonism? I can't remember which receptor subtype) starts to overwhelm the positive effects as well, and I become a nervous idiot in social situations.
I was prescribed methylphenidate to help with the concentration issues, but it took a very high dose (40 - 60 mg/day) which left me in irritable withdrawal every night. Once the Prozac was out of my system, I could have a very productive day on only 10 mg methylphenidate.
As a sort of aside... I know most of us believe this here, but it's worth repeating: the secondary affinities of "selective" drugs like the SSRIs are highly significant. Prozac at the NE transporter, Zoloft at the DA transporter, (Strattera at the kappa opiate receptor...not a SSRI, but still), Lexapro doing...something sleepy... all of these things are /supposed/ to be clinically insignificant, but those of us who have tried these drugs know they're not.
Posted by circusboy on November 13, 2007, at 15:34:42
In reply to you have a point, but I think it's not so bad. » Questionmark, posted by rgb on November 6, 2007, at 12:25:44
> I've been on sertraline for half a year and it's still working fine. Though I agree that the beginning was the best (I had some really nice feelings starting on day 3, but as you say, not the stimulant-kind euphoria, actually it slightly reminded me of 5-HT2A agonists :) A major advantage over dopamine euphoria is that there is zero desire to redose.).
>
> Maybe the apathy will slowly creep up on me, but for now I will stick with the sertraline and see how it affects me /personally/.
>After swearing off SSRIs forever for the reasons above, I've started another trial of Zoloft. It was the very first antidepressant I tried (10 years ago now), and, nostalgia aside, I think it was the most effective.
Two concerns: I was very depressed then, and didn't respond until we'd gone up to 200 mg and added Li. My depression is closer to dysthimia now (with the fun recent addition of obsessive thoughts), so hopefully this time I can stay at a low dose and avoid the lithium. Also, the sexual side effects were terrible. Again, I'm hoping I can cope with them at a low dose (25 - 50 mg).
Way back then when my pdoc switched me from Zoloft to Prozac (after a brief and ill-advised stop in Serzone land), my mood was dimmer and flatter. Prozac was better than Serzone and the sexual side effects were minimal, so I kept coming back to it when depression would descend on me again and the other drugs proved unsatisfactory. I still thought of Zoloft as the best... but those sexual side effects!
I -- like you -- am hoping that Zoloft's affinity for the DA transporter will at least partially counter the DA dampening effect of long-term SSRI use. If I have to take Ritalin too, so be it.
But I think -- and again, hope -- that sertraline may be the only drug in the class that can prevent or stave off SSRI apathy. We'll see.
-cb
Posted by Bob on November 13, 2007, at 15:45:34
In reply to Re: Prozac in particular » War-Face, posted by circusboy on November 13, 2007, at 15:15:02
"...all of these things are /supposed/ to be clinically insignificant, but those of us who have tried these drugs know they're not."
God knows, if I made a list of all the things that are supposed to be insignificant but often turn out to be show-stoppers for people on these drugs, I may never finish.
Go forward in thread:
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.