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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 Racer on May 6, 2008, at 10:00:21
As those of you familiar with me already know, I don't have a great history of medications working well for me. Right now, my good and trusted friends are letting me down -- Wellbutrin XL 450 and Concerta 36 with the addition of 5 to 10 mg Methylin PRN.
And I spent hours trying to decide whether it was worth fighting on, or if it was time to lay down my sword. I'd say something really has to change.
So, I wrote my beloved pharmacologist, and told him I was in bad shape and didn't think I could wait until mid-June for something to change. He wrote back suggesting one of two things: rTMS or Effexor. He said that he knows Effexor causes one of the side effects I find most intolerable, but it's "predictable and quite effective." I wrote back, telling him that I wouldn't consider Effexor, because it wasn't effective for me until a low dose of Prozac was added, and that I'd be more willing to consider a low dose of Prozac -- but that I would be reluctant, based on past performance and because I thought I needed something which would kick in faster. I haven't heard back from him yet, but I thought I'd ask around about temporary options which might kick in faster?
There are a lot of options which aren't on the table here, for a variety of reasons. To begin with, we're talking about trying tianeptine in June, after he gets some questions answered. From the reading we've both done, I'm eager to try it, so I am not looking for a long term fix right now. Just a stop-gap measure. And I have had a lot of bad reactions to medications, so the following are off the table entirely:
MAOIs
TCAs
Remeron
Serzone
Effexor
Benzos
Zyprexa
LamictalThe following are mostly off the table, but I'd reluctantly consider them:
SSRIs
Seroquel
BetablockersI'd consider:
Provigil, but doubt he would, since I'm already on Concerta
Dexamethasone, since I've read of it kickstarting serious depression relief in small doses for a short course
Maybe a heavy tranquilizer, or even a heavy painkiller -- bring on the Percodan!I don't know -- and I'm afraid of sounding so recalcitrant about all this with him. But there are some things I just couldn't handle trying again -- and Effexor is one of them. Maybe I should write back and offer to try a low dose of Cymbalta as a compromise?
I hate this so much.
Any ideas for a jump start?
Posted by SLS on May 6, 2008, at 10:49:02
In reply to Fast acting options for suicidal ideation?, posted by Racer on May 6, 2008, at 10:00:21
Abilify will work, but there can be startup anxiety and restlessness that is often mistaken for akathisia. Akathisia is a possibility, thouoh, though. I didn't have much of a problem with that. I started off right at 20mg. While Abilify might not be the equal of Zyprexa, it does feel "cleaner".
Lithium perhaps.
- Scott
Posted by Bob on May 6, 2008, at 11:00:20
In reply to Fast acting options for suicidal ideation?, posted by Racer on May 6, 2008, at 10:00:21
Your post reveals that you are very close to my personal experiences. I am very intolerant of many, many meds and don't know where to turn any longer.
I am curious as to why you don't want Effexor. For me the withdrawl is too scary and I wouldn't want to do that again. You said that Effexor works if you supplement with Prozac, so why is that not an option now? Again, I'm not suggesting it, but just want to know.
MAOIs are tough for me because I think I might not survive the washout period if I was in a crisis. Why are they off limits for you?
Posted by Phillipa on May 6, 2008, at 11:31:15
In reply to Fast acting options for suicidal ideation?, posted by Racer on May 6, 2008, at 10:00:21
Cymbalta is worth a try for me nothing but we are all different. It does have more norepenephrine in it. Maybe you are an opiod responder? Maybe a pain killer would work as a temporary message. But seriously good luck. Phillipa
Posted by bipolarspectrum1 on May 6, 2008, at 13:38:45
In reply to Re: Fast acting options for suicidal ideation?, posted by Phillipa on May 6, 2008, at 11:31:15
Hi,
I'd agree with SLS that an atypical antipyschotic may help greatly...Abilify has helped me out..Also, some other options good for depressive symptoms are lithium and lamotrigine.. both can be strong antidepressants.. lithium possibly being the better option because lamotrigine takes a long time to titrate to effective doses...
bps
Posted by twinleaf on May 6, 2008, at 13:55:31
In reply to Fast acting options for suicidal ideation?, posted by Racer on May 6, 2008, at 10:00:21
low dose lithium (300, 450,or 600 mg.) to what you're presently taking? It has the advantage of being effective immediately- if it is going to be helpful you will know right away.
You may know from older posts that rTMS has been extremely effective for me over the past five years. Are you anywhere near a center which offers it?
Posted by emme on May 6, 2008, at 16:32:07
In reply to Fast acting options for suicidal ideation?, posted by Racer on May 6, 2008, at 10:00:21
Hi Racer,
I will be the third to endorse Abilify. I found the effects kicked in after only about 4 days. I did not have startup anxiety or akathisia, but did have about 8 weeks of insomnia. YMMV, of course, but I find it pretty tolerable.
You said Zyprexa was off the table. Even for, say, a week? I found it put a *very* fast stop to suicidal thoughts within a couple of days and I did not revert too badly when I stopped it a couple of weeks later.
I'm sorry you're feeling so awful. Good luck.
emme
Posted by SLS on May 6, 2008, at 17:46:43
In reply to Fast acting options for suicidal ideation?, posted by Racer on May 6, 2008, at 10:00:21
What was your reaction to Zyprexa?
- Scott
Posted by bleauberry on May 6, 2008, at 17:47:28
In reply to Fast acting options for suicidal ideation?, posted by Racer on May 6, 2008, at 10:00:21
I pretty much agree with everyone.
Lithium at a low dose 100mg-300mg-600mg...if it is going to help lift depression it will do so fast, like in a day or two. If it isn't doing anything for mood by day 4, forget it. It could in the longrun be a good stabilizer and antidepressant, but that isn't what you are looking for at this moment. You need a quick stepping stone. Low dose lithium when I tried it was oh my god fast. I was looking for longterm, and the stimulation it gave me was too much.
Abilify I have no experience with but I do feel all the APs, especially zyprexa and abilify, have an extraordinary ability to rejumpstart ongoing meds within days.
Not sure what the resistance to prozac+effexor is, but that seems like a decent option. Who cares if someone thinks it weird to combine different ssris. I sure don't. All I care about is what works, and to heck with trying to explain why or justifying it. If it works it works, period.
As you mentioned, Duloxetine is an option. Most people do not see it as being a replacement for effexor though. They are in the same family but quite different. And unlike the previous mentioned medicines, duloxetine is not likely to produce fast results.
Too bad we don't have overseas Milnacipran or Trivastal handy. Though anecdotal on this board and other forums, about 90% of people who tried these felt a lot better within 1 to 7 days.
Damn I wish you weren't feeling so bad. Breaks my heart. I am wishing for you not just a quick fix or some decent meds down the road, but a complete remission.
Posted by SLS on May 6, 2008, at 17:53:33
In reply to Fast acting options for suicidal ideation?, posted by Racer on May 6, 2008, at 10:00:21
> What was your reaction to Zyprexa?
Depending on how you answer that question...
You could start taking Zyprexa immediately and crossover to Abilify, leaving an overlap to counter any startup anxiety or insomnia that may result from the Abilify.
- Scott
Posted by Racer on May 6, 2008, at 20:44:27
In reply to Re: Fast acting options for suicidal ideation? » Racer, posted by SLS on May 6, 2008, at 17:53:33
Sorry, everyone -- too tired to do this individually...
A couple of posters asked why I wouldn't go with Effexor again -- first, I'm looking for a temporary fix, something that would jump in and save the day. I'm not looking for something I'd stick with for any length of time. Effexor was not an effective choice for me -- with low dose Prozac, it made life bearable for a while. At a high cost -- side effects included elevated blood sugar, constipation, insomnia, anorgasmia, weight gain, foggy-headedness, etc. That just wasn't good enough I'd try it again, you know?
Cymbalta -- been there, done that, not something that would kick in fast enough to be worth it.
Zyprexa -- not a chance, nope, nuh-uh, no way. Sorry -- because of the weight gain, I won't even try it, not even as a temporary measure.
Abilify -- tried it, with BAD results. Too much agitation, too upsetting -- and in this situation, I think that would be a Very Bad Risk, you know?
And I can't remember if there were other suggestions made? Sorry -- I need a nap...
Posted by Phillipa on May 6, 2008, at 20:53:13
In reply to Random answers to various questions, posted by Racer on May 6, 2008, at 20:44:27
Racer didn't want to post this as not good reviews but some are good ECT? Quick and no weightgain. When lived in Ct they had drive through type ones no hospital stays. Now don't get angry but that is all I can think off. Only other thing I'd ask if you're happy with you life? I know I'm not so no med is going to help me only change. Love Phillipa
Posted by emme on May 6, 2008, at 21:20:18
In reply to Random answers to various questions, posted by Racer on May 6, 2008, at 20:44:27
> Zyprexa -- not a chance, nope, nuh-uh, no way. Sorry -- because of the weight gain, I won't even try it, not even as a temporary measure.
If by temporary one meant a few weeks, then yes indeedy, you'd certainly run the risk of weight gain. That and the sedation are why I stopped it. BUT, if you only took 4 or 5 doses to put out this emotional fire, I think you might very well escape weight gain.
Can you plan to use it for just a handful of days with the understanding that if you start gaining, you stop it? You can always stop it. You don't have to stick with an intolerable side effect. The thing is, I found it so *unbelievably* efficient at rapidly improving mood that I'd hate to see you miss out on something that could boost you out of this terrible state.
> Abilify -- tried it, with BAD results. Too much agitation, too upsetting -- and in this situation, I think that would be a Very Bad Risk, you know?
Yes, the agitation would be bad risk. But there may be ways around that. Do you think a benzo would offset some of that agitation? (I forget if you're already on one.) I know many people feel worried about taking two antipsychotics, but a dash of seroquel might also take the edge off of the Abilify - at least until your body adjusts to it. I used a little seroquel for a while to help with temporaroy insomnia from Abilify and it worked out great. Anyway, just some thoughts.
I hope you get some relief soon.
emme
Posted by Emily Elizabeth on May 6, 2008, at 21:44:57
In reply to Random answers to various questions, posted by Racer on May 6, 2008, at 20:44:27
I haven't read all of the above, so I don't know if it has been suggested...but I'd think about lithium. Li has been shown to specifically help with suicidal ideation. I personally have found this to be true too. Li is also something that acts quickly, so you wouldn't have to wait weeks to see if it works. Some people get worried about Li side effects, but I personally have not had a prob with them. I think at low doses they are less common.
Keeping my fingers crossed that something helps!
Best,
EE
Posted by cactus on May 6, 2008, at 23:28:47
In reply to Fast acting options for suicidal ideation?, posted by Racer on May 6, 2008, at 10:00:21
sorry to hear you're in a bad way, I have been in the same situation myself many times after trying many different drugs.
I too wouldn't go anywhere near Zyprexa, it's No.1 on my list of... no way never again and effexor comes in second.
The only 2 drugs I have ever had stop suicidal idealization within a day or 2 were ropinirole and modafinil. Good luck, I've never tried lithium though and don't plan to.
Posted by Justherself54 on May 7, 2008, at 0:30:09
In reply to Fast acting options for suicidal ideation?, posted by Racer on May 6, 2008, at 10:00:21
Fastest working SSRI for me was Lexapro...full benefits in one week...was kind of shocked how fast it worked. Suicidal ideation is no fun...I hope you can get some relief soon. I take 25 mg seroquel at bed for sleep. I was really scared to go on it at first but it's very calming and I can sleep the whole night through.
Posted by Sigismund on May 7, 2008, at 14:42:45
In reply to Fast acting options for suicidal ideation?, posted by Racer on May 6, 2008, at 10:00:21
Racer
Tianeptine, Trivastal and rhodiola have something in common with the drugs that seem to have agreed with you.
I expect none of these would be able to get you over the hump.
That might depend on what mood accompanied the SI??
Tianeptine and Trivastal I can take on as needs basis.
I don't take them most of the time.
Posted by undopaminergic on May 7, 2008, at 15:10:37
In reply to Fast acting options for suicidal ideation?, posted by Racer on May 6, 2008, at 10:00:21
Sulpiride (and probably amisulpride) has a rapid onset of action - within hours in my experience.
Selegiline also act rapidly, whether due to the elevation of phenylethylamine (PEA) or the amphetamine metabolites. Augmentation with phenylalanine or PEA is possible if selegiline monotherapy proves insufficient.
Dextroamphetamine (Dexedrine) and other amphetamines definitely have a rapid onset of effects. However, tolerance often devlops rapidly, and many users notice a "crash".
Pramipexole (and probably ropinirole) produces noticeable effects within hours, although nausea may be a troublesome adverse effect.
Reboxetine produced definite effects within a couple of days for me, and its reduction of negative and self-critical thinking has lasted to this day (many years after quitting it).
Lithium and memantine are options worthy of consideration.
Posted by emme on May 7, 2008, at 16:34:16
In reply to Re: Fast acting options for suicidal ideation?, posted by undopaminergic on May 7, 2008, at 15:10:37
> Selegiline also act rapidly, whether due to the elevation of phenylethylamine (PEA) or the amphetamine metabolites. Augmentation with phenylalanine or PEA is possible if selegiline monotherapy proves insufficient.I forgot about selegiline. It yanked me out of a few bad spots, literally within hours.
emme
Posted by bleauberry on May 7, 2008, at 17:35:36
In reply to Fast acting options for suicidal ideation?, posted by Racer on May 6, 2008, at 10:00:21
Hi Racer, I hope today is a little better than yesterday. I had some thoughts on your situation today.
One thing that might help is to reduce the doses of meds, probably wellbutrin first. Really. I know that sounds weird. You know yourself that when something isn't working and you stop it you actually feel a little better almost right away. I'm not saying stop any drug, just cut back on dosage. I know that sounds weird but I am serious.
Too much dopamine and/or norepinephrine stuff will make a majority of people very depressed. For example, one of the common consequences of high dose stimulants for some time period is either psychosis or depression. You would by no means be the first person that got depressed on wellbutrin, even after it had once worked very well in the past. You would by no means be the first person that got depressed at too high of a dose of wellbutrin. The other meds are also pumping up dopamine and norepinephrine and that can lead to a very dysphoric depressed lethargic feeling, way beyond the window of feeling energy and joy from dopamine enhancement.
Didn't you recently stop a lengthy failed trial of Ensam? If that was you, well, there again is a clue that the dopamine/norepinephrine accumulation thing is not what your brain needs at this point in history. Maybe you would do better with things that stimulate the release of neurotransmitters versus damming them up at the synapse.
Someone else mentioned Memantine and while that post could easily be missed or quickly forgotten, I think there is a ton of potential in that one. If you once did well on the dopamine/norepinephrine stuff but now you aren't, Memantine is known to restore those good effects. There have been a couple spectacular examples at this site and I've seen them at other forums also. I mention it because everyone who responded to it did so within about a week.
Posted by cumulative on May 7, 2008, at 18:32:44
In reply to Fast acting options for suicidal ideation?, posted by Racer on May 6, 2008, at 10:00:21
Your regimen is dopaminergic psychostimulants. This is what I, typically low-energy and lacking in volition/"spark/joie de vivre, respond to as well. Unfortunately the mood improvement from these tends to be a bit flighty, and in some users, following tolerance to most of the mood effect there is a sort of deadening feeling. Perhaps the prefrontal stimulation (which tends to sensitize) clamping down on limbic dopamine transmission. That is of course pure theory.
Anyway, memantine. Have you considered memantine?
This seems to have worked fantastically for some people here in regards to completely halting the tolerance to the stimulant mood improvement, as well as apparently having fairly significant antidepressive effects on its own.
Posted by undopaminergic on May 7, 2008, at 20:51:23
In reply to Re: Fast acting options for suicidal ideation?, posted by bleauberry on May 7, 2008, at 17:35:36
>
> Too much dopamine and/or norepinephrine stuff will make a majority of people very depressed. For example, one of the common consequences of high dose stimulants for some time period is either psychosis or depression.
>
> The other meds are also pumping up dopamine and norepinephrine and that can lead to a very dysphoric depressed lethargic feeling, way beyond the window of feeling energy and joy from dopamine enhancement.
>A depressive state often results from the withdrawal of stimulants - however, that does not seem applicable in this case. It is rather more likely that a pre-existent underlying depression is becoming unmasked as tolerance to stimulants is setting in. Due to tolerance, a functional dopamine deficit can exist even though synaptic concentrations of the neurotransmitter remain normal or elevated above normal. Cessation or dose-reduction will probably aggravate the depressive symptoms initially, but may be necessary to restore responsiveness to the drugs. Alternatively, as has been suggested, memantine can be tried.
Posted by yxibow on May 8, 2008, at 0:19:12
In reply to Re: Fast acting options for suicidal ideation? » Racer, posted by Sigismund on May 7, 2008, at 14:42:45
What really defines ideation though? I have ideation at times but for a variety of reasons including not hurting my parents and the fear of death (and mostly the fear of life, which is why people feel that way), but that doesn't mean anything more than thoughts that are in our minds.
This differs from -- and I'm not going to go into it, but some plan already defined....
One doesn't have to load themselves up with medication if it is merely ideation.
As for medications though, the fastest way that I've heard to stop suicide is Lithium. It has its problems, shaky side effects and unknowns, and the need for at least preliminary monitoring of salt levels.
Yes, atypicals or certain typicals for that matter are also choices, but the benefit has to outweigh the risks.
Antidepressants of many classes are a choice too but they take much longer than the initial period that APs provide. Remeron in my experience has a shorter lag time.
"Everybody hurts sometimes... hold on" -- REM
-- best wishes
Jay
Posted by cactus on May 8, 2008, at 13:53:22
In reply to Fast acting options for suicidal ideation?, posted by Racer on May 6, 2008, at 10:00:21
Hey racer, what undoperminergic said about dopamine agonists is true........
*Pramipexole (and probably ropinirole) produces noticeable effects within hours, although nausea may be a troublesome adverse effect.*
...... but if you start ropinirole at a very low dose and titrate up very slowly, it's fine for most people. Ropinirole acts very quickly and if you're only going to use it for short term relief I cant see why it would be a problem, as you would be on a very low dose. It also helps you sleep too. Good luck, I hope you're feeling better. C
I had to stop it because I couldn't get past 2mg and my doc wanted me at 4mg. I started at either 0.25mg or 0.5mg and felt great the next day. I haven't tried mirapex, but requip works lightning fast.
Posted by Maxime on May 8, 2008, at 22:12:21
In reply to Fast acting options for suicidal ideation?, posted by Racer on May 6, 2008, at 10:00:21
Sh*t, I should have contacted you. :(
I tried Dexamethasone once and was on it for 10 days. I felt better on the 8th day and then after I was taken off it I crashed so bad that I ended up in the psych ward. I know we all respond differently, but that's what happened to me.
Zyprexa might be a good short term option. It's kicks depression in the *ss, and you won't be on it long enough to gain weight.
Hang in there!
Maxime
This is the end of the thread.
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