![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 19 of 19. This is the beginning of the thread.
Posted by glennb on December 4, 2008, at 16:24:57
I have been in a trd/mdd episode for over a year. Was previously taking fluoxetine on and off for about 10 years with different augmentors never really reaching remission or eating into dysthymia but staying mostly functional. Over the years experimented with most of the other SSRIs, wellbutrin, lamictal (i think was somewhat helpful), depakote.
This year I started to spiral and spend full days in bed. I switched to a lengthy effexor trial which didn't go well, and also tried to augment effexor with mirtazapine. By this point I was in bed sleeping 16 or so hours most days for several months and doctors were recommending ECT.
I opted instead to try a TCA and have had a partial response to nortriptyline. It's been about 10 weeks and I basically have blocks of mediocre/good days followed by blocks of really, really bad days. I hit about 50/50 mediocre/good days to bad days 8 or so weeks in. I then slipped back and am now in bed for 10+ days and I'm hearing ECT and partial hospitalization again.
Next steps before the relapse was to augment with lithium; given the relapse, does it indicate the partial response to nortriptyline was placebic, noise, or just not significant enough to warrant trying to augment? in other words, should I drop the nortriptyline entirely and try another TCA (anafranil would probably be next) or just try lithium augmentation with fluoxetine, the only real anti-depressent I've had a response from.
I have no history of bipolar though am very irritable and sometimes have raciness and difficulty focusing which I attribute to the OCD. No mania or euphoria. I have comorbid ocd which is not bothering me as much as the depression. I have irritability which is controlled by SSRIs but is now pretty high; the nortriptyline doesn't seem to control it.
I currently also take 1mg klonopin nightly and 5-10mg ambien. Have had to bump up ambien to 20mg recently, which is very odd, been steady on 5-10 for probably close to 10 years.
I appreciate very much any thoughts.
Posted by elanor roosevelt on December 4, 2008, at 17:12:23
In reply to Nortriptyline trial a failure?, posted by glennb on December 4, 2008, at 16:24:57
The last argument I had with my pdoc was over nortripyline
he prescribed it and it was an unusual time
my daughter was opstate with her dad for a long visit and I was working at home on a project that involved research and writingusually when i am working at home i schedule my days so that i go to the gym or to the drawing studio in the morning
it took me several days to realize i had been making excuses to stay in, answering calls only from my daughter and replying only to emails that pertained to the project
well sh*t
i slowly came to an understanding that i was afraid to go out or communicate with the outside worldwhen my pdoc scolded me for stopping the med w/out consulting him -- duh--had to explain that i wouldn't have been able to make the call
so yes, you might want to get off the med ond on to a quick-fix like lexapro
good luck
Posted by SLS on December 4, 2008, at 17:46:33
In reply to Nortriptyline trial a failure?, posted by glennb on December 4, 2008, at 16:24:57
Raise the dosage of nortriptyline. Most people respond to 75mg. I take 150mg. If you are curious, there are tests that assay blood levels for this drug. The therapeutic range is listed to be between 50-150ng/ml. This is best used only as a rough guideline. Finding the right dosage is still a matter of trial and error. However, this can be done relatively quickly. I wouldn't spend more than 3-4 weeks at any one dosage if you are not benefiting from it. At least try 100mg if you haven't already.
- Scott
Posted by bleauberry on December 4, 2008, at 17:59:21
In reply to Nortriptyline trial a failure?, posted by glennb on December 4, 2008, at 16:24:57
No way for any of us to know, but my guess is the thing that has been missing from the mix all along is an antipsychotic. Not for psychosis, but as a mood stabilizer and antidepressant turbocharger. For example, Prozac+Zyprexa; Lexapro+Risperdal. Since you are so familiar with Prozac, it might be a smoother more comfortable journey to go with it. Add zyprexa to it.
Prozac to me was similar to your experience with it. When my doc added zyprexa, it was at a time when the combo was just being discovered for its unique synergistic power. I was surprised to see it gave me great sleep, improved sexual function, cut the edge off prozac jitters, about a 60% improvevment in the dysthymia which always made me wonder if sometimes what we think is depression/dysthymia could actually be a moderate form of the negative symptoms of schizophrenia. They look so much alike. Anyway, we later added Adrafinil (Provigil's parent) and I was probably 90% cured for about 6 years. They were actually good productive years with only very distant traces of any lingering problems. I went for months at a time feeling perfectly normal with only a few scattered dysthymic hours here and there. I later discovered I was battling longterm low level chronic mercury exposure which eventually overwhelmed the great meds.
I would imagine a direct switch to prozac + zyprexa (probably 5mg), and shortly later at Provigil to it, you could be a different person.
A friend of mine with longterm depression was given lexapro + risperdal right from the start and he was already kicking in within 4 days.
Antipsychotics in combination do several things. They increase serotonin, NE, and DA levels in the brain from 100% to 300% more than the antidepressant alone. They partially block the receptors responsible for sexual dysfunction. The partially block the receptors responsible for anxiety/agitation.
The downside of weight gain should be ignored in a case like yours. Besides, I only gained 12 pounds. You do have to take on a new responsibility of eating healthy stuff geared toward good health and low weight. That is a ton better than a hospital or ECT.
ECT. Don't do it. I am a survivor. It sucks worse than words can describe. I see absolutely zero sense in even thinking about it until you've tried a prozac+zyprexa combo, lex+risp combo, provigil added to them, and a few other combos. ECT is for doctors who aren't creative enough with their prescription pads.
Posted by azalea on December 4, 2008, at 19:02:09
In reply to Nortriptyline trial a failure?, posted by glennb on December 4, 2008, at 16:24:57
Why not start the Lamictal titration? It helped before, and it's an good mood stabilizer with antidepressant properties.
Although you mention no mania and no euphoria, you clearly describe mood cycling between dysthymia and major depression. Research suggests that mood stabilizers are more effective the antidepressants for people with chronic depression that respond but do not achieve remission with traditional antidepressants.
> I have been in a trd/mdd episode for over a year. Was previously taking fluoxetine on and off for about 10 years with different augmentors never really reaching remission or eating into dysthymia but staying mostly functional. Over the years experimented with most of the other SSRIs, wellbutrin, lamictal (i think was somewhat helpful), depakote.> I have no history of bipolar though am very irritable and sometimes have raciness and difficulty focusing which I attribute to the OCD. No mania or euphoria. I have comorbid ocd which is not bothering me as much as the depression. I have irritability which is controlled by SSRIs but is now pretty high; the nortriptyline doesn't seem to control it.
Posted by desolationrower on December 4, 2008, at 19:05:33
In reply to Nortriptyline trial a failure?, posted by glennb on December 4, 2008, at 16:24:57
I mostly agree with the previous posters. Neuroleptics are ick, but they can be quite helpful for irritability (esp since valproate didn't help)and ocd - but for ocd they need to be added to an sri. So since prozac has been your best drug, i would add that to a sufficient dose of nort, and if that is insufficient, try an AP. Between the nort and prozac its plenty of serotonergic blockade, so what you are really looking for is dopamine effects. Olazapine and aripiprazole would be the 2 i would try. With that much hypersomnia, provigil would be good to add soon, since most stimulants could worsen the irritability. And if all that doesn't work out, phenelzine. good luck.
-d/r
Posted by Phillipa on December 5, 2008, at 0:12:15
In reply to Re: Nortriptyline trial a failure?, posted by desolationrower on December 4, 2008, at 19:05:33
I agree with the lamictal no side effects except spitting no insomnia or irritibility. Phillipa
Posted by glennb on December 5, 2008, at 12:27:07
In reply to Nortriptyline trial a failure?, posted by glennb on December 4, 2008, at 16:24:57
I should have included that I have tried some antipsychotics. abilify gave me akathisia, risperedone I was on for awhile with both prozac (in this episode) and effexor and it didn't seem to do much, seroquel I was on at the same time as lamictal. The suggestions to try zyprexa are interesting to me. I gave Celexa a decent trial year back so lexapro doesn't excite me to much. I had thought of raising the nortriptyline and will bring that up when I find a new pdoc, my blood levels are at 140 on 75mg so I'm not going to mess with it on my own. An MAOI may be the next step though I'm discouraged by the star*d numbers.
Thanks for all the suggestions.
Posted by bleauberry on December 5, 2008, at 15:20:13
In reply to Re: Nortriptyline trial a failure?, posted by glennb on December 5, 2008, at 12:27:07
Interesting updates. Ok. That kind of changes the picture a little bit.
Don't rule out zyprexa. It is different than the others, especially good with prozac. Also, while I touched on Provigil, overnight I was thinking about that and realized I had totally forgotten the stimulant route. Ya know, Ritalin and Adderall and Dexedrine and Provigil are all strong contenders for treatment resistant depression/anhedonia/energy/lack of motivation when combined with an SSRI. They can be troublesome by themselves, but somehow the SSRI can be a synergistic ingredient. People have responded remarkably well to those combos in as little as one to a few days, even after failing to improve on ECT. If agitation is ever an issue, a tiny dash of klonopin or lorazepam should fix that.
Anyway, as I see it, the potentials on your radar screen include all the stimulants, Prozac, Zyprexa, possible benzo. After that, MAOIs. But hopefully you'll be well long before then.
AND, this is very important, do not get suckered by the insurance game...insist on and pay the higher price for BRAND names. No generics! If this were a gambling hand in Las Vegas, you need every potential winning wild card in your hand, and going brand is one way to do that. Brand equals higher success odds, generic equals lower success odds. Simple as that.
> I should have included that I have tried some antipsychotics. abilify gave me akathisia, risperedone I was on for awhile with both prozac (in this episode) and effexor and it didn't seem to do much, seroquel I was on at the same time as lamictal. The suggestions to try zyprexa are interesting to me. I gave Celexa a decent trial year back so lexapro doesn't excite me to much. I had thought of raising the nortriptyline and will bring that up when I find a new pdoc, my blood levels are at 140 on 75mg so I'm not going to mess with it on my own. An MAOI may be the next step though I'm discouraged by the star*d numbers.
>
> Thanks for all the suggestions.
Posted by glennb on December 6, 2008, at 22:25:18
In reply to Re: Nortriptyline trial a failure? » glennb, posted by bleauberry on December 5, 2008, at 15:20:13
Thanks for the updated thoughts. I will definitely do some research on zyprexa. I neglected to mention I've tried the stimulants. Adderall has been useful to me when I'm up and about and trying to focus on work and being productive but none of the stimulants are useful to get me out of bed if I'm feeling severely depressed; basically I just lay in bed uncomfortably stimulated. I just trialed provigil as an augmentor for nortriptyline. I slipped into this relapse a few days in..went up to 400mg on the provigil, still wasn't enough to get me out of it. I wonder if other people feel this sort of binary function/can't function thing. The only thing I've found useful to break the grip is oxycodone. I was prescribed it, but am no longer using that doc and am about to run out. For this relapse, it hasn't really gotten me going, but it has allowed me to get online and do some research and post here, and it has very dramatically eased the 'psychic' pain which is getting uncomfortably high with each relapse. I guess for me (and I wonder how it is for other people), it's not motivation or stimulation that I'm lacking when I can't get out of bed, it's more like there is a force keeping me in bed. I often have the sensation of fear, without actually fearing anything so it seems like some sort of emotional paralysis (for lack of a better term).
> Interesting updates. Ok. That kind of changes the picture a little bit.
>
> Don't rule out zyprexa. It is different than the others, especially good with prozac. Also, while I touched on Provigil, overnight I was thinking about that and realized I had totally forgotten the stimulant route. Ya know, Ritalin and Adderall and Dexedrine and Provigil are all strong contenders for treatment resistant depression/anhedonia/energy/lack of motivation when combined with an SSRI. They can be troublesome by themselves, but somehow the SSRI can be a synergistic ingredient. People have responded remarkably well to those combos in as little as one to a few days, even after failing to improve on ECT. If agitation is ever an issue, a tiny dash of klonopin or lorazepam should fix that.
>
> Anyway, as I see it, the potentials on your radar screen include all the stimulants, Prozac, Zyprexa, possible benzo. After that, MAOIs. But hopefully you'll be well long before then.
>
> AND, this is very important, do not get suckered by the insurance game...insist on and pay the higher price for BRAND names. No generics! If this were a gambling hand in Las Vegas, you need every potential winning wild card in your hand, and going brand is one way to do that. Brand equals higher success odds, generic equals lower success odds. Simple as that.
>
>
>
> > I should have included that I have tried some antipsychotics. abilify gave me akathisia, risperedone I was on for awhile with both prozac (in this episode) and effexor and it didn't seem to do much, seroquel I was on at the same time as lamictal. The suggestions to try zyprexa are interesting to me. I gave Celexa a decent trial year back so lexapro doesn't excite me to much. I had thought of raising the nortriptyline and will bring that up when I find a new pdoc, my blood levels are at 140 on 75mg so I'm not going to mess with it on my own. An MAOI may be the next step though I'm discouraged by the star*d numbers.
> >
> > Thanks for all the suggestions.
>
>
Posted by bleauberry on December 7, 2008, at 10:56:04
In reply to Re: Nortriptyline trial a failure?, posted by glennb on December 6, 2008, at 22:25:18
Yeah, I hear ya on Provigil. Ya know, it actually made me slip into a deeper depression really fast? Lots of people think they just sunk deeper as a natural part of the disease but never figure it was the med doing it. I've done challenge tests with various meds to confirm whether they really were bad for me or not. Scary. Every time, bad or worse than the first.
As for the stimulants, I'm not sure if you took them in combination with serotonin ADs? That seems to be the way they work the best. But the correct dosage and length of time (2 to 3 weeks) is needed. Sure they hit fast, but that is not the true effect. The other real important thing, as far as I am concerned, is that the meds are brand and not generic. For example, generic Dexedrine is a world different than GSK Dexedrine, with GSK being profoundly better and feels like a different drug.
You mentioned something interesting. There could be an opioid connection. That would bring into the picture two easily attainable things of different mechanisms but both enhancing the opioid function. One would be Tramadol. At other forums you would be amazed how many people have found it to be that magic med they've missed for tens of years. Dependence, sure. But who cares if one can assume a normal life again. Heck, diabetics and heart patients are dependent on their meds too. The other strategy would be LDN (low dose naltrexone) in combination with whatever else helps you. Do a google search on LDN. Doses of just 1.5mg to 4.5mg can do some astounding things. I was only on 1.5mg monotherapy for 2 weeks and I have to admit I was impressed. I plan to go back on, but for now my main focus is an antiobiotic assault without anything else in the mix.
Posted by JadeKelly on December 8, 2008, at 14:10:56
In reply to Nortriptyline trial a failure?, posted by glennb on December 4, 2008, at 16:24:57
Hi,
Two things, first, wonder why MAOI's are not up front on the list here, with irritablity, I would think Nardil the better choice, or Parnate with an augment for irritability.
Second, you may want a second opinion on your diagnosis. Increasing irritablity/aggressiveness can be form of mania. Just a thought.
~Jade
Posted by glennb on December 8, 2008, at 18:24:40
In reply to Re: Nortriptyline trial a failure? » glennb, posted by bleauberry on December 7, 2008, at 10:56:04
You're trying antibiotics to attack depression or do you have other problems?
LTN, I had never heard of. I just googled and I see it looks interesting. I know there are lots of other boards but what are the essential boards you use to keep on top of things?
On the stimulants. I took adderall for about a year with prozac and for awhile the mix included risperidone. For the first few months I did well and then started to decline. I don't believe the adderall had anything to do with, it just happened to be in the mix at the time.
Then I went off of it and when on an effexor trial which was a total bust. Then a different doctor prescribed me oxycodone for depression and also put me on adderall and prozac at the same time. I tried this for a week, nothing dramatic. I complained of nauseau so was switched to dexedrine and did another week, nothing dramatic and then that experiment was scratched. It is the left over oxycodone that I have been playing with. I think it has worked better now because I was in more distress when I initially was put on it. I also am on a TCA now and wikipedia says TCA's and opiods reinforce each other, though I have no idea whether that's true or not.
> Yeah, I hear ya on Provigil. Ya know, it actually made me slip into a deeper depression really fast? Lots of people think they just sunk deeper as a natural part of the disease but never figure it was the med doing it. I've done challenge tests with various meds to confirm whether they really were bad for me or not. Scary. Every time, bad or worse than the first.
>
> As for the stimulants, I'm not sure if you took them in combination with serotonin ADs? That seems to be the way they work the best. But the correct dosage and length of time (2 to 3 weeks) is needed. Sure they hit fast, but that is not the true effect. The other real important thing, as far as I am concerned, is that the meds are brand and not generic. For example, generic Dexedrine is a world different than GSK Dexedrine, with GSK being profoundly better and feels like a different drug.
>
> You mentioned something interesting. There could be an opioid connection. That would bring into the picture two easily attainable things of different mechanisms but both enhancing the opioid function. One would be Tramadol. At other forums you would be amazed how many people have found it to be that magic med they've missed for tens of years. Dependence, sure. But who cares if one can assume a normal life again. Heck, diabetics and heart patients are dependent on their meds too. The other strategy would be LDN (low dose naltrexone) in combination with whatever else helps you. Do a google search on LDN. Doses of just 1.5mg to 4.5mg can do some astounding things. I was only on 1.5mg monotherapy for 2 weeks and I have to admit I was impressed. I plan to go back on, but for now my main focus is an antiobiotic assault without anything else in the mix.
Posted by glennb on December 8, 2008, at 18:30:04
In reply to Re: Nortriptyline trial a failure? » glennb, posted by JadeKelly on December 8, 2008, at 14:10:56
MAOIs are on my short list. I am trying to get into Columbia's expert evaluation service and am waiting on a call back to get an updated diagnosis. I've often wondered if the irritability indicates some sort of bipolarity and one pdoc suggested bipolar II, but I really just think it's a symptom of either my ocd or depression or just a personality flaw. When I am off everything it is probably my primary symptom. I wonder if that means anything. And even 20mg of prozac seems to mask it.
> Hi,
>
> Two things, first, wonder why MAOI's are not up front on the list here, with irritablity, I would think Nardil the better choice, or Parnate with an augment for irritability.
>
> Second, you may want a second opinion on your diagnosis. Increasing irritablity/aggressiveness can be form of mania. Just a thought.
>
> ~Jade
Posted by JadeKelly on December 9, 2008, at 20:45:08
In reply to Re: Nortriptyline trial a failure? » glennb, posted by JadeKelly on December 8, 2008, at 14:10:56
Hi Glenn,
First, before I forget (we're identical in the lethargic dept. Cognitively not there either. But I did remember this). I'm on Parnate, tolerable sides, but not a/d effect yet. You may want to get comfortable in that bed if you decide to try one (MAOI).
What I recently found was an article re: the STAR*D study where they (I believe NIMH) actually reported that MAOI's low result profile is now felt to be, by them, due to inadequate dosing (doses were not therapeutic for a robust response). Interesting, eh? So you may want to rethink that. Its a commitment, but I am cooresponding with 2 people on this board that, while I 've been "talking" to them seem to be responding. Don't exclude it from your list!
Let me know what you find to get up and going. PLEASE! haha I'll do same. Good luck with your decision.
~Jade
Posted by SLS on December 10, 2008, at 6:05:12
In reply to Nortriptyline trial a failure? STAR*D Surprise » JadeKelly, posted by JadeKelly on December 9, 2008, at 20:45:08
> Hi Glenn,
>
> First, before I forget (we're identical in the lethargic dept. Cognitively not there either. But I did remember this). I'm on Parnate, tolerable sides, but not a/d effect yet. You may want to get comfortable in that bed if you decide to try one (MAOI).
>
> What I recently found was an article re: the STAR*D study where they (I believe NIMH) actually reported that MAOI's low result profile is now felt to be, by them, due to inadequate dosing (doses were not therapeutic for a robust response). Interesting, eh? So you may want to rethink that. Its a commitment, but I am cooresponding with 2 people on this board that, while I 've been "talking" to them seem to be responding. Don't exclude it from your list!
>
> Let me know what you find to get up and going. PLEASE! haha I'll do same. Good luck with your decision.
>
> ~Jade
From my personal experience and in conversation with several doctors, the normal therapeutic dosages should be:Parnate 40-80mg
Nardil 60-90mg
* Jade, is that STAR*D article you read on the Internet? I may need to present evidence to my insurance company that 80mg is necessary for some people in order to respond.
- Scott
Posted by JadeKelly on December 10, 2008, at 10:58:15
In reply to Re: Nortriptyline trial a failure? STAR*D Surprise » JadeKelly, posted by SLS on December 10, 2008, at 6:05:12
> > Hi Glenn,
> >
> > First, before I forget (we're identical in the lethargic dept. Cognitively not there either. But I did remember this). I'm on Parnate, tolerable sides, but not a/d effect yet. You may want to get comfortable in that bed if you decide to try one (MAOI).
> >
> > What I recently found was an article re: the STAR*D study where they (I believe NIMH) actually reported that MAOI's low result profile is now felt to be, by them, due to inadequate dosing (doses were not therapeutic for a robust response). Interesting, eh? So you may want to rethink that. Its a commitment, but I am cooresponding with 2 people on this board that, while I 've been "talking" to them seem to be responding. Don't exclude it from your list!
> >
> > Let me know what you find to get up and going. PLEASE! haha I'll do same. Good luck with your decision.
> >
> > ~Jade
>
>
> From my personal experience and in conversation with several doctors, the normal therapeutic dosages should be:
>
> Parnate 40-80mg
>
> Nardil 60-90mg
>
>
> * Jade, is that STAR*D article you read on the Internet? I may need to present evidence to my insurance company that 80mg is necessary for some people in order to respond.
>
>
> - ScottHi Scott,
Lost my original post to you but found there is alot of info online re: higher doses. Jonathon Cole at Mclean Hospital, Professor at Harvard I believe. I'm sure you are familiar. A second article, interview at Cloumbia University said they use higher doses Maoi's for tr/dep or MDD. If you google The Carlot Psychiatry Report, Dr. Cole has good article. I think it was Dr.Cole who used to be affiliated with NIMH. Anyway, plenty of use of higher doses used by respected MD,s. Not sure thats enough for your insur company. If you need actual study results get back to me, I'll look further.
~Jade
>
PS-will keep looking for STAR*D Article as well
Posted by glennb on December 10, 2008, at 15:36:10
In reply to Re: Nortriptyline trial a failure? STAR*D Surprise » SLS, posted by JadeKelly on December 10, 2008, at 10:58:15
Jade, you're right about the dosing problems in star*d on the MAOIs. I hope it works for you. Keep me posted.
Posted by desolationrower on December 10, 2008, at 16:40:02
In reply to Re: Nortriptyline trial a failure? STAR*D Surprise, posted by glennb on December 10, 2008, at 15:36:10
The TCP group in STARD also was not the same as the group getting venlafaxine & mirt, they were twice as likely to have quit other drugs for side effects, so not 1/1 comparison. also not account for 2 week extra washout people had for tcp. really stard was all kinds of messed up, more of a reassurance that current practice is working and no investigation of alternate protocols
-d/r
This is the end of the 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.