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Dr. Bob is Robert Hsiung, MD,
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Posted by X-ray on November 26, 2009, at 10:43:54
Essential psychopharmacology: neuroscientific basis and practical applications
Stephen M. Stahl has singled out 13 successful drug combinations (Heroic combos).The point is to use safe and rational drug combinations that exploit expected
pharmacological and molecular synergies while even promoting mutual tolerabilities (Stahl).Heroic combos
1: High dose venlaxafine + mirtazapine =California rocket fuel
2: High dose venlaxafine + NDRI (bupropion)
3: High dose venlaxafine + NRI (selective reboxetine or a nonselective TCA)
4: High dose venlaxafine + stimulant
5: Venlaxafine + nefazodone
6: Mirtazapine + SSRI
7: Mirtazapine + NRI (reboxetine)
8: Mirtazapine + NDRI (bupropion)
9: Mirtazapine + stimulant
10: SSRI + NRI (selective reboxetine)
11: SSRI + NDRI (bupropion)
12: SSRI + stimulant
13: Nefazodone + NDRI (bupropion)3: nonselective TCA such as desipramine, maprotilene, nortriptyline, or protriptyline
4: stimulants: d-amphetamine, methylphenidate, phentermine, or diethylpropion
4: could also include direct-acting dopamine agonists such as pramipexole
9: stimulants: d-amphetamine, methylphenidate, phentermine, or diethylpropion
9: could also include direct-acting dopamine agonists such as pramipexole
12: stimulants: d-amphetamine, methylphenidate, phentermine, or diethylpropion
12: could also include direct-acting dopamine agonists such as pramipexoleBest regards,
X-ray
Posted by mtdewcmu on November 26, 2009, at 11:16:13
In reply to Heroic combos, posted by X-ray on November 26, 2009, at 10:43:54
I have two questions:
1. Are those listed in order of effectiveness, or is the order arbitrary?
2. Does he have hard numbers to support the enhanced effectiveness of those mixtures, or are they based on conjecture and anecdote?
Posted by X-ray on November 26, 2009, at 13:40:40
In reply to Re: Heroic combos, posted by mtdewcmu on November 26, 2009, at 11:16:13
There is no ranking order between these combos.
I don't think that Stahl has numbers to lean on,
but he explains the theory behind every combination of these drugs.For instance, Heroic combo 8: Mirtazapine + NDRI:
Here NE is double-boosted, and 5HT and DA are single-boosted.You can Google and read for yourself.
Search Heroic combo 1, "Heroic combo 2, etc.X-ray
Posted by mtdewcmu on November 26, 2009, at 13:46:38
In reply to Re: Heroic combos, posted by X-ray on November 26, 2009, at 13:40:40
> There is no ranking order between these combos.
>
> I don't think that Stahl has numbers to lean on,
> but he explains the theory behind every combination of these drugs.
>
> For instance, Heroic combo 8: Mirtazapine + NDRI:
> Here NE is double-boosted, and 5HT and DA are single-boosted.
>
> You can Google and read for yourself.
> Search Heroic combo 1, "Heroic combo 2, etc.
>
> X-ray
>Thanks. Those look good on paper, but it would be interesting to have some numbers.
Posted by Phillipa on November 26, 2009, at 23:11:48
In reply to Re: Heroic combos, posted by mtdewcmu on November 26, 2009, at 13:46:38
Some did nothing and some couldn't tolerate. Phillipa
Posted by mtdewcmu on November 27, 2009, at 0:12:00
In reply to Re: Heroic combos, posted by Phillipa on November 26, 2009, at 23:11:48
I am on a heroic triple: Remeron, Zoloft, and Wellbutrin. All of their effects are complementary. I am also taking Abilify, but I am not convinced that it is helping.
If one or two ADs doesn't work, why not add a third?
Posted by SLS on November 27, 2009, at 4:30:50
In reply to Re: Heroic combos, posted by mtdewcmu on November 27, 2009, at 0:12:00
> I am on a heroic triple: Remeron, Zoloft, and Wellbutrin. All of their effects are complementary.
Pretty smart.
Zoloft is a great drug. Effexor and Lexapro would be good replacements for Zoloft were it ever to become necessary to make a switch.
> I am also taking Abilify, but I am not convinced that it is helping.
How much are you taking?
How are you feeling currently?
- Scott
Posted by SLS on November 27, 2009, at 4:32:45
In reply to Re: Heroic combos, posted by mtdewcmu on November 27, 2009, at 0:12:00
> I am on a heroic triple: Remeron, Zoloft, and Wellbutrin. All of their effects are complementary.
Pretty smart.
Zoloft is a great drug. Effexor and Lexapro would be good replacements for Zoloft were it ever to become necessary to make a switch.
> I am also taking Abilify, but I am not convinced that it is helping.
How much are you taking?
How are you feeling currently?
- Scott
Posted by mtdewcmu on November 27, 2009, at 12:23:12
In reply to Re: Heroic combos » mtdewcmu, posted by SLS on November 27, 2009, at 4:30:50
> > I am on a heroic triple: Remeron, Zoloft, and Wellbutrin. All of their effects are complementary.
>
> Pretty smart.
>
> Zoloft is a great drug. Effexor and Lexapro would be good replacements for Zoloft were it ever to become necessary to make a switch.
>
> > I am also taking Abilify, but I am not convinced that it is helping.
>
> How much are you taking?
>
> How are you feeling currently?
>
>
> - ScottI have been feeling very much improved since I started this regimen, with very few and minor side effects. I am not symptom-free, but for the first time since I started trying to switch meds 3 months ago, I feel like I could live indefinitely with this mixture. For once I am not anxiously counting the days until my next pdoc appointment so I can make a change.
Here is what I take:
Zoloft 100mg
Wellbutrin XL 300mg
Remeron 15mg
Abilify 2mgI agree that Lexapro sounds like a great drug, but I was on Celexa for several years prior and it pooped out, so I am afraid that Lexapro might be somewhat pooped out for me, too.
Actually, one side effect I am having is early awakening from sleep. On the whole, my sleeping patterns are better, since I am sleeping at a normal time now, and I haven't had a great deal of difficulty falling asleep. But, I have been waking up after 4-6 hours. Remeron has not been anywhere near as sedating as advertised (not surprising, because I found Elavil stimulating), so I am suspicious that it may be waking me up when I take it before bed. Today I took my dose in the morning.
Posted by SLS on November 27, 2009, at 16:15:49
In reply to Re: Heroic combos, posted by mtdewcmu on November 27, 2009, at 12:23:12
> Actually, one side effect I am having is early awakening from sleep. On the whole, my sleeping patterns are better, since I am sleeping at a normal time now, and I haven't had a great deal of difficulty falling asleep. But, I have been waking up after 4-6 hours. Remeron has not been anywhere near as sedating as advertised (not surprising, because I found Elavil stimulating), so I am suspicious that it may be waking me up when I take it before bed. Today I took my dose in the morning.
I hope that works out for you.
- Scott
Posted by dcruik518 on December 5, 2009, at 10:37:42
In reply to Re: Heroic combos » mtdewcmu, posted by SLS on November 27, 2009, at 16:15:49
Actually, it may be the Zoloft that's causing you to wake up earlier than you'd like in the morning. It definitely has that effect on me, with or without abilify. Zoloft also causes very vivid and often disturbing dreams for me, but less so if I take it in the morning . It's weird because lower dose Zoloft makes me sleepy during the day. But I've found that if I get up to 150-200mg it starts to have a slight energizing effect. This doesn't surprise that much because I found the same thing with low and high doses of prozac, but prozac made me jumpy, too, which Zoloft doesn't. My guess is that at higher doses there may be a greater anti-depressant effect or else that I may actually be experiencing a very minor serotonin syndrome-like effect. I surmise that any SSRIs at very high doses will become stimulating if you start to have some mild serotonin syndrome.
I've had bad luck with Wellbutrin, but I wonder if it might work with Zoloft anyway? My main problem is lack of motivation and energy--but I also have social anxiety. I take Zoloft, Abilify, and Adderall, clonazepam during the day, and trazodone with melatonin at night.
Any thoughts?
Posted by dcruik518 on December 5, 2009, at 10:38:17
In reply to Re: Heroic combos » mtdewcmu, posted by SLS on November 27, 2009, at 16:15:49
Actually, it may be the Zoloft that's causing you to wake up earlier than you'd like in the morning. It definitely has that effect on me, with or without abilify. Zoloft also causes very vivid and often disturbing dreams for me, but less so if I take it in the morning . It's weird because lower dose Zoloft makes me sleepy during the day. But I've found that if I get up to 150-200mg it starts to have a slight energizing effect. This doesn't surprise that much because I found the same thing with low and high doses of prozac, but prozac made me jumpy, too, which Zoloft doesn't. My guess is that at higher doses there may be a greater anti-depressant effect or else that I may actually be experiencing a very minor serotonin syndrome-like effect. I surmise that any SSRIs at very high doses will become stimulating if you start to have some mild serotonin syndrome.
I've had bad luck with Wellbutrin, but I wonder if it might work with Zoloft anyway? My main problem is lack of motivation and energy--but I also have social anxiety. I take Zoloft, Abilify, and Adderall, clonazepam during the day, and trazodone with melatonin at night.
Any thoughts?
Posted by svk on February 9, 2010, at 17:04:34
In reply to Heroic combos, posted by X-ray on November 26, 2009, at 10:43:54
My doctor created a new heroic combo for me. I have extreme TRD. This combo keeps it managable.
stimulant + sertraline + bupropion + mirtazapine
(concerta + zoloft + Wellbutrin + Remeron)
Posted by Deneb on February 10, 2010, at 15:15:27
In reply to Re: Heroic combos, posted by svk on February 9, 2010, at 17:04:34
Hi SVK
Welcome to Psycho-Babble. Thanks for letting us know of your combo. It sounds good. I'm glad it's working for you.
Deneb
Posted by Cherry Carver on February 17, 2010, at 10:14:30
In reply to Re: Zoloft causes early waking for me » SLS, posted by dcruik518 on December 5, 2009, at 10:38:17
When doctors tried to take me off Klonopin (clonazepam), among other things they tried unsuccessfully were Wellbutrin and Desyrel (trazadone). I have severe panic disorder and Klonopin has worked well by itself, or with (in emergencies) Ativan (lorazepam). Desyrel made my heart race and I could not sleep while taking it. Abilify has so many bad side-effects that I would never take it. Melatonin mixed with all this stuff--wow! That is a LOT of medicine! Have you tried taking any one of these medications on its own? I feel concerned about you, because I have been in a situation where doctors put me on multiple meds at the same time despite the fact Klonopin was working by itself. The combinations they handed out caused problems that persist to this day.
> I've had bad luck with Wellbutrin, but I wonder if it might work with Zoloft anyway? My main problem is lack of motivation and energy--but I also have social anxiety. I take Zoloft, Abilify, and Adderall, clonazepam during the day, and trazodone with melatonin at night.
>
> Any thoughts?
Posted by highhatsize on February 18, 2010, at 20:01:46
In reply to Heroic combos, posted by X-ray on November 26, 2009, at 10:43:54
[Sigh!] Seven of those combinations are unobtainable in San Francisco where I live. Either they are not approved by the FDA or they include a stimulant that Shrinks will not prescribe.
It would be nice to have a Shrink in whose competency one had faith. I have had some in the past but lost them due to changes of domicile. After four years of fruitless verbal sparring with ones that didn't have a clue, I finally gave up and have been Shrink-free for two years.
Ironically, during that solo period I discovered by serendipity that a combination of low-dose Lexapro and diphenhydramine, (Benedryl), worked better than anything for my major depressive disorder.
Sure wish I had someone to turn to in a crisis, though. But I knew the the Shrinks that I had would have proven as inept in emergency as they are in normalcy.
Posted by Cherry Carver on February 20, 2010, at 1:07:02
In reply to Re: Heroic combos, posted by highhatsize on February 18, 2010, at 20:01:46
Benadryl is an awesome way to potentiate medication. I take it for sinus problems as well as for sleep.
I know what you mean about shrinks. I desperately need my meds adjusted to alleviate a bad bout of major depression and anxiety, which was aggravated this week by my new shrink's incompetent staff. They screwed me over royally--accidentally cancelled my appointment (which was supposed to be Thursday) and carelessly shoved it to April 15. (HELLO...tax time?!?) I can't wait that long, so BYE-BYE, SHRINK.
Right now there aren't enough bad words I can say about the doctors in this state. I can verify that it is worse than California (I used to live in Monterey).
> [Sigh!] Seven of those combinations are unobtainable in San Francisco where I live. Either they are not approved by the FDA or they include a stimulant that Shrinks will not prescribe.
>
> It would be nice to have a Shrink in whose competency one had faith. I have had some in the past but lost them due to changes of domicile. After four years of fruitless verbal sparring with ones that didn't have a clue, I finally gave up and have been Shrink-free for two years.
>
> Ironically, during that solo period I discovered by serendipity that a combination of low-dose Lexapro and diphenhydramine, (Benedryl), worked better than anything for my major depressive disorder.
>
> Sure wish I had someone to turn to in a crisis, though. But I knew the the Shrinks that I had would have proven as inept in emergency as they are in normalcy.
>
>
Posted by Brainbeard on February 24, 2010, at 11:33:51
In reply to Re: Heroic combos, posted by highhatsize on February 18, 2010, at 20:01:46
> Ironically, during that solo period I discovered by serendipity that a combination of low-dose Lexapro and diphenhydramine, (Benedryl), worked better than anything for my major depressive disorder.
What dose of Lexapro were/are you on?
Posted by highhatsize on February 24, 2010, at 12:01:44
In reply to Re: Heroic combos, posted by Brainbeard on February 24, 2010, at 11:33:51
> > Ironically, during that solo period I discovered by serendipity that a combination of low-dose Lexapro and diphenhydramine, (Benedryl), worked better than anything for my major depressive disorder.
>
> What dose of Lexapro were/are you on?Currently, I am at 2.5 mg. of Lexapro, down from 10 mg. when I started a few years ago.
Posted by Brainbeard on February 24, 2010, at 13:39:02
In reply to Re: Heroic combos, posted by highhatsize on February 24, 2010, at 12:01:44
> Currently, I am at 2.5 mg. of Lexapro, down from 10 mg. when I started a few years ago.
That's interesting. Would you say that 2.5mg is more effective for you than 5mg?
Posted by highhatsize on February 24, 2010, at 17:18:45
In reply to Re: Heroic combos, posted by Brainbeard on February 24, 2010, at 13:39:02
> > Currently, I am at 2.5 mg. of Lexapro, down from 10 mg. when I started a few years ago.
>
> That's interesting. Would you say that 2.5mg is more effective for you than 5mg?
>Not MORE effective, but equally effective and minus the side-effects that were present at 10 mg., or even 5.
Since my experience with the previous SSRI, Paxil, and the SSRI/SNRI, Cymbalta, was that they only took effect at twice the normal adult dose, I was pleasantly surprised.
Perhaps either would have been as effective if combined with diphenhydramine but the happy accident of my taking the latter drug for chronic rhinitis didn't occur when I was taking them.
Posted by paulbwell on February 24, 2010, at 22:58:22
In reply to Heroic combos, posted by X-ray on November 26, 2009, at 10:43:54
> Essential psychopharmacology: neuroscientific basis and practical applications
> Stephen M. Stahl has singled out 13 successful drug combinations (Heroic combos).
>
> The point is to use safe and rational drug combinations that exploit expected
> pharmacological and molecular synergies while even promoting mutual tolerabilities (Stahl).
>
> Heroic combosSearch 'Ame Sans Vie' and most long timers here will agree he was surly the king of herioc meds combo takers, what he took was staggering~25 pills a day. Script meth@amphetamines, several high dose benzos, 2-3 different barbiturates. He was a very interesting contributer to this site RIP.
>
> 1: High dose venlaxafine + mirtazapine =California rocket fuel
> 2: High dose venlaxafine + NDRI (bupropion)
> 3: High dose venlaxafine + NRI (selective reboxetine or a nonselective TCA)
> 4: High dose venlaxafine + stimulant
> 5: Venlaxafine + nefazodone
> 6: Mirtazapine + SSRI
> 7: Mirtazapine + NRI (reboxetine)
> 8: Mirtazapine + NDRI (bupropion)
> 9: Mirtazapine + stimulant
> 10: SSRI + NRI (selective reboxetine)
> 11: SSRI + NDRI (bupropion)
> 12: SSRI + stimulant
> 13: Nefazodone + NDRI (bupropion)
>
> 3: nonselective TCA such as desipramine, maprotilene, nortriptyline, or protriptyline
> 4: stimulants: d-amphetamine, methylphenidate, phentermine, or diethylpropion
> 4: could also include direct-acting dopamine agonists such as pramipexole
> 9: stimulants: d-amphetamine, methylphenidate, phentermine, or diethylpropion
> 9: could also include direct-acting dopamine agonists such as pramipexole
> 12: stimulants: d-amphetamine, methylphenidate, phentermine, or diethylpropion
> 12: could also include direct-acting dopamine agonists such as pramipexole
>
> Best regards,
> X-ray
>
Posted by Phillipa on February 24, 2010, at 23:38:44
In reply to Re:The deceased king of Heroic combos » X-ray, posted by paulbwell on February 24, 2010, at 22:58:22
Paulwell is correct unfortunately this great guy is no longer with us. I remember so well. Phillipa
Posted by Brainbeard on February 25, 2010, at 3:21:15
In reply to Re: Heroic combos, posted by highhatsize on February 24, 2010, at 17:18:45
What doses of diphenhydramine do you take, and do you take several doses a day?
Posted by highhatsize on February 25, 2010, at 10:36:58
In reply to Re: Heroic combos, posted by Brainbeard on February 25, 2010, at 3:21:15
> What doses of diphenhydramine do you take, and do you take several doses a day?
I take two 25 mg. capsules at a time. I try to take them every four hours but I don't pay close attention. When my rhinitis acts up, I take the diphenhydramine.I also use a nasal spray, (oxymetazoline hcl., [generic Afrin]), but I haven't read that this has any antidepressant effects.
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