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Dr. Bob is Robert Hsiung, MD,
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Posted by bleauberry on April 17, 2010, at 11:12:24
In reply to Severe anhedonia, posted by Maximus on April 16, 2010, at 11:48:18
Broadly speaking anhedonia seems to me to be a hypo-excitatory thing. Too much inhibition going on, not enough excitement going on. Inside the brain's workings that is.
Lamictal as I see it is definitely putting the brakes on excitation. I mean, that's what it is supposed to do, right? Stop seizures? Anti-excitation?
Effexor is predominantly serotonin, with a distant smidgen of norepinephrine and dopamine in there. The NE and DA increase more at the highest doses, but still is a tiny percent compared to the whopping effect on serotonin. Serotonin is inhibitory, not excitatory. Despite the weak effect on NE and DA, serotonin is likely squashing them out.
Abilify I think is harder to armchair quarterback. The way it interacts with dopamine and serotonin receptors in two different opposing directions, varying from person to person, and varying from dose-size to dose-size, means that at a certain dose it could be good for anhedonia and at another dose bad. But would vary from person to person. Generally speaking, based off of most comments of abilify users here over the last couple years, doses below 5mg were best for anhedonia. Doses at or above 5mg were too dulling and too much like a full-on antipsychotic. Just comments, not my own opinions. I don't have much personal experience with it.
It is risky to play around with doses. But from an armchair quarterback position, I would say the best way to improve the anhedonia thing would be to lessen the doses of all three meds to the bare minimum dose that keeps you well. If you aren't even at that goal on the doses you are on, then I can't even see the reasoning to keep them at all.
Take my comments with a grain of salt and please don't do anything without talking to your doctor. I just wanted to say that I see too much anti-excitatory stuff in this cocktail. Which is a good thing if control of BP is crucial. Not so good for anhedonia. It is a fine line to try to balance them out. At the current doses, the balance seems to be in favor of stability at the cost of pleasure.
Posted by Maximus on April 17, 2010, at 15:22:13
In reply to Re: Severe anhedonia, posted by bleauberry on April 17, 2010, at 11:12:24
> It is risky to play around with doses. But from an armchair quarterback position, I would say the best way to improve the anhedonia thing would be to lessen the doses of all three meds to the bare minimum dose that keeps you well. If you aren't even at that goal on the doses you are on, then I can't even see the reasoning to keep them at all.
>
> Take my comments with a grain of salt and please don't do anything without talking to your doctor. I just wanted to say that I see too much anti-excitatory stuff in this cocktail. Which is a good thing if control of BP is crucial. Not so good for anhedonia. It is a fine line to try to balance them out. At the current doses, the balance seems to be in favor of stability at the cost of pleasure.Hi,
Thank you very much for your input. I think it is a kind of trade-off. You see, when i decrease the dose of Effexor, i start again to feel and enjoy things. But within 3 or 4 days the melancholia is back with a vengeance. Sometimes i think that a TCA would be better than Effexor. But my pdoc wont take this route, not for a bp patient.
There is always my beloved Zyprexa. But then again, i'm afraid of the dreaded weight gain because i want to lose some... On the other hand my ultimate and real remission was brought by Zyprexa.
Posted by bulldog2 on April 17, 2010, at 17:21:05
In reply to Re: Severe anhedonia » bleauberry, posted by Maximus on April 17, 2010, at 15:22:13
> > It is risky to play around with doses. But from an armchair quarterback position, I would say the best way to improve the anhedonia thing would be to lessen the doses of all three meds to the bare minimum dose that keeps you well. If you aren't even at that goal on the doses you are on, then I can't even see the reasoning to keep them at all.
> >
> > Take my comments with a grain of salt and please don't do anything without talking to your doctor. I just wanted to say that I see too much anti-excitatory stuff in this cocktail. Which is a good thing if control of BP is crucial. Not so good for anhedonia. It is a fine line to try to balance them out. At the current doses, the balance seems to be in favor of stability at the cost of pleasure.
>
> Hi,
>
> Thank you very much for your input. I think it is a kind of trade-off. You see, when i decrease the dose of Effexor, i start again to feel and enjoy things. But within 3 or 4 days the melancholia is back with a vengeance. Sometimes i think that a TCA would be better than Effexor. But my pdoc wont take this route, not for a bp patient.
>
> There is always my beloved Zyprexa. But then again, i'm afraid of the dreaded weight gain because i want to lose some... On the other hand my ultimate and real remission was brought by Zyprexa.
>
>My p-doc started me on clomipramine 25 mg for depression,anhedonia with melancholia.
Posted by Economist on April 18, 2010, at 2:57:31
In reply to Re: Severe anhedonia, posted by bulldog2 on April 17, 2010, at 17:21:05
Hi bulldog,
Please update us in a few weeks if there are any changes in your anhedonia.
Posted by bulldog2 on April 18, 2010, at 8:31:33
In reply to Re: Severe anhedonia » bulldog2, posted by Economist on April 18, 2010, at 2:57:31
> Hi bulldog,
>
> Please update us in a few weeks if there are any changes in your anhedonia.I have been on 25 mg the lowest dose. It truely is powerful so hopefully I can get by on as little as 50 mg or even 25 mg. I still have no desire to seek out people but when I do encounter people I seem to be quite talkative end enjoy the encounters. I am enjoying my favorite tv shows again and found myself laughing this morning. So I would say that even at this dose there is a mood brightening effect. Hope things get even better at 50 mg..
Posted by alchemy on April 18, 2010, at 10:47:24
In reply to Re: Severe anhedonia, posted by bulldog2 on April 18, 2010, at 8:31:33
I recently added dexadrine to my mix. I am not ADD, but the depression, lack of pleasure & motivation are my main symptoms. The lack of motivation is extremely hard because I also feel "trapped" in time by not wanting to do anything.
I am also somewhat bipolar 2. W/out meds I am more agitated and there is some cycling between down & more down.
When I tried Adderall years ago I was not on a stabilizer. It caused me to have extreme swings, and mostly down-bad. But the first week was awesome. I felt like doing things and I wasn't anxious about how to get through the day. It really screwed me up.
I recently started dexadrine. This time I am on Lamictal (for me it hasn't made it worse). It is very subtle, and at first I wasn't sure if it was helping. But it has helped a little bit w/ motivation. It hasn't touched my depression, but it is nice to have my motivation helped maybe 15-20%.
Interesting how all of these mood & brain related circuits are so intertwined but can be somewhat separate. No mood change, but I can pass the time and get more things done without miserably forcing myself (like exercise).
Posted by alchemy on April 18, 2010, at 11:11:15
In reply to Severe anhedonia, posted by Maximus on April 16, 2010, at 11:48:18
I find it interesting that the trend on this bored is that SSRIs tend to create or worsen anhedonia. In many people it does the opposite, but they are probably the ones that get the initial happy response where they don't need additional help.
Posted by bulldog2 on April 18, 2010, at 11:24:41
In reply to Re: Severe anhedonia, posted by alchemy on April 18, 2010, at 11:11:15
> I find it interesting that the trend on this bored is that SSRIs tend to create or worsen anhedonia. In many people it does the opposite, but they are probably the ones that get the initial happy response where they don't need additional help.
I think that the ssris can lower dopamine which seems to be a factor in happiness,libido and interest in one's surroundings.
For some people stimulants do counter that ssri side effect.
Posted by Economist on April 18, 2010, at 13:17:18
In reply to Re: Severe anhedonia, posted by bulldog2 on April 18, 2010, at 8:31:33
bulldog,
Do you think it's the effect of the medication or perhaps a placebo effect?
Posted by bleauberry on April 18, 2010, at 13:38:14
In reply to Re: Severe anhedonia » bleauberry, posted by Maximus on April 17, 2010, at 15:22:13
Then go back to Zyprexa and make a lifelong change to eating mostly veggies and meats. Very little in the way of grains or carbs or sugars. That will provide less raw material for zyprexa to send to the fat department. And likely be a much healthier life in every other way as a benefit. Takes a couple months to get accustomed to, but well worth it. Once there, your old foods are not desired any longer. The taste buds change. I'm not saying we can totally beat back the weight gain of zyprexa in every person, but I am saying I feel it is very possible to beat back most of it or all of it in a majority of people. It isn't so much how much we eat, but what we eat. I mean, real simple, if someone's plate has mostly veggies on it and modest piece of lean meat, they aren't going to gain weight. Add in a piece of cake, slice of bread, etc, forget, the weight is going to pile on fast. Favorite foods don't have to be totally eliminated, but need to be once-a-week treats, not daily routines. "Eat for health, not for pleasure."
We're pretty lucky to have a choice actually. Think about it, back in the old days, they didn't even have a choice to eat for either health or pleasure. They had to eat whatever they could find at the time. We have a choice. For anyone taking zyprexa, nobody can choose to force fat fuel into the mouth except the person eating.
If you did that well on zyprexa, geez, you gotta get back on it. Changing the things you buy at the grocery store seems like a heck of a good deal to me to have remission. I would pay that price in a heartbeat!
Posted by bulldog2 on April 18, 2010, at 13:41:09
In reply to Re: Severe anhedonia » bulldog2, posted by Economist on April 18, 2010, at 13:17:18
> bulldog,
>
> Do you think it's the effect of the medication or perhaps a placebo effect?I'm not sure which med your talking about.
It's been documented that ssris do lower dopamine and dopamine is linked to the limbic areas of the brain which is associated with basic emotions and pleasure. If you lower dopamine too much it's will have a negative effect on your mood and also your hormones.It's ironic that an ad may cause anhedonia which is one of the prominent features of depression.
To counter the ssri effect you want meds that lower prolactin. ssris raise prolactin which lowers dopamine. So some use dopamine agonists to lower the prolactin. One recently talked about was carbergoline. Some use stimulants to stimulate the release of dopamine. I don't think any of these are placebo effect.
Sometimes I wonder if the maker of prozac knew about the dopamine effect and all the subsequent problems that would cause. If the FDA had known about this I wonder if the ssris would have been approved.
Posted by conundrum on April 18, 2010, at 15:08:28
In reply to Re: Severe anhedonia » alchemy, posted by bulldog2 on April 18, 2010, at 11:24:41
I'm not surprised about clomipramine then. It is a potent SRI but it blocks the serotonin from getting to the "bad" receptors that lower norepinephrine and dopamine.
In fact it should increase norepinephrine and dopamine release in some areas of the brain.
Its a hardcore AD so I hope its not placebo effect. Good Luck on it!
Posted by Economist on April 18, 2010, at 17:01:55
In reply to Re: Severe anhedonia, posted by bulldog2 on April 18, 2010, at 13:41:09
bulldog,
Sorry, I meant that if you thought the changes you are feeling in wanting to do things more and talk to people is a result of the clomipramine or just a placebo effect (ie, you feeling hopeful that the medication might be working even though it might not have kicked in yet).
Posted by bulldog2 on April 18, 2010, at 17:18:41
In reply to Re: Severe anhedonia » bulldog2, posted by Economist on April 18, 2010, at 17:01:55
> bulldog,
>
> Sorry, I meant that if you thought the changes you are feeling in wanting to do things more and talk to people is a result of the clomipramine or just a placebo effect (ie, you feeling hopeful that the medication might be working even though it might not have kicked in yet).That is a tough one to call. I've taken a lot of ads and generally I expect them not to work. I'll go out on a limb and say this is an early blip. I really think serotonin needs some norepinephrine for a balanced mood. Even though it is more serotonin I can feel the ne also in this med. I had been on low dose amitriptyline for a while so something may have been happening and maybe the shift to more serotonin did the trick.
Posted by meltingpot on April 19, 2010, at 7:14:41
In reply to Severe anhedonia, posted by Maximus on April 16, 2010, at 11:48:18
Hi,
When I was drug nieve in my 20s it felt as though pretty much anything I was prescribed for depression worked, I was so fortunate. First prothiaden (tricyclic) and later on Seroxat (SSRI). They both worked the same in that they increased pleasure, relaxation, motivation, sense of reward etc etc. I felt no difference between the two drugs other than I felt slightly more stimulated on the Seroxat initially (not euphoric but getting there.
Later on in my 30s when the Depression and anxiety came back for the first time ever I felt suicidal. For two years I tried so many drugs that all acted in different ways and to be honest there wasn't much difference in how I reacted to the SSRIs or the SNRIs, they all seemed to just increase the anxiety and give me more energy but it was a very anxious energy, not motivated energy.
Finally after two years a higher dose of Seroxat suddenly kicked in (after four days) and the anxiety seemed to cease and there was a return in pleasure and reward. Three years later and the Seroxat seemed to lose it's affect and what I've missed the most is the lack of reward and pleasure over the last five years.
I think another poster put it so well when they said that "everything just seems muted all of the time". I can function fairly well and I can do things, I go to work, I apply for other jobs, I work at the weekend as well as during the week, I go out and meet people, I write a lot but I feel bland all of the time, I can't even seem to get a rush from cigarettes or coffee. I don't really look forward to holidays anymore (and haven't for five years) and although I still have quite a strong libido I'm too tired and apathetic in the evening to do anything about it.
I've tried Clomipramine and I have to say that whilst it helped the depression and anxiety I still had that feeling of anhedonia, of the feeling that life is just passing by and nothing changes.
I'm not sure what to try anymore. I've been told by the NHS to try "mindfullness" in other words to just accept my condition and I'm contesting this! It seems like a cop out on their part.
I would consider ECT, in fact I would consider trying anything to just feel alive again.
Denise
Posted by bulldog2 on April 19, 2010, at 8:45:55
In reply to Re: Severe anhedonia, posted by meltingpot on April 19, 2010, at 7:14:41
> Hi,
>
> When I was drug nieve in my 20s it felt as though pretty much anything I was prescribed for depression worked, I was so fortunate. First prothiaden (tricyclic) and later on Seroxat (SSRI). They both worked the same in that they increased pleasure, relaxation, motivation, sense of reward etc etc. I felt no difference between the two drugs other than I felt slightly more stimulated on the Seroxat initially (not euphoric but getting there.
>
> Later on in my 30s when the Depression and anxiety came back for the first time ever I felt suicidal. For two years I tried so many drugs that all acted in different ways and to be honest there wasn't much difference in how I reacted to the SSRIs or the SNRIs, they all seemed to just increase the anxiety and give me more energy but it was a very anxious energy, not motivated energy.
>
> Finally after two years a higher dose of Seroxat suddenly kicked in (after four days) and the anxiety seemed to cease and there was a return in pleasure and reward. Three years later and the Seroxat seemed to lose it's affect and what I've missed the most is the lack of reward and pleasure over the last five years.
>
> I think another poster put it so well when they said that "everything just seems muted all of the time". I can function fairly well and I can do things, I go to work, I apply for other jobs, I work at the weekend as well as during the week, I go out and meet people, I write a lot but I feel bland all of the time, I can't even seem to get a rush from cigarettes or coffee. I don't really look forward to holidays anymore (and haven't for five years) and although I still have quite a strong libido I'm too tired and apathetic in the evening to do anything about it.
>
> I've tried Clomipramine and I have to say that whilst it helped the depression and anxiety I still had that feeling of anhedonia, of the feeling that life is just passing by and nothing changes.
>
> I'm not sure what to try anymore. I've been told by the NHS to try "mindfullness" in other words to just accept my condition and I'm contesting this! It seems like a cop out on their part.
>
> I would consider ECT, in fact I would consider trying anything to just feel alive again.
>
>
>
> DeniseI agree. Anhedonia is not acceptable to me. You can never convince me that this is the best life has to offer. Therefore I will continue to pursue treatment options.
Posted by meltingpot on April 19, 2010, at 9:16:53
In reply to Re: Severe anhedonia, posted by bulldog2 on April 19, 2010, at 8:45:55
Hi,
If you find anything that makes a difference then please, please let me know.
The psychiatrist has recently added Mirtazapine to the Seroxat (a combination I've already tried in the past) but it doesn't seem to be doing much.
Denise
Posted by SLS on April 19, 2010, at 9:41:21
In reply to Re: Severe anhedonia - To Bulldog, posted by meltingpot on April 19, 2010, at 9:16:53
> Hi,
>
> If you find anything that makes a difference then please, please let me know.
>
> The psychiatrist has recently added Mirtazapine to the Seroxat (a combination I've already tried in the past) but it doesn't seem to be doing much.
Will your doctor go up to 60mg of mirtazapine?
- Scott
Posted by meltingpot on April 20, 2010, at 8:37:13
In reply to Re: Severe anhedonia - To Bulldog » meltingpot, posted by SLS on April 19, 2010, at 9:41:21
Hi Scott,
I don't think so, I think she will switch me to mianserin, well at least I hope she will make some change.
Why, do you think it would be worth going up to 60mg of Remeron and if so why?
Denise
Posted by SLS on April 20, 2010, at 11:10:38
In reply to Re: Severe anhedonia - To SLS, posted by meltingpot on April 20, 2010, at 8:37:13
> Hi Scott,
>
> I don't think so, I think she will switch me to mianserin, well at least I hope she will make some change.
>
> Why, do you think it would be worth going up to 60mg of Remeron and if so why?
Am J Psychiatry. 2006 Jul;163(7):1161-72.
A comparison of mirtazapine and nortriptyline following two consecutive failed medication treatments for depressed outpatients: a STAR*D report.Fava M, Rush AJ, Wisniewski SR, Nierenberg AA, Alpert JE, McGrath PJ, Thase ME, Warden D, Biggs M, Luther JF, Niederehe G, Ritz L, Trivedi MH.
Depression Clinical and Research Program, Massachusetts General Hospital, Bulfinch 351, 55 Fruit St., Boston, MA 02114, USA. MFava@Partners.org
Comment in:
* Evid Based Ment Health. 2007 Feb;10(1):16.
* Am J Psychiatry. 2006 Jul;163(7):1123.Abstract
OBJECTIVE: Few controlled studies have addressed the issue of which antidepressant medications should be recommended for outpatients who have not responded to multiple treatment trials. This study compared the efficacy of switching to mirtazapine to that of switching to a tricyclic antidepressant (nortriptyline) following two prospective, consecutive, unsuccessful medication treatments for nonpsychotic major depressive disorder. METHOD: Following lack of remission or an inability to tolerate an initial trial of citalopram for up to 12 weeks (first step) and a second trial with either monotherapy involving another antidepressant or augmentation of citalopram with bupropion or buspirone (second step), adult outpatients (N=235) with nonpsychotic major depressive disorder were randomly assigned to 14 weeks of treatment with mirtazapine (up to 60 mg/day) (N=114) or nortriptyline (up to 200 mg/day) (N=121). The primary outcome, symptom remission, was defined a priori as a total exit score of </=7 on the 17-item Hamilton Rating Scale for Depression. The 16-item Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR(16)), obtained at treatment visits, provided secondary outcomes of remission (score </=5 at exit) and response (>/=50% reduction in score from baseline). RESULTS: For mirtazapine, remission rates were 12.3% and 8.0% per the Hamilton and QIDS-SR(16) scores, respectively. For nortriptyline, remission rates were 19.8% and 12.4%, respectively. QIDS-SR(16) response rates were 13.4% for mirtazapine and 16.5% for nortriptyline. Neither response nor remission rates statistically differed by treatment, nor did these two treatments differ in tolerability or adverse events. CONCLUSIONS: Switching to a third antidepressant monotherapy regimen after two consecutive unsuccessful antidepressant trials resulted in low remission rates (<20%) among patients with major depressive disorder.
Posted by sigismund on April 20, 2010, at 17:36:21
In reply to Re: Severe anhedonia, posted by bulldog2 on April 19, 2010, at 8:45:55
>I agree. Anhedonia is not acceptable to me. You can never convince me that this is the best life has to offer. Therefore I will continue to pursue treatment options.
The problem though is that some of the treatment options create or aggravate the anhedonia?
Posted by bulldog2 on April 20, 2010, at 17:59:15
In reply to Re: Severe anhedonia » bulldog2, posted by sigismund on April 20, 2010, at 17:36:21
> >I agree. Anhedonia is not acceptable to me. You can never convince me that this is the best life has to offer. Therefore I will continue to pursue treatment options.
>
> The problem though is that some of the treatment options create or aggravate the anhedonia?I guess that would not be the best treatment option for me. That's why I wouldn't run an ssri monotherapy because of dopamine downregulation.I guess there might be some situations where that might be a tradeoff.
Posted by Meltingpot on April 23, 2010, at 15:43:38
In reply to Re: Severe anhedonia, posted by bulldog2 on April 20, 2010, at 17:59:15
Hi,
What works best for anhedonia for you?
Denise
Posted by desolationrower on April 23, 2010, at 17:03:11
In reply to Re: Severe anhedonia - To Bulldog » meltingpot, posted by SLS on April 19, 2010, at 9:41:21
i don't see the point of switching to a medication that works in basically the same way, when you didn't take enough of the first med to either get side effect or benefit.
-d/r
Posted by bulldog2 on April 24, 2010, at 17:54:17
In reply to To Bulldog2, posted by Meltingpot on April 23, 2010, at 15:43:38
> Hi,
>
> What works best for anhedonia for you?
>
> DeniseHi Denise
I use high dose neurontin for anhedonia. That's 2400-3600 mg. The reason for such a high dose is I been on neurontin for three years. I have built up a tolerance to it and need the high doses for anhedonia. It seems that ad's never attack the anhedonia.
The neurontin just seems to lower inhibitions and make me more interested in my environment and also more sociable.
Also in the past the stimulants have worked for that but I build a quick tolerance to them with a quick poop out.
Also back to neurontin at high doses seems to also work on dopamine.
This is the end of the thread.
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