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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 29. This is the beginning of the thread.
Posted by Dima on July 31, 2010, at 10:52:36
Hi. I'm 19 years old. I've been depressed for as long as I can remember. Mildly depressed, at least. In January of 2010, I sunk into a much deeper depression. I had to leave college early because I lost the ability to focus on anything.
I've tried Paxil, which made me extremely tired the first time I took it for three days. I took it again recently for a week or two, with no effect. My doctor stopped it because I'm on Celexa as well.
I tried Wellbutrin for a month and it gave me a lump sensation in my throat and later caused a feeling similar to akathisia. No benefits, though.
I tried Zoloft for a month and a half, with no benefit, only brain zap withdrawal symptoms.
I tried Nortriptyline for about two weeks, and it also gave me a general body anxiety feeling like Wellbutrin.
I tried Effexor for two months, with no benefit.
Currently, I'm on trazadone for sleep for two months now. No antidepressant effect.
I'm also on Remeron for five weeks with no antidepressant effect.
I'm also on Celexa for about a month, with no antidepressant effect.
Most recently, I tried Abilify. The first time I took 5 mg, I got hiccups that didn't go away for a couple hours. The next few days I had slightly more energy, though. After a week, I tried "loading" Abilify with 20 mg, as I saw a post on here that mentioned that loading might help. The next morning I took 5 mg. The rest of the day, I felt what I guess is akathisia. It was one of the worst things I've ever felt. The next day, which was yesterday, the feeling was still there, so I went to the hospital. First they gave me IM Benadryl, which only made me a little more tired. Then I got 1 mg Cogentin, which took away some of the suffering, but not all. I suggested Propranolol, but the doctor said that's only for high heart rate. I'm pretty much back to normal now.
Anyway, after seeing what akathisia is like, I realized that the feeling is kind of an extreme version of what I always feel like. I always just want to move. Any time I get even a little bit of energy, I try to do as much as possible. Also, people describe the feeling as indescribable. That's what my depression is like. It's no sadness. I hardly even remember what sadness is like. I just have pretty much no emotion except for irritability. Also, I can only describe the feeling as "bad" because I don't even understand fully what I feel like.
Adderall is the only drug I've had that makes me feel really good. I'm pretty sure I haven't grown a tolerance since I very rarely use it, but it seems the effects these days are very short lived, followed by the restless akathisia feeling.
Any suggestions? I was thinking of trying Parnate after this Remeron, Celexa combination. If I get more energy from my recent dosing of Abilify, I may try that again at a 2.5 mg or 5 mg daily dose.
Could it be that my depression isn't just normal depression? Maybe BPD?
Posted by europerep on July 31, 2010, at 11:28:35
In reply to What steps should I take?, posted by Dima on July 31, 2010, at 10:52:36
hey there..
I'm sorry if I sound harsh, but this was the most chaotic description of which meds someone took at which point that I've seen on here.. have you always followed what your doctor has been telling you, in terms of when to stop taking a drug and considering it to be not working? because for almost every drug you mentioned, you very probably haven't taken it long enough to feel effects kick in or fully develop, as well as to have side effects subsiding after some more weeks.. this does not always happen of course, but it can.. if this was all your doctor's advice, I would suggest you change the doc.
but, just from reading your post, my first impression is that there might be some more complicated things going on. first of all, you must get your diagnosis straightened, and before that, you should not change meds or even go for an MAOI. some of the symptoms you describe sound like AD(H)D.. the inability to focus on anything for college.. the "mild" akathisia as a normal feeling.. also, the fact that you seem to be very curious about "trying things out", like going from abilify 5mg to 20mg in one step, which is something I would never ever dare or recommend to anyone.. but I know little about ADHD, I am sure someone on here can tell you more about that.. I personally do not read anything you wrote that might suggest that you are bipolar, though.
I just wanted to give you a first answer, others will be of more help, but, in my opinion, before trying any other drug you MUST get a thorough diagnosis..
oh yeah, and what's your parents' role in this? do you live alone, or did you live alone when you were in college? are you taking any drugs for "recreational" purposes?
there'll be others weighing in here soon!
bye for now..
Posted by Christ_empowered on July 31, 2010, at 11:38:37
In reply to Re: What steps should I take?, posted by europerep on July 31, 2010, at 11:28:35
describe your problems, and follow the instructions carefully. I know that sounds like the dumbest, most obvious advice ever, but I was once a 19 year old with problems (not the same as yours, though), and that advice is both basic and hard to follow when you're that young.
You might not benefit from antidepressants. I'm not a doctor, but some people don't; maybe its a brain chemistry thing, who knows, but maybe you should try something else.
Have you tried an anticonvulsant? Lamictal helps bipolar depression, but it can also help out with unipolar depression. Lamictal is pretty "clean" in terms of cognitive side effects, so it shouldn't dumb you down like some other drugs could.
Have you been prescribed a benzo? A lot of docs don't prescribe benzos at all, especially to younger patients (and if you have drug/alcohol abuse issues, say no to benzos, at least for now), but they can help a lot, especially if you can keep your use minimal and only use them a couple times weekly--that helps avoid full-blown dependence.
Sorry about your experience with Abilify. Maybe its for the best? I mean, I take Abilify, but I have a psychotic component to my illness. For me, the benefits outweigh the risks because untreated psychosis can ruin your life. If you're not psychotic, severely bipolar, or prone to intense agitation, I personally think you might want to steer clear of the antipsychotics, if you can.
BuSpar wasn't on your list of meds. I personally am not a big fan, but when you add Buspar to an antidepressant, sometimes good things happen in terms of both the effect on depression and an anti-anxiety action. So, if you decide to try another antidepressant, I'd see about taking Buspar with it.
Good luck to you; this is a rough situation, but with the proper help, you should come out of this soon enough.
Posted by Phillipa on July 31, 2010, at 12:43:55
In reply to get a good doctor..., posted by Christ_empowered on July 31, 2010, at 11:38:37
It really did sound like you've been on so many meds in a short time that you have not given any time to work. I know when young you're willing to just do things I agree is your doc starting and stopping the meds or are you. Oh I do relate as nothing is worse than bad side effects. Does your doc know you were in the Er yesterday? Phillipa
Posted by 8675309 on July 31, 2010, at 15:12:59
In reply to What steps should I take?, posted by Dima on July 31, 2010, at 10:52:36
You said = After a week, I tried "loading" Abilify with 20 mg, as I saw a post on here that mentioned that loading might help. =
You need a total evaluation for a diagnosis. Word of warning, use this and any other web info for info only to discuss with HCP. I suggest you not alter/add/subtract/change on your own because of that type of information.
Posted by Dima on July 31, 2010, at 16:02:43
In reply to Re: What steps should I take? » Dima, posted by 8675309 on July 31, 2010, at 15:12:59
Well, I tried the Effexor for two months, so it seems like some effects should have been noticeable by then.
Also, I forgot to mention, benzos don't do anything for me. I've taken Klonopin and Ativan, and neither seems to have any effect, which is another reason I think something's different about my depression.
Posted by ed_uk2010 on July 31, 2010, at 17:24:25
In reply to Re: What steps should I take?, posted by Dima on July 31, 2010, at 16:02:43
> Well, I tried the Effexor for two months, so it seems like some effects should have been noticeable by then.
>
> Also, I forgot to mention, benzos don't do anything for me. I've taken Klonopin and Ativan, and neither seems to have any effect, which is another reason I think something's different about my depression.Effexor should have worked after two months, yes. The usual effective dose is 75 to 150mg per day. Higher doses are often used but there is little evidence that such doses are more effective than standard doses. Did you take 150mg or more for two months? If so, I think it's fair to say that Effexor probably isn't the right treatment for your depression.
Benzodiazepines are not supposed to relieve depression: they are not antidepressants, although they can sometimes help to reduce associated anxiety and insomnia.
I assume you are seeing a psychiatrist on a regular basis? Also, have you been given a diagnosis? eg. major depressive disorder, or something else.
You mentioned irritability - and bipolar disorder. Irritability is a very common symptom of depression. Irritability is also common in bipolar disorder, but irritability in itself does not mean that you're bipolar. For a bipolar diagnosis to be made, you need to have had at least one manic, hypomanic or mixed mood episode. Mixed mood episodes (manic symptoms + depressive symptoms together) can be confused with 'agitated depression'. Features which are suggestive of mixed mood rather than plain depression include: racing/rapid thoughts, rapid/pressured speech, reduced need for sleep, anger/aggression, severe fluctuations in mood, aggravation of symptoms by SSRIs and other antidepressants, impulsive (risk-taking) behaviour, severe excitement and a family history of bipolar disorder.
Posted by sigismund on July 31, 2010, at 22:58:19
In reply to What steps should I take?, posted by Dima on July 31, 2010, at 10:52:36
>Adderall is the only drug I've had that makes me feel really good.
No surprises there
>Could it be that my depression isn't just normal depression? Maybe BPD?
I just wouldn't go there. Maybe the drugs (the ones you can easily get) are not that good. Borderline Personality Disorder, you mean that? They'll have you on a diet of APs.
Posted by sigismund on July 31, 2010, at 23:48:38
In reply to What steps should I take?, posted by Dima on July 31, 2010, at 10:52:36
You must mean bipolar.
I feel sorry for your brain, and yet you have to do something.
I'd keep the med trials to a necessary minimum to spare yourself future suffering.
Dexedrine instead of Adderall?
Great irritability? Hmmmmm. It's a common enough state. I just feel a bit anxious about you working your way through the armourmentarium. Some people report relief, iirc, from what treatment I don't know.
Posted by manic666 on August 1, 2010, at 4:29:26
In reply to Re: What steps should I take?, posted by Dima on July 31, 2010, at 16:02:43
my ad,s are ssri,s an they take 12 week,s to work on me
Posted by Dima on August 1, 2010, at 6:49:07
In reply to Re: What steps should I take?, posted by manic666 on August 1, 2010, at 4:29:26
It seems like the abilify might be working. I took 20 mg Wednesday night, and 5 mg the next morning. The half life is 75 hours so it would probably still be in my system. I woke up at 7 and left the house to run errands immediately. I thought it might have been the Remeron, because I tried 5 mg Abilify last Tuesday as well, along with 15 mg Remeron. I got hiccups from the Abilify so I stopped it and decided to wait till I'm used to Remeron. I had little energy bursts and better focus over the next few days but they went away. And now it seems it's returning. My mood is still crappy, but I have energy to walk and do things. Maybe I should ask my doctor to try 2.5 mg/day? The only thing is that the akathisia is scary as hell.
In terms of benzo's, it seems that they should have some sort of effect when I'm anxious, which is always. They don't do a thing when I try to face my social phobia, for instance. That's what makes me think it's not normal anxiety.
Also, I tried Buspar for 8 weeks, and didn't notice an effect.
Posted by chujoe on August 1, 2010, at 7:02:42
In reply to Re: What steps should I take?, posted by sigismund on July 31, 2010, at 23:48:38
My strictly amateur advice would be to back off the medications slowly for a few weeks while at the same time getting some talk therapy (with maybe a CBT component or Mindfulness training) going with someone you trust. Then, you can see about starting to use an SSRI or SNRI if you need it. I agree with others that you haven't given those other drugs a long enough time to work, but I think there is another aspect to taking psych meds that many people don't consider: a person taking meds needs to build on the openings the meds provide & consciously work with the meds for them to be fully effective. The brain is dynamic and constantly rebuilding itself -- not just its physical connections but the very sense of self sponsored by all those neurons & synapses. That means that thinking itself & behavior itself actively "rewire" the connections in your brain. I think meds simply make the rewiring more plastic. The implication of this view is that there is no drug you can take for psychological issues that will just turn off a problem the way you take a couple of ibuprofen for a headache.
Finally, I believe your symptoms are real -- I'm not minimizing your suffering, but I am suspicious of treating people in late adolescence with one drug after another. It is as if you are being treated for adolescence itself, which is the most emotionally turbulent period in life. That's why I suggest a good therapist & probably a new pdoc who won't just toss one magic pill after another at you.
Posted by chujoe on August 1, 2010, at 7:58:34
In reply to Re: What steps should I take?, posted by chujoe on August 1, 2010, at 7:02:42
In reading your most recent post, I guess I'd revise my earlier advice to back off the drugs, at least partly, since the Abilify seems to be working. Still, once you get stable you might want to look into some of the things I mentioned above. I feel compelled to say, though, that I'm not sure of the wisdom of giving an anti-psychotic like Abilify, which has so many possible adverse side effects, to a 19 year old who is not psychotic. (And I say this as someone who has vociferously defended the use of psych drugs on this forum from time to time.) I'm an old guy & I sincerely hope this does not sound condescending, Dima. I just think you should take a wider view of your issues and complaints.
Posted by Dima on August 1, 2010, at 9:14:35
In reply to Re: follow-up to my previous post, posted by chujoe on August 1, 2010, at 7:58:34
I am involved in talk therapy. It doesn't help bring back my focus or get me motivated to move, or help my weak muscles. I love the idea of therapy, but I can't even think straight, so I'd like to get at least some help from a drug.
Also, I can't relax. This goes with the not normal anxiety thing. Not if I'm laying on a beach with no responsibilities or listening to soothing music or taking a bath or getting a massage. The level of tension in my body doesn't change due to any external stimuli, it just goes up and down on its own.
Posted by europerep on August 1, 2010, at 10:09:08
In reply to Re: What steps should I take?, posted by Dima on August 1, 2010, at 6:49:07
> It seems like the abilify might be working. I took 20 mg Wednesday night, and 5 mg the next morning. The half life is 75 hours so it would probably still be in my system. I woke up at 7 and left the house to run errands immediately. I thought it might have been the Remeron, because I tried 5 mg Abilify last Tuesday as well, along with 15 mg Remeron. I got hiccups from the Abilify so I stopped it and decided to wait till I'm used to Remeron. I had little energy bursts and better focus over the next few days but they went away. And now it seems it's returning. My mood is still crappy, but I have energy to walk and do things. Maybe I should ask my doctor to try 2.5 mg/day? The only thing is that the akathisia is scary as hell.
so, wait a minute, do I understand it right that you are basically changing your med strategy by the day? seriously, I know it sounds condescending, but I do not think that you can conclude anything from such kind of experimentation.. and you might only confuse your brain even further. as I stated, you must FIRST of all get a diagnosis that explains at least the major symptoms you are feeling and THEN you can consider med strategies.. I understand that you are feeling bad, no question about that, but I do not think that the way you are trying to solve it is efficient, or actually effective at all.. and some drugs do indeed need more than eight weeks to kick in. and I do not entirely agree with ed when he said there is little evidence to try venlafaxine at doses above 150mg (that is less than half of what the manufacturer indicates as the maximum dose). really, in my opinion, you must get more coherence into your treatment, I still have not understood how exactly you feel.. is it depression mixed with social anxiety?
>
> In terms of benzo's, it seems that they should have some sort of effect when I'm anxious, which is always. They don't do a thing when I try to face my social phobia, for instance. That's what makes me think it's not normal anxiety.
>
how long have you been doing talk therapy so far? have you described to the therapist the whole image of symptoms? not that I suspect you of being dishonest, it's just that I know myself that it can be difficult to give the therapist the "whole picture" of the problems.. for example, are there experiences that have caused (or aggravated) your social phobia? if so, you have to mention them.and again, what's with your parents and relatives? does anyone of them suffer from mental illnesses, and if yes, which one?
Posted by manic666 on August 1, 2010, at 11:05:54
In reply to Re: follow-up to my previous post, posted by Dima on August 1, 2010, at 9:14:35
You say benzo,s dont touch you.If you can do without thats cool,but sometimes a doc will say take o.5 of ativan or 2mg of valium. when people go to a.an e with anxierty you get 2 mg of ativan..Now anyone with high level anxierty in a bad attack needs 2mg. If your just anxious deep breathing is all you can do. Anxierty is a illness om its own. Thats why i am a ativan addict i took to many, lots of ad,s have anxierty help in them.
Posted by ed_uk2010 on August 1, 2010, at 12:10:26
In reply to Re: What steps should I take?, posted by europerep on August 1, 2010, at 10:09:08
>I do not entirely agree with Ed when he said there is little evidence to try venlafaxine at doses above 150mg (that is less than half of what the manufacturer indicates as the maximum dose).
I do not entirely agree with myself either!I do think that venlafaxine can be more effective at high doses than at standard doses in some cases, but it's not consistently the case. I don't think I expressed myself well in my earlier post. What I meant to say is that if there has been no response at all to 150mg/day after two months, the probability of obtaining a good response on a higher dose is likely to be low. IIRC, this is not the case for you, however :)
AFAIK, Wyeth didn't do enough studies to establish a clear dose-response relationship in the pre-approval studies for venlafaxine. Their recommended maximum dose has more to do with evidence of safety at high doses than it has to do with evidence of enhanced efficacy.
Posted by manic666 on August 1, 2010, at 12:38:09
In reply to Re: What steps should I take? » europerep, posted by ed_uk2010 on August 1, 2010, at 12:10:26
When the mad shrink near as killed me. He had me on 225mg of effexor within 2 week,s . 150mg is when i took overdose. I was detoxing 10mg ativan an litre of brandy a day.The effexor at that speed would make me suicidal never mind the detox.My hair was falling out so i ditched the effexor as well. How am i still alive you say,i have half a brain the rest was nuked with lunitic doctoring. I WAS A VICTIM OF FRIENDLY FIRE
Posted by bleauberry on August 1, 2010, at 12:48:57
In reply to What steps should I take?, posted by Dima on July 31, 2010, at 10:52:36
I personally don't find categorizing depression in this way or that as being very helpful. It is so subjective to variable interpretation and there are too many overlaps without clear boundaries.
What is much better, IMO, is to use the clues from med trials. They tell a story.
You probably do not have a serotonin deficiency issue. Your drug trials have shown that.
You may have a dopamine issue, by process of elimination, and by the clues given by adderall and abilify. Norepinephrine may be a player, but with the overdrive from nortriptyline norepeniphrine might be too high rather than too low.
I personally think a better stimulant is ritalin over adderall. And even if we assume you do not have a serotonin issue, either of those is likely to work better in combination with a serotonin med. Some kind of synergy.
If you were to stay with abilify, the kinds of doses that generally work better on your symptom cluster are in the 2.5mg to 5mg range, sometimes even as low as 1mg every other day, sometimes as high as 10mg. To go that high and avoid the awful akathisia would require a long gradual titration, but still no guarantee the akathisia would not happen. My own theory, unsupported and unproved, is that akathisia has a major cause being the NE antagonism most of the antipsychotics have...it causes a release of more norepinephrine, while blocking serotonin and dopamine. Think about it, that's pretty bizarre. No wonder the crawling out the skin feeling. Abilify just happens to have a lot of that in its profile compared to others.
If you wanted a somewhat energetic antidepressant antianxiety antipsychotic, I know of no better choice than 25mg-50mg of amisulpride. Mail order.
So I guess what I'm saying is, think dopamine. That narrows the field, but still the field of dopamine is pretty large. Lots of narrowing to be done within that field.
Simple home tests can give strong clues and sometimes total healing. I'm thinking DLPA and tyrosine.
Wellbutrin doesn't really count. It has minimal effect on dopamine and norepinephrine. Its actual mechanism is unknown, and its dopamine effects are glorified and overstated. So your failure on that one does not deter my opinions.
And these are just that, opinions. Based on your history, med clues, and symptoms.
Posted by Dima on August 1, 2010, at 14:30:34
In reply to Re: What steps should I take?, posted by bleauberry on August 1, 2010, at 12:48:57
Thank you, that was very helpful. I took 2.5 mg Abilify. So that makes the following my regimen:
40 mg Celexa in the morning, five weeks, no effect
2.5 mg Abilify in the morning, just started, caused akathisia at 20 mg, possibly causes more energy at random times.
50 mg Trazadone at night for sleep, over two months in, seems to help sleep.
15 mg Remeron at night, two weeks, possibly caused energy, but it was probably Abilify.I'll look into Amisulpride. Does it work on Dopamine?
And are those tests for DLPA helpful? I've read that neurotransmitter tests don't provide any useful information.
Should I ask for Ritalin or Concerta for focus? I wouldn't use Adderall because of tolerance issues, but is Ritalin safer? I was also thinking about asking for Provigil.
Posted by Dima on August 1, 2010, at 14:32:45
In reply to Re: What steps should I take?, posted by Dima on August 1, 2010, at 14:30:34
Also, I've tried taking Tyrosine and DLPA supplements, and they definitely don't have a quick effect. I didn't try them for very long to see if the effects come gradually.
Posted by Dima on August 1, 2010, at 14:43:52
In reply to Re: What steps should I take?, posted by Dima on August 1, 2010, at 14:32:45
What do you think about an MAOI? I can't afford Amisulpride at those prices. Parnate and Nardil seem to help a lot of people on socialanxietysupport.com, and they work on dopamine, too.
Posted by europerep on August 1, 2010, at 15:34:53
In reply to Re: What steps should I take?, posted by Dima on August 1, 2010, at 14:43:52
it's not about giving him a superprecise diagnosis of his depression, but who knows whether there is a personality disorder involves, anything from axis II.. also, if his parents or near relatives suffer from something particular, it is very well possible that he is developing something similar..
.. dima, you are following the wrong path. reading stuff on the internet is always only complementary, and even people with excellent knowledge such as bleauberry can only respond to what you write down, which isn't but a tiny little fraction of the person behind your screenname.. your studious efforts show your determination, but you are trusting yourself too much at this early stage of suffering from a mental disease. again, going on an MAOI right now is possibly the biggest overkill you could make. change the doc, get a diagnosis validated by an experienced psychologist, and look from then on.. all the time you spend self-medicating is a waste of precious time, as it might negatively affect the course your illness is going to take.
but I'll be quiet from here on, it seems to me you are looking for a confirmation of what you are currently doing..
Posted by Dima on August 1, 2010, at 16:18:46
In reply to Re: What steps should I take?, posted by europerep on August 1, 2010, at 15:34:53
> it's not about giving him a superprecise diagnosis of his depression, but who knows whether there is a personality disorder involves, anything from axis II.. also, if his parents or near relatives suffer from something particular, it is very well possible that he is developing something similar..
>
> .. dima, you are following the wrong path. reading stuff on the internet is always only complementary, and even people with excellent knowledge such as bleauberry can only respond to what you write down, which isn't but a tiny little fraction of the person behind your screenname.. your studious efforts show your determination, but you are trusting yourself too much at this early stage of suffering from a mental disease. again, going on an MAOI right now is possibly the biggest overkill you could make. change the doc, get a diagnosis validated by an experienced psychologist, and look from then on.. all the time you spend self-medicating is a waste of precious time, as it might negatively affect the course your illness is going to take.
> but I'll be quiet from here on, it seems to me you are looking for a confirmation of what you are currently doing..ive seen multiple pcps and pdocs all of whom chose mdd as the main diagnosis. general anxiety and social phobia too. whats wrong with maois other than food/drug interactions which i can deal with.
also my dad and grandma have parkinsons. dad takes remeron for sleep. dad also had situational depression for six months which zoloft may have helped with.
Posted by chujoe on August 1, 2010, at 16:32:45
In reply to Re: What steps should I take?, posted by manic666 on August 1, 2010, at 12:38:09
Presumably the brandy was self-inflicted rather than friendly fire.
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