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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 9 of 9. This is the beginning of the thread.
Posted by bmwfan07 on December 8, 2010, at 14:45:25
Hi all,
The past four-plus months have been pretty tumultuous, after I impulsively quit my job to start a business that I ended up never actually starting.
I'd always had motivation, attention, and impulsive/hyperactive issues, so you can imagine what I then discovered about myself--that I had ADHD. I've also had OCD, social phobia, and maybe GAD for the better part of my life--I'm 21 now. I have, until now, however, never had clinical depression.
My OCD kicked into major high gear after I left my job (stress has been said to exacerbate the former) and I started getting horrible aggressive intrusive thoughts and became convinced (quite literally) that I was a psychopath. I didn't know about the potency of OCD at the time!
A month or so later, my GP prescribed Adderall to see if it would help me focus and apply said focus to finding a new job. I started out at 5mg twice per day. However, I noticed that by the third day, I woke up feeling quite depressed and moody. I interpreted my dad's normal morning routine as a severe slight (because he didn't simply acknowledge me) and then felt suicidal. The remainder of the day was dominated by feelings of depression, apathy, anhedonia, etc., but strangely also by some seeming hypomanic features, or else perhaps it was simply euthymia combined with depression as the onset of depression isn't typically instantaneous, because I was seemingly "over"-excited about seeing my friend at night. This prompted myself to overanalyze my behavior, and I became convinced I was having a mixed episode, which led to a panic attack (OCD surely played a role here).
Suffice it to say, I ceased taking Adderall and am to this day really not sure what happened, other than to say I'm pretty confident Adderall destabilized my already somewhat fragile (situationally, I believe) emotional state, and since then I haven't been my normal self. Specifically, I've been having bouts of atypical depression. Unfortunately, my memory seems pathologically (but chronically) awful, so I'm not able to recall exactly the course it's taken, but I had a few weeks of feeling very anergic, lethargic, exhausted, sleepy, depressed, mostly anhedonic, and had diurnal worsening at night--i.e. atypical depression. Then, and I can't remember "why," I felt better, though not completely, for about a week, after which I felt the cloud descending back on me over the course of a few days. Unfortunately, my 21st birthday occurred on the last of these days and I felt so bad because I was incapable of enjoying one of what I believed to be my most important birthdays. The depression after a few weeks then lifted somewhat for a few days to a week at a time and then came back but has definitely been there to varying extents for the past two-plus months--since I took the Adderall. I've noticed that it's predictably better on the day I see my psychologist and ADHD life coach, indicating that mood reactivity described in atypical depression.
I've only heard of Adderall doing this in the context of bipolar disorder, and I know atypical depression is more common in bipolar disorder, so I'm quite concerned that this is my actual condition. In fact, my obsessing over whether I might have bipolar disorder for the past couple of months (first it was Asperger's, then borderline personality disorder...then finally the correct self-, and then professional, diagnosis of ADHD), ironically probably caused a lot of this in some inexplicable way.
I've never had a hypomanic or mixed episode to my knowledge, but perhaps I really did have a mixed episode that day on Adderall (I don't really recall racing thoughts or extreme hand-wringing agitation, though, just a lot of anxiety *about* the possibility of having a mixed episode).
So. My question given my history--sorry for the novel!--is what you all recommend I start with to get out of this funk. I'm somewhat pessimistic given my extensive reading of bipolar and atypical depression and how chronic, often treatment-resistant, and awful, both (or are they the same, in actuality?) conditions are.
My p-doc wanted to prescribe Lexapro originally, but I've somewhat lost confidence in her (trust in the "pros" is an issue for me, for some reason...always has been...most likely because I've witnessed their ignorance and malpractice firsthand) because she didn't even probe (or particularly care, when prompted) about any atypical symptomatology or too much about bipolar (although she did ask), which might better indicate treatment with MAOIs. I'm mainly concerned about a) the SSRI not helping, b) the SSRI inducing a (hypo)manic or mixed episode, c) the SSRI "pooping out" after 6-12 months, as it seems to do with so many atypical or bipolar depressives, and d) the SSRI kindling or altering the course of bipolar, as I've read it can potentially do.
At the same time, I really want to feel better. I manage emotionally during the day, but my mood takes a steep dive at around 6pm every single night and I start having hopeless, suicidal, and other negative ruminations as well as a pervasively awful mood. I'm traveling over Christmas next week and I know it's gonna blow feeling like death for a large portion of it, but it's something I've already committed to.
So, any recommendations for what to start with given all of the above? Thanks in advance!
Posted by bmwfan07 on December 9, 2010, at 14:31:41
In reply to Best starting med for atypical depression?, posted by bmwfan07 on December 8, 2010, at 14:45:25
Bump. Any help? Sorry for the long-winded post... in retrospect, I realize that was probably excessive.
Posted by Tomatheus on December 9, 2010, at 21:06:16
In reply to Best starting med for atypical depression?, posted by bmwfan07 on December 8, 2010, at 14:45:25
bmwfan07,
Hello, and welcome to Psycho-Babble. I'm afraid that I don't have a whole lot of advice to give you other than to tell you to probably expect an SSRI, an SNRI, or possibly something like Wellbutrin as the first medication you'll be prescribed for your atypical depression. There is some evidence to indicate that MAOIs may be more effective than the TCAs when it comes to treating atypical depression, but for a doctor to prescribe an MAOI as first-line treatment for any type of depression these days is pretty unheard of, for better or for worse. I would express the concerns that you listed here about taking an SSRI to your prescribing doctor and then work with him or her from there to figure out which antidepressant you should try first.
I'm sorry if I couldn't be of more help, but I figured that I'd reply to your post.
Tomatheus
Posted by bmwfan07 on December 9, 2010, at 23:32:21
In reply to Re: Best starting med for atypical depression?, posted by Tomatheus on December 9, 2010, at 21:06:16
> bmwfan07,
>
> Hello, and welcome to Psycho-Babble. I'm afraid that I don't have a whole lot of advice to give you other than to tell you to probably expect an SSRI, an SNRI, or possibly something like Wellbutrin as the first medication you'll be prescribed for your atypical depression. There is some evidence to indicate that MAOIs may be more effective than the TCAs when it comes to treating atypical depression, but for a doctor to prescribe an MAOI as first-line treatment for any type of depression these days is pretty unheard of, for better or for worse. I would express the concerns that you listed here about taking an SSRI to your prescribing doctor and then work with him or her from there to figure out which antidepressant you should try first.
>
> I'm sorry if I couldn't be of more help, but I figured that I'd reply to your post.
>
> TomatheusI appreciate the reply. I suppose it is a little unrealistic to expect a p-doc to start out with what is decidedly a third-plus line AD these days, but I'm convinced it will be the best mainstream drug to start with for both social phobia and atypical depression.
I've yet to hear of anyone who has had long-term efficacy (12+ months) on an SSRI or SNRI for both social phobia and atypical depression, let alone either one! Atypical depression seems to be a whole different animal than melancholic depression and appears to be more related to bipolar disorder--as does social phobia (both appear to involve dopamine dysregulation in some way).
I bought some DLPA tonight on impulse, because I know people combine it with deprenyl sometimes for atypical depression. I figured I'd try it alone to see if it did anything, but I didn't notice anything (in fact, I felt worse, but that could be purely coincidental). Has anyone here had success combining deprenyl and DLPA? I know that too would likely only be possible from a practical standpoint well into the future, as deprenyl is a MAOI as well.
Just wondering what other combinations and cocktails, creative or otherwise, people have devised to treat this awful condition.
Posted by mellow on December 10, 2010, at 5:24:40
In reply to Re: Best starting med for atypical depression?, posted by bmwfan07 on December 9, 2010, at 23:32:21
>
>I appreciate the reply. I suppose it is a little unrealistic to expect a p-doc to start out with what is decidedly a third-plus line AD these days, but I'm convinced it will be the best mainstream drug to start with for both social phobia and atypical depression.
>
> I've yet to hear of anyone who has had long-term efficacy (12+ months) on an SSRI or SNRI for both social phobia and atypical depression, let alone either one! Atypical depression seems to be a whole different animal than melancholic depression and appears to be more related to bipolar disorder--as does social phobia (both appear to involve dopamine dysregulation in some way).
>
> I bought some DLPA tonight on impulse, because I know people combine it with deprenyl sometimes for atypical depression. I figured I'd try it alone to see if it did anything, but I didn't notice anything (in fact, I felt worse, but that could be purely coincidental). Has anyone here had success combining deprenyl and DLPA? I know that too would likely only be possible from a practical standpoint well into the future, as deprenyl is a MAOI as well.
>
> Just wondering what other combinations and cocktails, creative or otherwise, people have devised to treat this awful condition.
>
Welcome to babble and the world of psych meds. You seem very intelligent and well researched. This is good as you must be your own advocate, but my advice to you would be to put all of your energy into finding the best practitioners in your area rather than trying to figure out what med you think you should be on. Let your doc handle that. That's why they go to school for all those years. If you don't have faith in your practitioners (psychiatrist, talk therapists, message therapist, the people at your vitamin store, etc.) you shouldn't even delve into this stuff. Why bother if you don't trust the people you are paying to help you?You commented that you've yet to hear of anyone who had success with an SSRI/SNRI for more than 12 months. Honestly, most people don't have success with any variety of these meds for 12 months at a time. No matter if they are antidepressants, antipsychotics, benzos, hypnotics, stimulants, etc. You may make it 3-6 months without seeing your p doc...then you might see your doc 3 times in a month during crisis. Your cocktail will probably change quite often for a few years until you find what works. Your definition of "what works" may drastically change during your journey through this.
If you aren't sure if you have had a hypomanic episode I wouldn't jump to the conclusion that you are bipolar. I don't mean to sound like a debbie downer but I always warn people that simply starting an antidepressant can quickly turn into a 4-5 drug cocktail and being diagnosed with a "chronic course" disease. You may just have low mood and some emotional problems. It's great that you have a life coach!!! I would utilize talk therapy, moderate exercise, fruits, vegetables, Vitamins (particularly D3 and the B's) and plenty of time with friends/love ones before I would become over dependent on medications.
The ultimate healing experience will come from within. Life is a great teacher, sometimes our worst depressions and anxieties can shapes us into incredibly strong people when it's all said and done. Learning to cope is what it's all about. I hope you hang around babble. There are some cool cats around here. You will be fine. We are all stronger than we think!
peace
Posted by bleauberry on December 10, 2010, at 17:59:55
In reply to Best starting med for atypical depression?, posted by bmwfan07 on December 8, 2010, at 14:45:25
Best place to start? Well in my opinion, not at the doctors office. That is unless you are nonfunctional or suicidal, in which time I feel medical intervention is mandatory.
Is it a low serotonin problem? Easy to find out. Play with doses of 5htp and then tryptophan.
Is it a norepinephrine problem? Play with doses of DLPA and then tyrosine.
Same for dopamine.
Is GABA involved? Play with doses of GABA and glycine.
For all of them, or meds, a high quality B complex should be at the heart of whatever you do. By high quality, I mean it needs at least two versions of B12 in it (methylcobabaline mandatory and another), two versions of B6 (p5p mandatory and regular B6), two or three version of niacin (niacin, niacinamide). This strategy covers a lot of bases....the stuff that makes things work, and the methyl groups to help bridge any genetic defects.
Also at the heart of any treatment you try should be magnesium. Long story short, its functions in the brain are too numerous to count, and it is woefully deficient in the american food chain. Ones to try include MgMalate, MgGlycinate, MgTaurate, MgCitrate...in that order.
St Johns Wort.
Rhodiola Rosea.
SAMe.Food can also make a significant difference. Through home experiments about a week each, you can determine whether you are a high protein person or a high carb person...one or the other will help your symptoms somewhat, while the other makes them worse.
I would not recommend to anyone a medication to start with until they first went through all the above. Even supposing all the above fail, which is no more likely than a medication to fail, at least along the way you would have discovered some interesting clues that help to choose appropriate medications. At this point in time it is a pure guess.
Follow your doctor's advice on medication suggestions, follow the advice of others here for medication suggestions, or take control of your own treatment first by finding out what it is your body wants/needs that it doesn't have. I personally prefer to pose med suggestions after someone has already been engulfed in the medication circle and it isn't easy to get out. You aren't there and hopefully by trying some things never will be.
Posted by bmwfan07 on December 12, 2010, at 16:24:24
In reply to Re: Best starting med for atypical depression?, posted by mellow on December 10, 2010, at 5:24:40
> Welcome to babble and the world of psych meds. You seem very intelligent and well researched.
Thanks!
> Why bother if you don't trust the people you are paying to help you?
You raise an excellent point, one which my parents have reminded me of too. That said, I've had relatively poor experiences with doctors and their often dogmatic approach to what are clearly not matters of dogma, but of improvement of health. Western medicine promotes the idea that the patient knows nothing and the doctor knows all. Unfortunately, the majority of patients don't contradict, rather they affirm, this notion, and the cycle continues. When a doctor gets a patient like me who's a potential challenge to their authority and "omniscience," they tend to shut down and become sanctimonious, sensing a threat to their power, knowledge, and ego. I don't deal well with this, because the primary concern in any health care setting should be the proper diagnosis and treatment of health, not the patronization and submission of the patient.
I'm hoping this new p-doc whom I've set an appointment with is more open-minded and willing to hear me out. He's an osteopath and I've heard they're often a little less conventional, which is always good.
>
> You commented that you've yet to hear of anyone who had success with an SSRI/SNRI for more than 12 months. Honestly, most people don't have success with any variety of these meds for 12 months at a time. No matter if they are antidepressants, antipsychotics, benzos, hypnotics, stimulants, etc. You may make it 3-6 months without seeing your p doc...then you might see your doc 3 times in a month during crisis. Your cocktail will probably change quite often for a few years until you find what works. Your definition of "what works" may drastically change during your journey through this.Unfortunately, that seems to be the case in most people with chronic, atypical depression and bipolar disorder. I think one of the reasons is the widespread misdiagnosis of bipolar spectrum conditions as unipolar major depressive disorder, as well as the lack of differentiation in treatment and understanding between the melancholic and atypical depressive subtypes. The latter seems to correlate with bipolar disorder and responds to similar treatments (dopaminergic drugs more so than serotonergic), but most p-docs simply treat all manifestations of major depression identically. This knowledge gap might very well explain the common SSRI poop-out and treatment resistance so common in depression.
>
> If you aren't sure if you have had a hypomanic episode I wouldn't jump to the conclusion that you are bipolar. I don't mean to sound like a debbie downer but I always warn people that simply starting an antidepressant can quickly turn into a 4-5 drug cocktail and being diagnosed with a "chronic course" disease. You may just have low mood and some emotional problems. It's great that you have a life coach!!! I would utilize talk therapy, moderate exercise, fruits, vegetables, Vitamins (particularly D3 and the B's) and plenty of time with friends/love ones before I would become over dependent on medications.
>
> The ultimate healing experience will come from within. Life is a great teacher, sometimes our worst depressions and anxieties can shapes us into incredibly strong people when it's all said and done. Learning to cope is what it's all about. I hope you hang around babble. There are some cool cats around here. You will be fine. We are all stronger than we think!
>
> peace
>The problem is my depression seems very insidious and fundamentally neurochemical, and does not seem to be responsive to any form of therapy or social interaction (in fact, at times, the latter is far more emotionally painful than isolation). It seems to be fairly severe and, as I mentioned, chronic. It's quite frustrating, because when I'm depressed and I try to get out of the house and distract myself with friends, quite often I feel punished with heightened social anxiety, rejection sensitivity, and a feeling of general misery.
I think when I get the right med(s) to combat the neurochemical element of my depression, I'll be able to tackle some of the more psychological aspects of it--discovering and mitigating triggers, being more socially connected, working on CBT and questioning my beliefs, etc. I think this form of depression really does require a holistic approach, as you suggest; but I have a feeling medication is going to be one of the bigger pieces to the puzzle.
Posted by bmwfan07 on December 12, 2010, at 16:39:43
In reply to Re: Best starting med for atypical depression?, posted by bleauberry on December 10, 2010, at 17:59:55
> Best place to start? Well in my opinion, not at the doctors office. That is unless you are nonfunctional or suicidal, in which time I feel medical intervention is mandatory.
I am both, at times. I haven't actively planned or attempted suicide, but when it gets severe (particularly at night), I tend to ruminate somewhat obsessively about suicide. I'm typically able to distract myself sufficiently to cease this rumination, but during those times, it's almost always at the back of my mind, like a pesky fly.I am not really functional, but that might also be because I'm unemployed, which likely only exacerbates the situation. Looking for jobs when one is anergic, apathetic, exhausted and totally numb and listless is rather akin to doing endless favors for an old, thankless curmudgeon. It's very hard.
>
> Is it a low serotonin problem? Easy to find out. Play with doses of 5htp and then tryptophan.
>
> Is it a norepinephrine problem? Play with doses of DLPA and then tyrosine.
>
> Same for dopamine.
>
> Is GABA involved? Play with doses of GABA and glycine.As of yesterday, I started taking Perika, a formulation of St. John's wort--one of the highest rated and the standard in clinical trials. I also am taking 500mg of l-tyrosine per day, but I'm not sure if that's enough (also, would DLPA be beneficial over l-tyrosine?). I'm not sure if I've noticed a difference. I thought I did yesterday, but it was likely just placebo combined with the mood reactivity inherent to atypical depression. I was anticipating, and then participating in, a friend's housewarming party and my depression seemed to lift about 70%. Now, if only good things could happen every day!
>
> For all of them, or meds, a high quality B complex should be at the heart of whatever you do. By high quality, I mean it needs at least two versions of B12 in it (methylcobabaline mandatory and another), two versions of B6 (p5p mandatory and regular B6), two or three version of niacin (niacin, niacinamide). This strategy covers a lot of bases....the stuff that makes things work, and the methyl groups to help bridge any genetic defects.I took a Trader Joe's B-complex today with my second SJW, although I'm not sure it had methylcobaline in it. But should it be taken with a meal/fat?
>
> Also at the heart of any treatment you try should be magnesium. Long story short, its functions in the brain are too numerous to count, and it is woefully deficient in the american food chain. Ones to try include MgMalate, MgGlycinate, MgTaurate, MgCitrate...in that order.
>
> St Johns Wort.
> Rhodiola Rosea.
> SAMe.
>
I've heard about magnesium, too; I've just been overwhelmed with all the different possibilities. How much magnesium do you recommend?> Food can also make a significant difference. Through home experiments about a week each, you can determine whether you are a high protein person or a high carb person...one or the other will help your symptoms somewhat, while the other makes them worse.
>That's interesting. I'm not sure I possess the willpower when depressed to avoid the carbs that I sometimes crave, but perhaps this would be beneficial.
> I would not recommend to anyone a medication to start with until they first went through all the above. Even supposing all the above fail, which is no more likely than a medication to fail, at least along the way you would have discovered some interesting clues that help to choose appropriate medications. At this point in time it is a pure guess.
That is true!
>
> Follow your doctor's advice on medication suggestions, follow the advice of others here for medication suggestions, or take control of your own treatment first by finding out what it is your body wants/needs that it doesn't have. I personally prefer to pose med suggestions after someone has already been engulfed in the medication circle and it isn't easy to get out. You aren't there and hopefully by trying some things never will be.
>
>I definitely understand the concern about engulfment in mainstream medicine. I guess I'm just somewhat desperate at this point to feel better, and it's tough to exact much self-discipline as far as trying natural or behavioral remedies of less perceived scientific rigor. At least, that's what modern medicine wants us to believe. :)
Thanks for your help!
Posted by creepy on December 22, 2010, at 11:24:12
In reply to Best starting med for atypical depression?, posted by bmwfan07 on December 8, 2010, at 14:45:25
The problem I get on stimulants is the mood rollercoaster ride. Wellbutrin does the same thing. It doesnt last through the day and by the morning its gone and I cant get out of bed.
I took desipramine (an NRI) for awhile and that helped a bit. Not so sure it helped as much for depression.
SSRIs are the first line for OCD and depression treatment. celexa, zoloft and prozac. TCAs are used a lot too. fluvoxamine and clomipramine.
Just be careful when taking these drugs.. you may get a strong response to them, like a dysphoric hypomania. Best to start slow. I had no issues with celexa but my first trial of zoloft made me angry as hell all the time.
This is the end of the thread.
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