![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 35. This is the beginning of the thread.
Posted by policebox on June 27, 2011, at 18:43:15
I'm concerned about how to proceed with my condition and am feeling anxious about the situation I'm currently in.
In brief, heres my treatment history. Im currently a 36 year old male. I have received psychotherapy supplemented by medication for depression since I was about 19 or 20 years old. My primary complaints are difficulty with maintaining interpersonal relationships, academic difficulties (not attending classes), difficulty holding down a job for longer than a year, social anxiety, severe fatigue, and hypersomnia. From about 1995 to 2006, I was prescribed various SSRIs including Prozac, Celexa, and Lexapro, none of which helped at all. In 2006 I began taking Wellbutrin SR along with Lexapro. Wellbutrin was somewhat helpful in providing stimulation, but it did not seem to make any long-term impact in helping with my symptoms.
A few months ago I began investigating alternative medications or methods to try to help myself, because the results of not being able to have any stable relationships, holding down a job, or being able to finish school were leading me to suicidal ideation. Because fatigue and hypersomnia contribute tremendously to my school and work difficulties, my research suggested treatment with stimulants such as Adderall might be effective. However, the policy at the clinic I go to does not permit the prescription of stimulants without an ADHD assessment, which Im scheduled to have, but not until September (the soonest available). My research seemed to indicate that my symptoms were consistent with the atypical subtype of depression, although many of my functional impairments seem to be consistent with those described by ADD-PI.
My psychiatrist suggested we try a MAOi, which the literature indicated were particularly effective for treatment resistant depression and especially the atypical subtype. After reading up on MAOi drugs, I concluded that Parnate seemed to be the best choice for treating my symptoms and stood the best chance of providing the stimulation I need to overcome the fatigue and hypersomnia. My psychiatrist has had no prior personal experience prescribing MAOi drugs, so Ive relied largely on research articles and internet posts to help me thus far.
Before beginning the Parnate, I stopped taking Wellbutrin and had about a three week period without any medications. I began 05/25 with a dosage of 30mg per day, which he wants to titrate slowly upwards, if necessary. Prior to beginning Parnate, I persistently experienced circadian rhythm difficulties, which manifested itself as not being able to fall asleep until about 6am each day and then sleeping 18 hours or more non-stop (hypersomnia); also the sleep I received was never restful or refreshing.
Within 2 or 3 days of beginning Parnate, I began feeling sleepy and being able to fall asleep around midnight, then Id wake up (on my own without an alarm clock) at about 6am or 7am, feeling completely refreshed and full of energy. I felt motivated to be active and productive, which elevated my mood. For me, I thought I was having a personal miracle. I began to feel hopeful for the future, that Id finally be able to sleep normally and live normally throughout the day, enabling me to achieve the goals in life I had always wanted to fulfill. These feelings and the normalization of my sleep patterns was unfortunately short-lived. After about two weeks, periods of delayed sleep coupled with hypersomnia returned, as well as a decline in my mood.
After 3 weeks I increased the dosage to 40mg per day and have maintained that for two weeks so far; however, I have not noticed any positive change in my symptoms, with the periods of hypersomnia and fatigue becoming more prolonged.
One further complication is that I experience intermittent episodes of elevated blood pressure and heart palpitations (which last for 1 to 2 hours) since beginning Parnate. Ive been unable to find a pattern to these episodes. I adhere to the MAOi dietary restrictions. I have tried both taking the full 30mg or 40mg in the morning, or taking 10mg tablets spread-out throughout the day, but neither way seems to make a difference. Normal blood pressure readings have been around 123/74 and 121/77. But, when a period of elevated blood pressure strikes, it will go up to 150/90, 145/90, 143/84, 138/86, etc., usually after 1 to 2 hours after taking the medication, regardless of the dosage or period of time between it and the previous dose. And again, it doesnt happen every day.My options are to do nothing, change the dosage of Parnate, try a different medication, try a different treatment option, or give up.
Although its only speculation at this point, Im concerned I wont be able to tolerate a higher dosage of Parnate because of the elevated blood pressure episodes, and Im further worried that a higher dosage will not be any more effective in treating the fatigue and hypersomnia symptoms than the current dosage). Im also interested in a theory as to why the Parnate seemed to perfectly effective for about a week, after only taking it for a few days, but then stopped. Could it have been a synergistic effect of left-over bupropion in the blood-stream? Placebo effect? The effects of positive expectation?
So, Im not sure what to do at this point. I suppose Im here not only to express my feelings and concerns (your empathies I appreciate and thank you for), but for some advice based upon your own experiences and/or expertise. I appreciate any thoughtful reponses.
Posted by floatingbridge on June 27, 2011, at 21:57:44
In reply to Atypical depression - medication no longer helping, posted by policebox on June 27, 2011, at 18:43:15
Hi policebox,
I can't address your questions, but I think there are others who can. I wanted to welcome you and let you know I read your post.
What is the 'p' in ADD-PI? I am only familiar with ADD-I.
fb
Posted by policebox on June 28, 2011, at 0:19:01
In reply to Re: Atypical depression - medication no longer helping » policebox, posted by floatingbridge on June 27, 2011, at 21:57:44
> Hi policebox,
>
> I can't address your questions, but I think there are others who can. I wanted to welcome you and let you know I read your post.
>
> What is the 'p' in ADD-PI? I am only familiar with ADD-I.
>
> fb
>
>The PI stands for "predominantly inattentive". It looks like ADHD-I and ADHD-PI are both used for this diagnosis.
Posted by Terry8 on June 28, 2011, at 9:19:03
In reply to Atypical depression - medication no longer helping, posted by policebox on June 27, 2011, at 18:43:15
> One further complication is that I experience intermittent episodes of elevated blood pressure and heart palpitations (which last for 1 to 2 hours) since beginning Parnate. Ive been unable to find a pattern to these episodes. I adhere to the MAOi dietary restrictions. I have tried both taking the full 30mg or 40mg in the morning, or taking 10mg tablets spread-out throughout the day, but neither way seems to make a difference. Normal blood pressure readings have been around 123/74 and 121/77. But, when a period of elevated blood pressure strikes, it will go up to 150/90, 145/90, 143/84, 138/86, etc., usually after 1 to 2 hours after taking the medication, regardless of the dosage or period of time between it and the previous dose. And again, it doesnt happen every day.
>I've had exactly the same reaction to Parnate. The only difference is that my normal blood pressure is more a bit lower, more like 80/50 or 90/60, but I'd spike to about the same point -- 140/90 or 150/100 -- with heart palpitations and sometimes a moderate headache, often following a dose (usually one of the ones later in the day) and sometimes for no reason that I can fathom (though I did eventually pin down a few food triggers that one wouldn't expect, and taking the doses further apart did seem to help some). I'm currently stable on 40 mg a day, but had this reaction anew with each dosage increase (I started at 10 mg and titrated more slowly than you did). But here's the good news: it mostly went away with time for me, perhaps after six weeks at each new dosage. We never increased the dose until the spikes had calmed down enough that I felt confident about handling the next increase (like you, I'd said more than once that there was no way I could go higher, but time proved otherwise). Since you've only been on the med for a month total, there's still a very good chance the blood pressure spikes will calm down a bit.
Next bit of possibly good news: my full response to Parnate only kicked in after about 12 weeks. I also had the immediate positive upswing for a few days after starting, but it was actually followed by a week or two of feeling worse than when I'd started. This repeated with each dose increase: a couple good days, a week or two of dooooooom, and then a slow march upward.
My inclination is to give it more time. Your mileage may vary, of course, and I know how frustrating it is to be patient when feeling like crap, but these's a chance things might still improve just where you are. I hope you find some relief soon!
Posted by deepreason on June 28, 2011, at 16:41:22
In reply to Re: Atypical depression - medication no longer helping, posted by Terry8 on June 28, 2011, at 9:19:03
I had the exact same spikes of BP with Nardil until my Pdoc told me to cut chocolate from my diet completely. It seemed a bit odd as the chocolate hadn't caused any problems for the first month or so but he was right. Stable BP since droping the choccies!
Posted by floatingbridge on June 28, 2011, at 17:29:46
In reply to Re: Atypical depression - medication no longer helping, posted by deepreason on June 28, 2011, at 16:41:22
> I had the exact same spikes of BP with Nardil until my Pdoc told me to cut chocolate from my diet completely. It seemed a bit odd as the chocolate hadn't caused any problems for the first month or so but he was right. Stable BP since droping the choccies!
Chocolate has PEA. I'm not sure what
that is yet. A post by zonked on a recent
nardil thread said maoi's act on this.
Posted by sigismund on June 28, 2011, at 17:31:23
In reply to Re: Atypical depression - medication no longer helping, posted by deepreason on June 28, 2011, at 16:41:22
I had elevated BP on Parnate in which chocolate my have been implicated.
Posted by Terry8 on June 28, 2011, at 17:32:36
In reply to Re: Atypical depression - medication no longer helping, posted by deepreason on June 28, 2011, at 16:41:22
> I had the exact same spikes of BP with Nardil until my Pdoc told me to cut chocolate from my diet completely. It seemed a bit odd as the chocolate hadn't caused any problems for the first month or so but he was right. Stable BP since droping the choccies!
It's happened for me as well that foods that were fine at first starting causing problems later on. Chocolate was one of them. Cocoa and good-quality dark chocolate were a problem from the start, but inexpensive chocolate with hardly any cocoa content, like M&Ms, began causing elevated BP over time as well. (Almonds were another. I guess that means chocolate-covered almonds are out of the question, more's the pity...)
Posted by Bob on June 28, 2011, at 19:54:04
In reply to Atypical depression - medication no longer helping, posted by policebox on June 27, 2011, at 18:43:15
> I'm concerned about how to proceed with my condition and am feeling anxious about the situation I'm currently in.
>
> In brief, heres my treatment history. Im currently a 36 year old male. I have received psychotherapy supplemented by medication for depression since I was about 19 or 20 years old. My primary complaints are difficulty with maintaining interpersonal relationships, academic difficulties (not attending classes), difficulty holding down a job for longer than a year, social anxiety, severe fatigue, and hypersomnia. From about 1995 to 2006, I was prescribed various SSRIs including Prozac, Celexa, and Lexapro, none of which helped at all. In 2006 I began taking Wellbutrin SR along with Lexapro. Wellbutrin was somewhat helpful in providing stimulation, but it did not seem to make any long-term impact in helping with my symptoms.
>
> A few months ago I began investigating alternative medications or methods to try to help myself, because the results of not being able to have any stable relationships, holding down a job, or being able to finish school were leading me to suicidal ideation. Because fatigue and hypersomnia contribute tremendously to my school and work difficulties, my research suggested treatment with stimulants such as Adderall might be effective. However, the policy at the clinic I go to does not permit the prescription of stimulants without an ADHD assessment, which Im scheduled to have, but not until September (the soonest available). My research seemed to indicate that my symptoms were consistent with the atypical subtype of depression, although many of my functional impairments seem to be consistent with those described by ADD-PI.
>
> My psychiatrist suggested we try a MAOi, which the literature indicated were particularly effective for treatment resistant depression and especially the atypical subtype. After reading up on MAOi drugs, I concluded that Parnate seemed to be the best choice for treating my symptoms and stood the best chance of providing the stimulation I need to overcome the fatigue and hypersomnia. My psychiatrist has had no prior personal experience prescribing MAOi drugs, so Ive relied largely on research articles and internet posts to help me thus far.
>
> Before beginning the Parnate, I stopped taking Wellbutrin and had about a three week period without any medications. I began 05/25 with a dosage of 30mg per day, which he wants to titrate slowly upwards, if necessary. Prior to beginning Parnate, I persistently experienced circadian rhythm difficulties, which manifested itself as not being able to fall asleep until about 6am each day and then sleeping 18 hours or more non-stop (hypersomnia); also the sleep I received was never restful or refreshing.
>
> Within 2 or 3 days of beginning Parnate, I began feeling sleepy and being able to fall asleep around midnight, then Id wake up (on my own without an alarm clock) at about 6am or 7am, feeling completely refreshed and full of energy. I felt motivated to be active and productive, which elevated my mood. For me, I thought I was having a personal miracle. I began to feel hopeful for the future, that Id finally be able to sleep normally and live normally throughout the day, enabling me to achieve the goals in life I had always wanted to fulfill. These feelings and the normalization of my sleep patterns was unfortunately short-lived. After about two weeks, periods of delayed sleep coupled with hypersomnia returned, as well as a decline in my mood.
>
> After 3 weeks I increased the dosage to 40mg per day and have maintained that for two weeks so far; however, I have not noticed any positive change in my symptoms, with the periods of hypersomnia and fatigue becoming more prolonged.
> One further complication is that I experience intermittent episodes of elevated blood pressure and heart palpitations (which last for 1 to 2 hours) since beginning Parnate. Ive been unable to find a pattern to these episodes. I adhere to the MAOi dietary restrictions. I have tried both taking the full 30mg or 40mg in the morning, or taking 10mg tablets spread-out throughout the day, but neither way seems to make a difference. Normal blood pressure readings have been around 123/74 and 121/77. But, when a period of elevated blood pressure strikes, it will go up to 150/90, 145/90, 143/84, 138/86, etc., usually after 1 to 2 hours after taking the medication, regardless of the dosage or period of time between it and the previous dose. And again, it doesnt happen every day.
>
> My options are to do nothing, change the dosage of Parnate, try a different medication, try a different treatment option, or give up.
>
> Although its only speculation at this point, Im concerned I wont be able to tolerate a higher dosage of Parnate because of the elevated blood pressure episodes, and Im further worried that a higher dosage will not be any more effective in treating the fatigue and hypersomnia symptoms than the current dosage). Im also interested in a theory as to why the Parnate seemed to perfectly effective for about a week, after only taking it for a few days, but then stopped. Could it have been a synergistic effect of left-over bupropion in the blood-stream? Placebo effect? The effects of positive expectation?
>
> So, Im not sure what to do at this point. I suppose Im here not only to express my feelings and concerns (your empathies I appreciate and thank you for), but for some advice based upon your own experiences and/or expertise. I appreciate any thoughtful reponses.I don't have any solutions to your problem, but I wanted to mention how similar my problem is to yours. I too have taken meds since the early to mid nineties and my condition and response is somewhat similar to you. I too experience fatigue and hypersomnia and have great difficulty concentrating as well as holding down a job. My condition is marked by significant anxiety problems as well.
More importantly, I too have gotten short duration responses to the drugs which have worked at all. The responses have been getting shorter over time as well as less robust. It seems that my brain somehow 'adapts' to the chemicals and then never responds the same way again. Nobody has ever been able to explain why and it just keeps getting worse. I have decided that I cannot try MAOIs because I would never survive the discontinuation and washout periods. The first time I tried Wellbutrin with Celexa it was robust and good for about a week, then it went downhill. I've tried it again a few times but never got any response nearly as effective.
This atypical condition is not good.
Posted by Bob on June 28, 2011, at 20:04:23
In reply to Atypical depression - medication no longer helping, posted by policebox on June 27, 2011, at 18:43:15
Oh... forgot to mention the other important aspect that I seem to share with you concerning my illness - and that is that if a treatment seems to work at all I start exhibiting that clock shift phenomenon that you speak of where I begin staying awake until between 4 and 6am and then sleeping late into the next morning afternoon. I have never been able to change this much.
Posted by Phillipa on June 30, 2011, at 10:58:31
In reply to Re: Atypical depression - medication no longer helping » policebox, posted by Bob on June 28, 2011, at 20:04:23
All this is due to Maoi's? Phillipa
Posted by jedi on July 1, 2011, at 1:25:01
In reply to Re: Atypical depression - medication no longer helping » policebox, posted by Bob on June 28, 2011, at 19:54:04
> I don't have any solutions to your problem, but I wanted to mention how similar my problem is to yours. I too have taken meds since the early to mid nineties and my condition and response is somewhat similar to you. I too experience fatigue and hypersomnia and have great difficulty concentrating as well as holding down a job. My condition is marked by significant anxiety problems as well.
>
> More importantly, I too have gotten short duration responses to the drugs which have worked at all. The responses have been getting shorter over time as well as less robust. It seems that my brain somehow 'adapts' to the chemicals and then never responds the same way again. Nobody has ever been able to explain why and it just keeps getting worse. I have decided that I cannot try MAOIs because I would never survive the discontinuation and washout periods. The first time I tried Wellbutrin with Celexa it was robust and good for about a week, then it went downhill. I've tried it again a few times but never got any response nearly as effective.
>
> This atypical condition is not good.Bob,
Nardil is the "BOMB" for atypical depression with anxiety. It will work when so many other meds have not. Most meds have a two week washout. Prozac is said to be five. When Nardil works for atypical depression it is like throwing a switch. The light just comes on when it kicks in. I used high dose benzos to get through the pain while I gave the Nardil a chance to work. Don't look past the MAOIs if you have treatment resistant atypical depression.
Be well,
Jedi
Posted by Roslynn on July 1, 2011, at 15:16:53
In reply to Re: Atypical depression - medication no longer helping » Bob, posted by jedi on July 1, 2011, at 1:25:01
Dear Jedi,
You mention below using high-dose benzos to make it through the transition to Nardil. Did your doctor recommend this approach? Can you tell me more about it? Sorry if too personal.
I think MAOIs would work for me but I'm so scared of the Prozac washout.
Thanks,
Roslynn> Nardil is the "BOMB" for atypical depression with anxiety. It will work when so many other meds have not. Most meds have a two week washout. Prozac is said to be five. When Nardil works for atypical depression it is like throwing a switch. The light just comes on when it kicks in. I used high dose benzos to get through the pain while I gave the Nardil a chance to work. Don't look past the MAOIs if you have treatment resistant atypical depression.
> Be well,
> Jedi
>
>
Posted by Terry8 on July 1, 2011, at 16:07:28
In reply to Re: Atypical depression - medication no longer helping » jedi, posted by Roslynn on July 1, 2011, at 15:16:53
> I think MAOIs would work for me but I'm so scared of the Prozac washout.
>
>Five weeks of hell with an end point in sight, or the possibility of the rest of your life with depression and no end in sight? It's tough, but think the washout is worth it.
Posted by jedi on July 1, 2011, at 18:23:39
In reply to Re: Atypical depression - medication no longer helping » jedi, posted by Roslynn on July 1, 2011, at 15:16:53
Hi Roslynn,
Yes it was prescribed by my PDOC in 1998, when my first major depression hit. Looked back at my records and it was 4mg daily of clonazepam. I remember it knocked me for a loop, but I was able to get by for a while. When the Nardil kicked in, I was back down to 1mg. I've used between one and two milligrams for years for sleep and to augment Nardil for my social anxiety. I still take .5mg heading for zero because of the memory problems with clonazepam. Very slow taper, but I've been taking it for a long time. Because of the memory issues, I wouldn't recommend long term use.
Be Well,
Jedi
> Dear Jedi,
>
> You mention below using high-dose benzos to make it through the transition to Nardil. Did your doctor recommend this approach? Can you tell me more about it? Sorry if too personal.
>
> I think MAOIs would work for me but I'm so scared of the Prozac washout.
>
> Thanks,
> Roslynn
>
> > Nardil is the "BOMB" for atypical depression with anxiety. It will work when so many other meds have not. Most meds have a two week washout. Prozac is said to be five. When Nardil works for atypical depression it is like throwing a switch. The light just comes on when it kicks in. I used high dose benzos to get through the pain while I gave the Nardil a chance to work. Don't look past the MAOIs if you have treatment resistant atypical depression.
> > Be well,
> > Jedi
Posted by Roslynn on July 2, 2011, at 10:44:32
In reply to Re: Atypical depression - medication no longer helping » Roslynn, posted by jedi on July 1, 2011, at 18:23:39
Dear Jedi,
Thank you so much for your informative answer. I may well end up going with clonazepam if/when I try to taper off Prozac. I take Ativan but I think it's a "lighter" med than clonazepam.
Thanks again,
Roslynn
> Hi Roslynn,
> Yes it was prescribed by my PDOC in 1998, when my first major depression hit. Looked back at my records and it was 4mg daily of clonazepam. I remember it knocked me for a loop, but I was able to get by for a while. When the Nardil kicked in, I was back down to 1mg. I've used between one and two milligrams for years for sleep and to augment Nardil for my social anxiety. I still take .5mg heading for zero because of the memory problems with clonazepam. Very slow taper, but I've been taking it for a long time. Because of the memory issues, I wouldn't recommend long term use.
> Be Well,
> Jedi
>
>
> > Dear Jedi,
> >
> > You mention below using high-dose benzos to make it through the transition to Nardil. Did your doctor recommend this approach? Can you tell me more about it? Sorry if too personal.
> >
> > I think MAOIs would work for me but I'm so scared of the Prozac washout.
> >
> > Thanks,
> > Roslynn
> >
> > > Nardil is the "BOMB" for atypical depression with anxiety. It will work when so many other meds have not. Most meds have a two week washout. Prozac is said to be five. When Nardil works for atypical depression it is like throwing a switch. The light just comes on when it kicks in. I used high dose benzos to get through the pain while I gave the Nardil a chance to work. Don't look past the MAOIs if you have treatment resistant atypical depression.
> > > Be well,
> > > Jedi
>
>
Posted by Roslynn on July 2, 2011, at 10:47:43
In reply to Re: Atypical depression - medication no longer helping » Roslynn, posted by Terry8 on July 1, 2011, at 16:07:28
I agree it is worth it. However, I tend to get into an agitated state without the Prozac. Jedi mentioned taking clonazepam during the washout and I think this could be a possibility.
Best,
Roslynn> > I think MAOIs would work for me but I'm so scared of the Prozac washout.
> >
> >
>
> Five weeks of hell with an end point in sight, or the possibility of the rest of your life with depression and no end in sight? It's tough, but think the washout is worth it.
Posted by kirbyw on July 3, 2011, at 11:27:24
In reply to Atypical depression - medication no longer helping, posted by policebox on June 27, 2011, at 18:43:15
I have experienced similar rises in blood pressure on 50 or 60 mg of parnate. The numbers you cite would not be dangerous at all, although you can consult a cardiologist. In my case the blood pressure drops within an hour to to the normal range.
Rick in Costa Rica.> I'm concerned about how to proceed with my condition and am feeling anxious about the situation I'm currently in.
>
> In brief, heres my treatment history. Im currently a 36 year old male. I have received psychotherapy supplemented by medication for depression since I was about 19 or 20 years old. My primary complaints are difficulty with maintaining interpersonal relationships, academic difficulties (not attending classes), difficulty holding down a job for longer than a year, social anxiety, severe fatigue, and hypersomnia. From about 1995 to 2006, I was prescribed various SSRIs including Prozac, Celexa, and Lexapro, none of which helped at all. In 2006 I began taking Wellbutrin SR along with Lexapro. Wellbutrin was somewhat helpful in providing stimulation, but it did not seem to make any long-term impact in helping with my symptoms.
>
> A few months ago I began investigating alternative medications or methods to try to help myself, because the results of not being able to have any stable relationships, holding down a job, or being able to finish school were leading me to suicidal ideation. Because fatigue and hypersomnia contribute tremendously to my school and work difficulties, my research suggested treatment with stimulants such as Adderall might be effective. However, the policy at the clinic I go to does not permit the prescription of stimulants without an ADHD assessment, which Im scheduled to have, but not until September (the soonest available). My research seemed to indicate that my symptoms were consistent with the atypical subtype of depression, although many of my functional impairments seem to be consistent with those described by ADD-PI.
>
> My psychiatrist suggested we try a MAOi, which the literature indicated were particularly effective for treatment resistant depression and especially the atypical subtype. After reading up on MAOi drugs, I concluded that Parnate seemed to be the best choice for treating my symptoms and stood the best chance of providing the stimulation I need to overcome the fatigue and hypersomnia. My psychiatrist has had no prior personal experience prescribing MAOi drugs, so Ive relied largely on research articles and internet posts to help me thus far.
>
> Before beginning the Parnate, I stopped taking Wellbutrin and had about a three week period without any medications. I began 05/25 with a dosage of 30mg per day, which he wants to titrate slowly upwards, if necessary. Prior to beginning Parnate, I persistently experienced circadian rhythm difficulties, which manifested itself as not being able to fall asleep until about 6am each day and then sleeping 18 hours or more non-stop (hypersomnia); also the sleep I received was never restful or refreshing.
>
> Within 2 or 3 days of beginning Parnate, I began feeling sleepy and being able to fall asleep around midnight, then Id wake up (on my own without an alarm clock) at about 6am or 7am, feeling completely refreshed and full of energy. I felt motivated to be active and productive, which elevated my mood. For me, I thought I was having a personal miracle. I began to feel hopeful for the future, that Id finally be able to sleep normally and live normally throughout the day, enabling me to achieve the goals in life I had always wanted to fulfill. These feelings and the normalization of my sleep patterns was unfortunately short-lived. After about two weeks, periods of delayed sleep coupled with hypersomnia returned, as well as a decline in my mood.
>
> After 3 weeks I increased the dosage to 40mg per day and have maintained that for two weeks so far; however, I have not noticed any positive change in my symptoms, with the periods of hypersomnia and fatigue becoming more prolonged.
> One further complication is that I experience intermittent episodes of elevated blood pressure and heart palpitations (which last for 1 to 2 hours) since beginning Parnate. Ive been unable to find a pattern to these episodes. I adhere to the MAOi dietary restrictions. I have tried both taking the full 30mg or 40mg in the morning, or taking 10mg tablets spread-out throughout the day, but neither way seems to make a difference. Normal blood pressure readings have been around 123/74 and 121/77. But, when a period of elevated blood pressure strikes, it will go up to 150/90, 145/90, 143/84, 138/86, etc., usually after 1 to 2 hours after taking the medication, regardless of the dosage or period of time between it and the previous dose. And again, it doesnt happen every day.
>
> My options are to do nothing, change the dosage of Parnate, try a different medication, try a different treatment option, or give up.
>
> Although its only speculation at this point, Im concerned I wont be able to tolerate a higher dosage of Parnate because of the elevated blood pressure episodes, and Im further worried that a higher dosage will not be any more effective in treating the fatigue and hypersomnia symptoms than the current dosage). Im also interested in a theory as to why the Parnate seemed to perfectly effective for about a week, after only taking it for a few days, but then stopped. Could it have been a synergistic effect of left-over bupropion in the blood-stream? Placebo effect? The effects of positive expectation?
>
> So, Im not sure what to do at this point. I suppose Im here not only to express my feelings and concerns (your empathies I appreciate and thank you for), but for some advice based upon your own experiences and/or expertise. I appreciate any thoughtful reponses.
Posted by Bob on July 3, 2011, at 16:50:01
In reply to Re: Atypical depression - medication no longer helping » Roslynn, posted by Terry8 on July 1, 2011, at 16:07:28
> > I think MAOIs would work for me but I'm so scared of the Prozac washout.
> >
> >
>
> Five weeks of hell with an end point in sight, or the possibility of the rest of your life with depression and no end in sight? It's tough, but think the washout is worth it.
The problem for me personally is that, not only would the washout be indescribably tough but also life threatening. To taper down and have nothing helping would put my life in peril. If the MAOI didn't work then the whole thing would be an exercise in trying to withstand suicidality. Then I'd have to try to get back off of the MAOI. If this hypothetical scenario did play out I could be looking at 2-3 months of severe instability: 2 weeks minimum washout, up to twelve weeks of waiting for Nardil or Parnate to work, and then possibly 2+ weeks of tapering down the MAOI.
Posted by Bob on July 3, 2011, at 17:04:58
In reply to Re: Atypical depression - medication no longer helping » Bob, posted by jedi on July 1, 2011, at 1:25:01
> > I don't have any solutions to your problem, but I wanted to mention how similar my problem is to yours. I too have taken meds since the early to mid nineties and my condition and response is somewhat similar to you. I too experience fatigue and hypersomnia and have great difficulty concentrating as well as holding down a job. My condition is marked by significant anxiety problems as well.
> >
> > More importantly, I too have gotten short duration responses to the drugs which have worked at all. The responses have been getting shorter over time as well as less robust. It seems that my brain somehow 'adapts' to the chemicals and then never responds the same way again. Nobody has ever been able to explain why and it just keeps getting worse. I have decided that I cannot try MAOIs because I would never survive the discontinuation and washout periods. The first time I tried Wellbutrin with Celexa it was robust and good for about a week, then it went downhill. I've tried it again a few times but never got any response nearly as effective.
> >
> > This atypical condition is not good.
>
> Bob,
> Nardil is the "BOMB" for atypical depression with anxiety. It will work when so many other meds have not. Most meds have a two week washout. Prozac is said to be five. When Nardil works for atypical depression it is like throwing a switch. The light just comes on when it kicks in. I used high dose benzos to get through the pain while I gave the Nardil a chance to work. Don't look past the MAOIs if you have treatment resistant atypical depression.
> Be well,
> Jedi
>
>Hey Jedi,
Here are some major concerns I would have with starting an MAOI:
- The taper down from what I'm on now would be life threatening. I have never had a good discontinuation and now I am quite sick. I have some serious doubts about whether I could survive it. Then if the Nardil didn't work it would be a serious disaster, effectively lengthening my crisis by weeks or months as I try to get back off of the Nardil. I've had so many crises.
- I thought Nardil was infamous for massive weight gain and significant sexual dysfunction? I have already been carrying around a good deal of extra weight from these terrible medicines and my genitals are already numb.
- I have great problems with fatigue and oversleeping as well as my shifted circadian rhythm. I have heard anecdotally about the MAOIs sometimes exacerbating these things.
- I could develop anger and irritability that could become problematic.
- There's always the whole blood pressure and diet thing as well.
None of these points would be as serious if the washout period wasn't required before AND after a possibly failed trial. In the end though if there's nothing left I may have to take all these risks anyway.Bob
Posted by floatingbridge on July 3, 2011, at 18:23:33
In reply to Re: Atypical depression - medication no longer helping » Terry8, posted by Bob on July 3, 2011, at 16:50:01
Bob,
I would never advise anyone to do an unsupported wash ever! (My big opinion.) I hear you. It can be very big for some. Others expecting to knuckle through might make it--or find themselves in an unexpected crisis.
I don't know how some folks manage,
but I would need a doctor onboard with me. Do you have one? (Not that you are going to do this, but I think you are realistic in laying this all out.)This is just me writing here having had the daylights kicked out of me for going
off meds w/o supervision :-/I think online, it's easy to sound more casual about the process than any poster intended. I don't think anyone here would really (or should ever!) reccommend that anyone 'just do it'.
You have a good doc working with you? I hear there are doctors who will work very closely to sped up the transition process and monitor patients closely.
I am no expert on these matters!
fb
> > > I think MAOIs would work for me but I'm so scared of the Prozac washout.
> > >
> > >
> >
> > Five weeks of hell with an end point in sight, or the possibility of the rest of your life with depression and no end in sight? It's tough, but think the washout is worth it.
>
>
> The problem for me personally is that, not only would the washout be indescribably tough but also life threatening. To taper down and have nothing helping would put my life in peril. If the MAOI didn't work then the whole thing would be an exercise in trying to withstand suicidality. Then I'd have to try to get back off of the MAOI. If this hypothetical scenario did play out I could be looking at 2-3 months of severe instability: 2 weeks minimum washout, up to twelve weeks of waiting for Nardil or Parnate to work, and then possibly 2+ weeks of tapering down the MAOI.
>
>
Posted by hyperfocus on July 10, 2011, at 21:45:08
In reply to Atypical depression - medication no longer helping, posted by policebox on June 27, 2011, at 18:43:15
If you responded partially to Wellbutrin then you should have tried meds with a strong NE effect like Effexor or Pristiq or Cymbalta or Remeron, or TCAs like amitriptyline or desipramine. You could also try combinations of these drugs like Effexor + Wellbutrin. MAOIs are sort of the nuclear option - they tend to work but the side-effects are serious. But if you want to stick with the Parnate you should give it at least 4 weeks. I think the fact that you responded to it for the first week is very encouraging. Nardil also seems to have this acute positive effect for the first few days, which then diminshes, until the true AD theraputic response appears weeks later. I know it's tough to stick it out for a couple of weeks on a med you're not sure is gonna work, but you can get through it. If you've waited a lot of years to find something that can really help, like most of us, then another couple of weeks won't be that bad. If it doesn't work you could try Nardil which could help a lot with the social anxiety, or step back from the MAOI plate and try some of the NE-meds.
Posted by Avenarius on July 18, 2011, at 21:21:14
In reply to Re: Atypical depression - medication no longer helping » policebox, posted by hyperfocus on July 10, 2011, at 21:45:08
My situation is very similar to that of the original poster - atypical with anxiety. After 18 years of partial improvement on paxil and effexor severe anticholinergic side effects forced me to search for something I could tolerate. In June I had a consultation with Dr. Steven Dubovsky (he's mentioned a bit on this site; I highly recommend him if you can get to Buffalo, NY; $350 for an hour but I would have paid 10 times that amount.) Following his advice, I've just completed a washout period during which I relied on 50mg / day Desipramine and occasional clonapin. It sucked but tomorrow I start taking Selegiline (oral, not the Emsam patch). For some reason I'm confident it's going to work out for me. I've heard that it can help to make sure you take it with food, perhaps true of other MAOIs as well. If it doesn't there are other options along the lines of what hyperfocus has spelled out.
Incidentally, I came across an interesting algorithm for the diagnosis and treatment of depression published by Harvard:
http://www.mhc.com/Algorithms/Depression/frames.htmI wish the doctors I've seen over the years could have executed this properly. It might have saved me a good 27 years of trouble
> If you responded partially to Wellbutrin then you should have tried meds with a strong NE effect like Effexor or Pristiq or Cymbalta or Remeron, or TCAs like amitriptyline or desipramine. You could also try combinations of these drugs like Effexor + Wellbutrin. MAOIs are sort of the nuclear option - they tend to work but the side-effects are serious. But if you want to stick with the Parnate you should give it at least 4 weeks. I think the fact that you responded to it for the first week is very encouraging. Nardil also seems to have this acute positive effect for the first few days, which then diminshes, until the true AD theraputic response appears weeks later. I know it's tough to stick it out for a couple of weeks on a med you're not sure is gonna work, but you can get through it. If you've waited a lot of years to find something that can really help, like most of us, then another couple of weeks won't be that bad. If it doesn't work you could try Nardil which could help a lot with the social anxiety, or step back from the MAOI plate and try some of the NE-meds.
Posted by floatingbridge on July 18, 2011, at 22:01:18
In reply to Re: Atypical depression - medication no longer helping, posted by Avenarius on July 18, 2011, at 21:21:14
Thank you for this link. I might print out the flow chart.
Very best to you with the segiline and everything going forward. I was responsive to Emsam after 12 years of ssri/snri therapy. Good luck!
Posted by Phillipa on July 18, 2011, at 23:33:55
In reply to Re: Atypical depression - medication no longer helping, posted by floatingbridge on July 18, 2011, at 22:01:18
FB please don't forget to write that down for your doc visit. Love Phillipa
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