![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 32. This is the beginning of the thread.
Posted by Conundrum on September 5, 2011, at 21:09:43
It seems that since I've started Nardil I've been more lethargic and lazy than normal. Usually I just want to sleep or do nothing. I find less interest in things that always helped my anhedonia a little like video games.
I am wondering if things improve with a higher dose, or perhaps I should consider asking my pdoc on wednesday for nortriptyline, desipramine, or protriptyline to help with the anhedonia. I know he likes the stim + MAOI combo, but I have never had positive or pleasant experiences from stimulants.
So does anyone have an idea what adding a TCA would do? I that this is part of your combo Scott.
Posted by jono_in_adelaide on September 5, 2011, at 22:16:11
In reply to Nardil anhedonia, need TCA? SLS?, posted by Conundrum on September 5, 2011, at 21:09:43
You could try adding nortriptyline, this would boost your noradrenalin levels and give you more motivation etc.
If that isnt a goer, you could try changing to Parnate
Posted by creepy on September 5, 2011, at 23:28:34
In reply to Nardil anhedonia, need TCA? SLS?, posted by Conundrum on September 5, 2011, at 21:09:43
The only thing that seemed to touch my SSRI-induced anhedonia was adderall.
Wellbutrin might if you havent taken it before and had it poop out on you. I think I did pretty well on it in my first trial.
Desipramine gave me some extra energy but not motivation. I just kind of moped around feeling energized.
Other TCAs might not be safe with an MAOI.
Posted by Phillipa on September 5, 2011, at 23:49:28
In reply to Re: Nardil anhedonia, need TCA? SLS?, posted by creepy on September 5, 2011, at 23:28:34
True. Phillipa
Posted by SLS on September 6, 2011, at 10:36:22
In reply to Nardil anhedonia, need TCA? SLS?, posted by Conundrum on September 5, 2011, at 21:09:43
> It seems that since I've started Nardil I've been more lethargic and lazy than normal. Usually I just want to sleep or do nothing. I find less interest in things that always helped my anhedonia a little like video games.
>
> I am wondering if things improve with a higher dose, or perhaps I should consider asking my pdoc on wednesday for nortriptyline, desipramine, or protriptyline to help with the anhedonia. I know he likes the stim + MAOI combo, but I have never had positive or pleasant experiences from stimulants.The first time I added desipramine to Parnate, I experienced a robust improvement that lasted for several months. It was as if the Parnate helped to stabilize the tricyclic response. Otherwise, desipramine poops-out on me within three days of the appearance of an antidepressant response.
Regarding anhedonia, TCAs can do a good job. No theory here. It is simply an empirical observation. Theory is often a fruitless way to attack depressive illness.
- Scott
Posted by creepy on September 6, 2011, at 14:45:54
In reply to Re: Nardil anhedonia, need TCA? SLS? » Conundrum, posted by SLS on September 6, 2011, at 10:36:22
Weird, I never got any AD effects from it. Maybe I didnt go high enough on dose at the time. I think I topped out at 100mg since I was getting a lot of headaches and other side effects.
It was -really- good on my pain though, I miss it a lot.
Another weird side effect was that like sudafed it relieves congestion, but this went one step further and restored my sense of smell for awhile.
Could have also been some sort of hypomanic symptom at the time, I never followed up on it.
Posted by Conundrum on September 6, 2011, at 16:36:10
In reply to Re: Nardil anhedonia, need TCA? SLS? » Conundrum, posted by SLS on September 6, 2011, at 10:36:22
> > It seems that since I've started Nardil I've been more lethargic and lazy than normal. Usually I just want to sleep or do nothing. I find less interest in things that always helped my anhedonia a little like video games.
> >
> > I am wondering if things improve with a higher dose, or perhaps I should consider asking my pdoc on wednesday for nortriptyline, desipramine, or protriptyline to help with the anhedonia. I know he likes the stim + MAOI combo, but I have never had positive or pleasant experiences from stimulants.
>
> The first time I added desipramine to Parnate, I experienced a robust improvement that lasted for several months. It was as if the Parnate helped to stabilize the tricyclic response. Otherwise, desipramine poops-out on me within three days of the appearance of an antidepressant response.
>
> Regarding anhedonia, TCAs can do a good job. No theory here. It is simply an empirical observation. Theory is often a fruitless way to attack depressive illness.
>
>
> - ScottThanks Scott. Are there any TCAs in particular that you have seen anhedonia respond to and others not so well?
Posted by pedr on September 8, 2011, at 10:08:34
In reply to Nardil anhedonia, need TCA? SLS?, posted by Conundrum on September 5, 2011, at 21:09:43
> It seems that since I've started Nardil I've been more lethargic and lazy than normal. Usually I just want to sleep or do nothing. I find less interest in things that always helped my anhedonia a little like video games.
>
> I am wondering if things improve with a higher dose, or perhaps I should consider asking my pdoc on wednesday for nortriptyline, desipramine, or protriptyline to help with the anhedonia. I know he likes the stim + MAOI combo, but I have never had positive or pleasant experiences from stimulants.
>
> So does anyone have an idea what adding a TCA would do? I that this is part of your combo Scott.Hi, I have been on Nardil for some time now and experienced the same lethargy and anhedonia. Whilst Nardil was saving me from being in a very, very bad place, the somnolence and apathy wasn't/isn't great.
I tried a swathe of adjuncts, mostly AP's and Stims to no avail. Lastly I have tried Abilify and found that even 2mg is too much. 1mg / day abilify and 60mg/day Nardil seems (touch wood, no predictions made) to be working pretty well for me. The abilify certainly helps with the lack of energy and motivation. It screws my sleep up even more than before but it's worth it.
HTH
Pedr
Posted by Conundrum on September 8, 2011, at 12:58:21
In reply to Re: Nardil anhedonia, need TCA? SLS?, posted by pedr on September 8, 2011, at 10:08:34
> > It seems that since I've started Nardil I've been more lethargic and lazy than normal. Usually I just want to sleep or do nothing. I find less interest in things that always helped my anhedonia a little like video games.
> >
> > I am wondering if things improve with a higher dose, or perhaps I should consider asking my pdoc on wednesday for nortriptyline, desipramine, or protriptyline to help with the anhedonia. I know he likes the stim + MAOI combo, but I have never had positive or pleasant experiences from stimulants.
> >
> > So does anyone have an idea what adding a TCA would do? I that this is part of your combo Scott.
>
> Hi, I have been on Nardil for some time now and experienced the same lethargy and anhedonia. Whilst Nardil was saving me from being in a very, very bad place, the somnolence and apathy wasn't/isn't great.
> I tried a swathe of adjuncts, mostly AP's and Stims to no avail. Lastly I have tried Abilify and found that even 2mg is too much. 1mg / day abilify and 60mg/day Nardil seems (touch wood, no predictions made) to be working pretty well for me. The abilify certainly helps with the lack of energy and motivation. It screws my sleep up even more than before but it's worth it.
> HTHMy Pdoc wanted to add a stim to Nardil, but I've never responded or tolerated them very well so I convinced him to let me try desipramine.
I'm just worried that if I try desipramine and if it kinda works and then I were to switch to nortripytline, which blocks receptors that historically my brain likes blocked, the reuptake effects would be a lot less potent, after being exposed to the more NE potent desipramine.
Hmm. Makes sense right?
Posted by Conundrum on September 14, 2011, at 15:11:57
In reply to Re: Nardil anhedonia, need TCA? SLS?, posted by pedr on September 8, 2011, at 10:08:34
I saw my pdoc and we decided to add desipramine to Nardil. The lethargy from Nardil has gotten pretty bad. I thought it was bad before I started this, but I really don't want to do anything on this med. I hope adding desipramine helps. I wanted to avoid stims since I've never liked the way they make me feel. So now I'm on 60mgs Nardil and 25 mg Desipramine.
My mom recently went to 75mgs Nardil and is finding relief from her depression. I'm wondering if the lethargy decreases as the you raise the dose and the drug becomes more effective? I think it was making her tired for awhile. My pdoc didn't want to up the dose though because I am dizzy on 60mg.
Posted by SLS on September 14, 2011, at 15:25:39
In reply to Re: Nardil + Desipramine, posted by Conundrum on September 14, 2011, at 15:11:57
> I saw my pdoc and we decided to add desipramine to Nardil
Take care not to titrate desipramine too rapidly. Doing so might trigger side effects that wouldn't otherwise have evolved. I found this to be true for urinary retention / delayed micturition. Hypotension can get worse, too via the NE alpha-1 receptor antagonism exerted by desipramine.
I once had luck adding desipramine to Parnate. Within three months, I achieved remission and lived a normal life for another six months. My doctor at the time withdrew both medications when mania became evident. Once I relapsed into depression, he stubbornly avoided using the same treatment that got me well the first time. I no longer respond to this drug combination.
Good luck.
- Scott
Posted by Conundrum on September 14, 2011, at 20:26:32
In reply to Re: Nardil + Desipramine » Conundrum, posted by SLS on September 14, 2011, at 15:25:39
> > I saw my pdoc and we decided to add desipramine to Nardil
>
> Take care not to titrate desipramine too rapidly. Doing so might trigger side effects that wouldn't otherwise have evolved. I found this to be true for urinary retention / delayed micturition. Hypotension can get worse, too via the NE alpha-1 receptor antagonism exerted by desipramine.
>
> I once had luck adding desipramine to Parnate. Within three months, I achieved remission and lived a normal life for another six months. My doctor at the time withdrew both medications when mania became evident. Once I relapsed into depression, he stubbornly avoided using the same treatment that got me well the first time. I no longer respond to this drug combination.
>
> Good luck.
>
>
> - ScottThanks Scott,
My doc started me off at 25mg which I thought was a little high. I thought it was normal to start off with 10mg. I think I'm already experiencing constipation, but it is too soon to say. I hope I have a response to it. I've tried so many meds I'm starting to lose hope that anything will help.
Posted by Phillipa on September 14, 2011, at 20:54:11
In reply to Re: Nardil + Desipramine » Conundrum, posted by SLS on September 14, 2011, at 15:25:39
Scott that out and out stinks!!!! Could a lower dose have avoided the mania but allowed you to live normal? Phillipa
Posted by SLS on September 14, 2011, at 22:09:37
In reply to Re: Nardil + Desipramine » SLS, posted by Conundrum on September 14, 2011, at 20:26:32
> > > I saw my pdoc and we decided to add desipramine to Nardil
> >
> > Take care not to titrate desipramine too rapidly. Doing so might trigger side effects that wouldn't otherwise have evolved. I found this to be true for urinary retention / delayed micturition. Hypotension can get worse, too via the NE alpha-1 receptor antagonism exerted by desipramine.
> >
> > I once had luck adding desipramine to Parnate. Within three months, I achieved remission and lived a normal life for another six months. My doctor at the time withdrew both medications when mania became evident. Once I relapsed into depression, he stubbornly avoided using the same treatment that got me well the first time. I no longer respond to this drug combination.
> >
> > Good luck.
> >
> >
> > - Scott
>
> Thanks Scott,
>
> My doc started me off at 25mg which I thought was a little high. I thought it was normal to start off with 10mg. I think I'm already experiencing constipation, but it is too soon to say. I hope I have a response to it. I've tried so many meds I'm starting to lose hope that anything will help.I know the feeling.
Psychiatry is a field of medicine that is still primitive in concept and awkward in practice. There is just so much uncertainty as to what causes mental illness and why some drugs work to treat it. The uncertainty is what helps me remain hopeful. I have lived my life with depression, but I refuse to die with it. Why does one person respond to Pristiq and not Effexor? Were someone to entertain their vain attempts at figuring out how to cure themselves, they might forgo Pristiq because it is "nothing more" than the principle active metabolite of Effexor. This person is too smart to get well.
I guess what I am trying to say is that there is not a person alive who can guarantee for you that you would never get well. Where there is uncertainty, there is hope.
I wish I could find the words that would encourage you to look forward and keep your eye on the prize.
I am not immune from falling into deep, dark waters of dispair. I think I succumbed to the temptation to give up and euthanize myself a few times. I came closest to suicide ten years ago after failing to respond to reboxetine. I even moved money around so that my family would get all of what little I had and leave the state to pay for the funeral. When I told my parents that I was setting my affairs in order, they offered no resistance. I guess the Yankees were playing that day. Gosh.
I am often saved by logic. If I can conceive of an untried therapy with existing drugs or devices, I have every reason to believe that I might respond to it.
For reasons that I don't understand, I usually remain positive, constructive, and persistent despite having failed to respond to well over 50 drugs in perhaps 100 combinations. The number of permutations of drug combinations is virtually inexhaustable. The more drugs that come to market, the larger the number alternative permutations that will become available.
Do I actually believe all of this? Yes.
So, what about the times when I lost my belief in all of this? For me, my spirituality has been crucial. However, I don't want to open that Pandora's Box just yet.
- Scott
Posted by SLS on September 14, 2011, at 22:19:03
In reply to Re: Nardil + Desipramine » SLS, posted by Phillipa on September 14, 2011, at 20:54:11
> Scott that out and out stinks!!!! Could a lower dose have avoided the mania but allowed you to live normal? Phillipa
It really does stink.
:-(
Your idea regarding reducing the dosage is logical, but probably would not have worked for me. However, I believe that restarting the effective treatment with lithium and clonazepam added as prophylactics against mania would have. There is a bit more to this story, though. Perhaps I will recount it another time.
Take care, Phillipa.
- Scott
Posted by Phillipa on September 15, 2011, at 0:07:52
In reply to Re: Nardil + Desipramine » Phillipa, posted by SLS on September 14, 2011, at 22:19:03
Scott I wish you would. And post it here. Then a lot of input might help solve the mystery or what might work. See already you mention lithium and klonopin for that time. Maybe again just maybe? Phillipa
Posted by SLS on September 15, 2011, at 5:41:27
In reply to Re: Nardil + Desipramine » SLS, posted by Phillipa on September 15, 2011, at 0:07:52
> Scott I wish you would. And post it here. Then a lot of input might help solve the mystery or what might work. See already you mention lithium and klonopin for that time.
Yes. It is unfortunate that Depakote and Zyprexa weren't available then. Lithium is only mildly effective for me. However, Depakote squashes mania almost as quickly as Zyprexa. Of course, these two drugs have their own undesirable properties, but they both put the fire of mania out very quickly. In the days before these two drugs were available, one trick used for non-response or delayed response to lithium was the addition of a BZD.
As I had guessed, my prescription plan denied coverage of Viibryd. I have a starter pack, but I wanted to force the issue of coverage as soon as possible, as it might take a few weeks to resolve.
Prescription plan insurance companies are forever more usurping the role of doctors, and forcing them to revise or abandon treatment plans based on constantly changing formularies to suit their ledgers. This is a horrendous state of affairs.
- Scott
Posted by Conundrum on September 18, 2011, at 10:34:27
In reply to Re: Nardil + Desipramine » Conundrum, posted by SLS on September 14, 2011, at 22:09:37
> > > > I saw my pdoc and we decided to add desipramine to Nardil
> > >
> > > Take care not to titrate desipramine too rapidly. Doing so might trigger side effects that wouldn't otherwise have evolved. I found this to be true for urinary retention / delayed micturition. Hypotension can get worse, too via the NE alpha-1 receptor antagonism exerted by desipramine.
> > >
> > > I once had luck adding desipramine to Parnate. Within three months, I achieved remission and lived a normal life for another six months. My doctor at the time withdrew both medications when mania became evident. Once I relapsed into depression, he stubbornly avoided using the same treatment that got me well the first time. I no longer respond to this drug combination.
> > >
> > > Good luck.
> > >
> > >
> > > - Scott
> >
> > Thanks Scott,
> >
> > My doc started me off at 25mg which I thought was a little high. I thought it was normal to start off with 10mg. I think I'm already experiencing constipation, but it is too soon to say. I hope I have a response to it. I've tried so many meds I'm starting to lose hope that anything will help.
>
> I know the feeling.
>
> Psychiatry is a field of medicine that is still primitive in concept and awkward in practice. There is just so much uncertainty as to what causes mental illness and why some drugs work to treat it. The uncertainty is what helps me remain hopeful. I have lived my life with depression, but I refuse to die with it. Why does one person respond to Pristiq and not Effexor? Were someone to entertain their vain attempts at figuring out how to cure themselves, they might forgo Pristiq because it is "nothing more" than the principle active metabolite of Effexor. This person is too smart to get well.
>
> I guess what I am trying to say is that there is not a person alive who can guarantee for you that you would never get well. Where there is uncertainty, there is hope.Good point, although I tend to thing the more meds fail the more likely the next med won't work.
> I wish I could find the words that would encourage you to look forward and keep your eye on the prize.
>
> I am not immune from falling into deep, dark waters of dispair. I think I succumbed to the temptation to give up and euthanize myself a few times. I came closest to suicide ten years ago after failing to respond to reboxetine. I even moved money around so that my family would get all of what little I had and leave the state to pay for the funeral. When I told my parents that I was setting my affairs in order, they offered no resistance. I guess the Yankees were playing that day. Gosh.Wow thats terrible. That would be quite a loss just from what I can tell from "knowing" you on this forum. Hopefully you have some friends around you to go to instead of an unresponsive family.
> I am often saved by logic. If I can conceive of an untried therapy with existing drugs or devices, I have every reason to believe that I might respond to it.
>
> For reasons that I don't understand, I usually remain positive, constructive, and persistent despite having failed to respond to well over 50 drugs in perhaps 100 combinations. The number of permutations of drug combinations is virtually inexhaustable. The more drugs that come to market, the larger the number alternative permutations that will become available.
>
> Do I actually believe all of this? Yes.I am glad you have the ability to do this. I tend to think my problems all stemmed from taking and then stopping prozac, so I tend to view my problem as brain damage more than just normal depression and since I think it might be brain damage, there might be no drug cure available to fix the anhedonia, memory, and concentration problems I have. Perhaps some type of stem cell therapy in the future, but I'm skeptical of using drugs to fix something that *might* be caused by a drug. On the other hand I could be wrong and perhaps stopping prozac just sent me to where my depression could have progressed had I never taken anything. I wish I had never taken fluoxetine in the first place though.
My view is that maybe something will help but at some point I may have to just accept this is how my life will be and hopefully there will be some kinda afterlife where I can play music like I thought I was intended too, where my abilities will be restored and creativity will still flow.
> So, what about the times when I lost my belief in all of this? For me, my spirituality has been crucial. However, I don't want to open that Pandora's Box just yet.
>
>
> - Scott
>
Sorry for not seeing this post sooner, it was very thoughtful. Thank you.
Posted by SLS on September 21, 2011, at 9:45:16
In reply to Re: Nardil + Desipramine » SLS, posted by Conundrum on September 18, 2011, at 10:34:27
> ...I tend to thing the more meds fail the more likely the next med won't work.
I think there are statistics that support your hypothesis.
I believe strongly that exposure to multiple drugs can alter, and perhaps reduce, the responsivity of the brain to subsequent drug trials. Similarly, multiple exposures to the same drug can reduce responsivity to that drug in subsequent administrations.
What better choices do we have in 2011 but to try these drugs and risk creating a state of increased treatment resistance? The alternative is to live and die depressed, right?
- Scott
Posted by Conundrum on September 25, 2011, at 22:40:05
In reply to Re: Nardil + Desipramine » Conundrum, posted by SLS on September 21, 2011, at 9:45:16
> > ...I tend to thing the more meds fail the more likely the next med won't work.
>
> I think there are statistics that support your hypothesis.
>
> I believe strongly that exposure to multiple drugs can alter, and perhaps reduce, the responsivity of the brain to subsequent drug trials. Similarly, multiple exposures to the same drug can reduce responsivity to that drug in subsequent administrations.
>
> What better choices do we have in 2011 but to try these drugs and risk creating a state of increased treatment resistance? The alternative is to live and die depressed, right?
>
>
> - ScottUnfortunately things don't seem to be working out with desipramine. At first I felt a little something, but then that feeling fade. I continued to experience palpitations and worsening sleep. This may have led to an increase in worry. Also my blood pressure went up. So I cut back to 12.5 mg and informed my doctor and he said I made a wise choice. Not sure what to do now.
Nardil makes me incredibly tired and somewhat dizzy.
What do you guys experienced with nardil think? Would increasing it be a waste do to side effects?
Also my anhedonia has gotten worse on Nardil so perhaps there would be no benefit to increasing. This is what I tend to believe, but I have read that some fair better on higher doses.
Any ideas would be appriciated. I don't see my pdoc until the middle of October.
Posted by SLS on September 26, 2011, at 7:46:06
In reply to Re: Update Nardil + decreasing desipramine, posted by Conundrum on September 25, 2011, at 22:40:05
> Unfortunately things don't seem to be working out with desipramine.
Perhaps the addition of a TCA will be of no help. However, desipramine is a bit harsh with respect to cardiovascular side effects. I would say that, generally speaking, the side effects of nortriptyline are milder. It is my experience that the dosage of TCA required to elicit a response when combined with a MAOI is the same as when the TCA is used alone.
You could switch to nortriptyline first, then switch to Parnate if the results are inadequate. I am having some success with the addition of lithium 300mg. Lithium added to Parnate is a treatment that was used with some success in the "old days".
- Scott
Posted by Conundrum on September 26, 2011, at 10:12:01
In reply to Re: Update Nardil + decreasing desipramine » Conundrum, posted by SLS on September 26, 2011, at 7:46:06
> > Unfortunately things don't seem to be working out with desipramine.
>
> Perhaps the addition of a TCA will be of no help. However, desipramine is a bit harsh with respect to cardiovascular side effects. I would say that, generally speaking, the side effects of nortriptyline are milder. It is my experience that the dosage of TCA required to elicit a response when combined with a MAOI is the same as when the TCA is used alone.
>
> You could switch to nortriptyline first, then switch to Parnate if the results are inadequate. I am having some success with the addition of lithium 300mg. Lithium added to Parnate is a treatment that was used with some success in the "old days".
>
>
> - ScottYeh perhaps adding nortriptyline instead will allow me to increase the Nardil further without getting dizzy. I'm curious as to how a higher dose will effect my emotional valence even though the lower doses have seemed to flatten me out.
Posted by SLS on September 26, 2011, at 11:51:08
In reply to Re: Update Nardil + decreasing desipramine » SLS, posted by Conundrum on September 26, 2011, at 10:12:01
> > > Unfortunately things don't seem to be working out with desipramine.
> >
> > Perhaps the addition of a TCA will be of no help. However, desipramine is a bit harsh with respect to cardiovascular side effects. I would say that, generally speaking, the side effects of nortriptyline are milder. It is my experience that the dosage of TCA required to elicit a response when combined with a MAOI is the same as when the TCA is used alone.
> >
> > You could switch to nortriptyline first, then switch to Parnate if the results are inadequate. I am having some success with the addition of lithium 300mg. Lithium added to Parnate is a treatment that was used with some success in the "old days".
> >
> >
> > - Scott
>
> Yeh perhaps adding nortriptyline instead will allow me to increase the Nardil further without getting dizzy. I'm curious as to how a higher dose will effect my emotional valence even though the lower doses have seemed to flatten me out.
I don't know about a flattening effect, but I find that I feel weird just before I respond to Nardil. It is a sort of brain-fog that tends to numb your sense of things around you. It is like living in your own little cloud. For me, this is a good sign. It is during this time that the color of my urine changes from being clear to being yellow. This is a consistent observation of mine.
- Scott
Posted by Phillipa on September 26, 2011, at 19:10:20
In reply to Re: Update Nardil + decreasing desipramine » Conundrum, posted by SLS on September 26, 2011, at 11:51:08
That is strange? Phillipa
Posted by SLS on September 26, 2011, at 20:40:21
In reply to Re: Update Nardil + decreasing desipramine » SLS, posted by Phillipa on September 26, 2011, at 19:10:20
> That is strange? Phillipa
I always thought that it was a sign of increased nitrogen turnover; perhaps the result of increased secretion of GH as neuroendocrine function normalizes.
- Scott
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