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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 21 of 21. This is the beginning of the thread.
Posted by mellow on September 28, 2011, at 21:31:53
Hey guys...been gone a few weeks. Feeling absolutely horrible. I want to scream and cry but I can't. I'm a ball of emotion stuck in my skull. I just kind of shake and have a knot in my gut. I can't really describe my symptoms other than having a crummy outlook on life and being really sensitive to rejection. I swing back in forth all day between wanting to jump off a building and being able to cope with my anxiety and anhedonia. It's like I can't find any joy at all. I've gone to buddhist ceremonies and meditated. I read self help. I play with my dog etc. and I just can't get going for more than an hour or so. I never touch my guitars anymore. I haven't put on my running shoes in 8 weeks.
I feel stuck in therapy. I actually brought my therapist close to tears last week b/c she doesn't understand why I don't see how "wonderful a person I am"...But as we all know it doesn't make a difference to hear that stuff when you feel depersonalized and isolated from the rest of the world.
Anyhow pdoc started me on Effexor 37.5 today. Said it should take two week and I should be skeptical (assume I am manic) if it comes on too fast. Told me to be careful. I have read that it is not approved for bipolar associated depression for this reason but I am on stabilizers so I may be ok. He also mentioned that we may need to discontinue it because I might get my usual spring time hypomania in the new year and Effexor may really complicate that. This really concerns me because I have heard Effexor is nearly impossible to taper. He warned of brain zaps. He does not plan to go above 37.5 however. He says lower doses are more serotogenic rather than effecting the norepinephrine components of the brain.
All in all this puts me on four drugs and I am worried about this just making me more unstable, but it beats the alternative of going on like I have been. I have been getting progressively more depressed and anxious for 5 months. So if anyone has any kind words or experience with Effexor or other NRI's in a cocktail please please post.
Dx: Bipolar II Cyclothymic
Cocktail:
Effexor 37.5
Risperidone 1.5
Lamotrigine 150
Topiramate 50Fish oil 2000
Mega B stress
High Energy Multi
D3 10006-8 cups of coffee daily (And no I can't quit!)
Thanks, mellow
Posted by floatingbridge on September 28, 2011, at 22:03:16
In reply to Effexor...is there hope, posted by mellow on September 28, 2011, at 21:31:53
mellow, you have been down (quaint term) for awhile. I remember your posts. I think a number of bipolar posters have taken effexor or pristiq and have not had it propel them into mania. It sounds like you have a doctor who is keeping tabs on you.
It crossed my mind just now that this could help push through the therapeutic piece of things, too. I mean, I hope it will. Feeling that worthless feeling is one I'm familiar with, and so is being Teflon when it comes to taking in others appreciation
of my basic goodness (geez, a bit of nerves writing that last sentence out). Seems there is the depressive physiological piece and the psychological piece that might simply come about as a coping mechanism for feeling crummy.I'm rambling here. I think it's because I am sorry things have been on the decline for you because from your posts, I feel you are a very worthwhile person and have shown me such encouragement.
Well, I will let those who have been bipolar on effexor speak.
Your dose is very low. Did your doc have a plan to withdraw you in the spring if necessary? Like a short switch to Prozac?Very best with this. Maybe you would update us?
In answer to your question, absolutely. There is hope.
Posted by Phillipa on September 28, 2011, at 23:21:05
In reply to Re: Effexor...is there hope » mellow, posted by floatingbridge on September 28, 2011, at 22:03:16
Mellow you mention Spring are you in Australia as Spring has sprung in Aussie Land. Go slow be alert, Have someone watch for signs of hypomania. Two weeks and you will know so that is good. I also have missed your posts and sorry you have been so down. Definitely season light changes effect even unipolar. Sad creeps in. Phillipa
Posted by mellow on September 29, 2011, at 0:43:44
In reply to Re: Effexor...is there hope, posted by Phillipa on September 28, 2011, at 23:21:05
No Phillipa I'm in America the doc was just worried we will have to discontinue the Effexor come feb/april when I get my usual lift into hyper madness. But honestly I could use some of that ;) I miss the days of running around my house dancing to jazz with morning coffee and being happy.
floating thank you for the kind words. I'm glad you are doing well. I know it has been a rough few months. Just roll with it girl!
mellow
Posted by SLS on September 29, 2011, at 4:39:20
In reply to Effexor...is there hope, posted by mellow on September 28, 2011, at 21:31:53
> Anyhow pdoc started me on Effexor 37.5 today. Said it should take two week and I should be skeptical (assume I am manic) if it comes on too fast.
It is possible to to experience a subtle improvement during the first week, even in unipolar Major Depressive Disorder. You brain is not "clean". You have had psychotropic substances flowing through your veins for awhile now. It is difficult to be certain that these drugs have not produced changes that will allow the Effexor to work faster. On the other hand, two weeks will not be enough time to see a response if you have not reached a therapeutic dosage.
I would not be so afraid of hypomania. It is likely that it can be prevented with APs and/or AEDs. Lamotrigine is usally not a good anti-manic drug, but risperidone is. I like Topiramate 100mg for mixed-state bipolar II. You can always use Depakote as a mood-stabilizer.
How do you like risperidone? Any complaints?
> I have read that it is not approved for bipolar associated depression for this reason but I am on stabilizers so I may be ok.
I agree with you.
There are certain people for whom almost no drug will control mania. They are considered to be treatment resistent. Rarely, ECT can be used for such manic conditions. I think this sort of thing is more likely to occur with bipolar I than bipolar II.
> This really concerns me because I have heard Effexor is nearly impossible to taper. He warned of brain zaps. He does not plan to go above 37.5 however. He says lower doses are more serotogenic rather than effecting the norepinephrine
omponents of the brain.I disagree with your doctor. He might be thinking a little too much (theorizing) and treating too little (under-dosing). Go ahead and follow your doctor's recommendations. Perhaps you will get lucky. Perhaps your doctor has seen his treatment strategy work for his other patients. However, if you should get "stuck", I cannot see abandoning Effexor until you reach a dosage of 300mg.
> All in all this puts me on four drugs and I am worried about this just making me more unstable,
Don't count drugs. Count days in remission. Count side effects. What if a new set of drugs were designed so that each performed only one action? You might need four or more to complete a cocktail specific to your unique biology. There is no such thing as "too many" drugs to be defined using some unjustified philosophy. Do what works.
> Dx: Bipolar II Cyclothymic
Cyclothymic? How did that get in there? How would one separate out cyclothymia from bipolar disorder. Perhaps you are rapid-cycling or seasonal, but cyclothymic?
> Cocktail:
> Effexor 37.5 (probably too low)
> Risperidone 1.5 (possibly too low for the prevention of mania)
> Lamotrigine 150 (possibly too low - 200mg is the average)
> Topiramate 50 (probably too low to treat bipolar disorder - 100-200mg is average)
>
> Fish oil 2000 (nice in concept, but can precipitate mania or make depression worse)
> Mega B stress (good)
> High Energy Multi (probably good)
> D3 1000 (probably unnecessary)
>
> 6-8 cups of coffee daily (And no I can't quit!) (good)
>
> Thanks, mellowThese are my opions based upon medical literature, personal experience, communications with doctors, and the obervation of a great many patients in a partial hospitalization setting.
Good luck with whatever you choose to do. When you feel better - and you will - please post your experiences to arrive at an effective treatment.
- Scott
Posted by bleauberry on September 29, 2011, at 6:18:53
In reply to Effexor...is there hope, posted by mellow on September 28, 2011, at 21:31:53
I just wanted to comment that effexor really isn't a NRi or SNRI. It's impact on norepinephrine is very weak and it is actually mostly a SSRI. Ratio of serotonin to NE is 30:1, For comparison, savella is 3:2, cymbalta is 9:1. Not that those numbers make any difference really. Just worth noting.
That said, all the meds have unique features and effexor might do the trick. I like the idea of the low dose. At med rating forums I remember seeing several reports of people doing well at 37.5mg but not so well at higher doses.
I would also wonder, since things have been progressively getting worse for 5 months, why the other meds are not being questioned. Three meds and you are still in bad shape? That kind of hints to me that at least 1 or 2 of them are either useless or making things worse instead of better.
I prefer to make custom NRIs by combining ssri + tca, such as zoloft+nortriptyline.
Whenever I've been in your shoes....a few times too many....what was able to bring it under control rather quickly was either zoloft or savella, though savella initially made it worse for a couple days. The "sensitive to rejection" thing points to serotonin dysfunction. Having no interest in your guitars is more of a dodpamine/norepinephrine thing. So we're probably dealing with something that is impacting everything globally and not just one neuro or the other.
Of your meds the one I would be most suspicious of is risperidone. Especially if you started it anywhere within the last 6 months. The primary symptoms you've mentioned are common side effects with it. The "anxiety" like stuff and the emotional emptiness stuff. 1.5mg is a pretty hefty dose for many people. If it were me, my next move....in addition to adding an antidepressant....would be to wean down the dose of risperdone to see what happens. There are much better means of mood stabilization than risperdal. Personally anyone I know of who wants input on bipolar stuff, I usually mention magnesium before meds.
Posted by SLS on September 29, 2011, at 6:21:32
In reply to Re: Effexor...is there hope » mellow, posted by SLS on September 29, 2011, at 4:39:20
> You can always use Depakote as a mood-stabilizer.
Sorry...
I forgot to mention that if you choose to go with Depakote, you will need to reduce the dosage of Lamictal by 50%. 100mg might be a good dosage to arrive at.
- Scott
Posted by SLS on September 29, 2011, at 6:30:33
In reply to Re: Effexor...is there hope, posted by bleauberry on September 29, 2011, at 6:18:53
> I like the idea of the low dose. At med rating forums I remember seeing several reports of people doing well at 37.5mg but not so well at higher doses.
It would be interesting to know what percentage of people achieving remission when taking Effexor do so at 37.5mg versus 300mg. I would think that more people would respond to 300mg.
What do you think? Which dosage would get more people well?
What would you do if you didn't respond to 3.75mg of Effexor? Would you abandon it or would you raise the dosage?
- Scott
Posted by SLS on September 29, 2011, at 7:14:00
In reply to Re: Effexor...is there hope » bleauberry, posted by SLS on September 29, 2011, at 6:30:33
> What would you do if you didn't respond to 3.75mg of Effexor? Would you abandon it or would you raise the dosage?
I meant 37.5mg.
- Scott
Posted by b2chica on September 29, 2011, at 10:02:35
In reply to Re: Effexor...is there hope, posted by SLS on September 29, 2011, at 6:21:32
i agree with scott about not abandoning effexor at less than 300.
i made it up to 150 before i had to stop.
i started noticing cycling effects at 75 but at 150 was terrible.
so you may not notice any good or bad at dose you're on. i titrate slowly and keep a close eye on yourself.best wishes
b2c.
Posted by SLS on September 29, 2011, at 11:49:56
In reply to Re: Effexor...is there hope, posted by b2chica on September 29, 2011, at 10:02:35
Hi b2c.
> i made it up to 150 before i had to stop.
> i started noticing cycling effects at 75 but at 150 was terrible.Can you describe your cycling in more detail?
Is there a chance that you can employ mood stabiizing drugs while on Effexor?
What are you taking as a mood-stabilzer?
- Scott
Posted by kakalak on September 29, 2011, at 14:01:00
In reply to Effexor...is there hope, posted by mellow on September 28, 2011, at 21:31:53
Effexor is not impossible to taper. It's HORRIBLE, but not impossible. I recently tapered in one week (from 300mg) without the use of any other meds. This was super fast and not recommended, but I had to do it for numerous reasons. When the time comes to taper, do it slowly and introduce Prozac or other meds to assist with the withdrawals if you are able to. Also knowing that it will suck and the withdrawals do go away helps a bit.
I've heard alot of people say that they would have never taken Effexor if they knew about the withdrawals. My doc never told me about them and I found out like many others from accidentally missing just 1 dose. For 6 years Effexor helped me immensely. I'm glad I took it and would have taken it even if I knew about the withdrawals. It was the only drug that seemed to work for me at the time. Over the years I had to increase the dosage several times and introduce Depakote (for chronic headaches) and Buspar for increased anxiety OCD like behaviors, but still the pros of taking it outweighed the cons. Unfortunately the side effects slowly but surely increased and over time they either stopped working as well and/or my depression & anxiety changed. Who knows? I would still be taking Effexor with a slew of other meds if hadnt found my current pdoc. I could go into great detail about the pros and cons, but as with any medication, the (side) effects differ from person to person. I dont know anything about the other meds you are taking and how they may interact with Effexor, but I would not let the tapering from Effexor deter you from taking it.
I hope you start feeling better so
Posted by b2chica on September 29, 2011, at 14:28:12
In reply to Re: Effexor...is there hope » b2chica, posted by SLS on September 29, 2011, at 11:49:56
this was way back in the day about 7 years ago. let see.
i remember most of the time i was on effexor was like a haze. i was really out of it. derealization, and i remember the cycling was about three days crying could barely move and three days bright alert out drinking like a mad woman.i was just commenting to mellow about when i was on it i started to get effects about the 75/150 range
Posted by floatingbridge on September 29, 2011, at 16:48:56
In reply to Effexor...is there hope, posted by mellow on September 28, 2011, at 21:31:53
The addition of a fourth med seems to be helping me. I take emsam, risperidone, gabapentin, and a sleep aid. If the sleep aid category is looked at, it is tenazepam and Xanax XR. (The Xanax XR is being slowly tapered at my request.). Technically that make five meds. The Xanax XR is around because of physical dependence....
BTW, I didn't notice the cyclothymia dx reading your first post. That was my first dx. Now it was most recently called BPll. I don't know how these categories are divided.
Someone else posted about the effexor withdrawal. I went through it too, and fun it isn't, but I found it doable.
Hope today is going well-enough for you.
Posted by SLS on September 29, 2011, at 18:02:54
In reply to Re: Effexor...is there hope » mellow, posted by floatingbridge on September 29, 2011, at 16:48:56
> BTW, I didn't notice the cyclothymia dx reading your first post. That was my first dx. Now it was most recently called BPll. I don't know how these categories are divided.
http://www.mentalhealth.com/dis/p20-md03.html
- Scott
Posted by mellow on September 29, 2011, at 21:36:11
In reply to Re: Effexor...is there hope » mellow, posted by SLS on September 29, 2011, at 4:39:20
Thank you all for the comments and suggestions.
Scott,
Per your question of how I ended up Cyclothymic. I was dxed depression/anxiety at 18. Tried zoloft. Got at least hypomanic from what I recall. I was seeing a GP not a pdoc. I did paxil when I was 23 and ended up going completely psychotic. (thought people were after me!) got dxed schizophreniform after 11 days inpatient. A few months later after changing jobs about four times and slicing my wrist open my therapist simply called my pdoc and told him she thought I was bipolar. He started me on two anticonvulsants at her request because she said lithium was too old school and would make me a zombie.I complained about my care and she finally took out the DSM and read through all the bipolar categories and said I was closest to Cyclothymic. My doctor never gave me a firm dx he just doped me up. His practice was criminal.
I'm managed to quit drinking and doing drugs and I am gainfully employed but I haven't had emotional stability since I was a young kid...even then I was emotional. Getting a bit tired of this!
mellow
Posted by floatingbridge on September 29, 2011, at 21:44:34
In reply to Re: Effexor...is there hope, posted by SLS on September 29, 2011, at 18:02:54
Thanks Scott, I think I might finally get it. The major depression tipped it to BPll.
I wish I had taken my initial dx more seriously.
Posted by SLS on September 29, 2011, at 22:12:47
In reply to Re: Effexor...is there hope » SLS, posted by mellow on September 29, 2011, at 21:36:11
> Thank you all for the comments and suggestions.
>
> Scott,
> Per your question of how I ended up Cyclothymic. I was dxed depression/anxiety at 18. Tried zoloft. Got at least hypomanic from what I recall. I was seeing a GP not a pdoc. I did paxil when I was 23 and ended up going completely psychotic.The only times when I became manic were in association with antidepressant treatment. That I became psychotic led William Z. Potter MD at the NIMH to place my diagnosis closer to bipolar I than to bipolar II. Lithium is more effecive in bipolar I than in bipolar II.
> He started me on two anticonvulsants at her request because she said lithium was too old school and would make me a zombie.
That is far from being a certainty. It is inaccurate and counterproductive to view lithium this way. Some of the old ways are only now being appreciated as effective therapeutic tools that have a place in the modern psychiatic armamentarium. I am currently taking 300mg of lithium without the slightest hint of zombification. I have taken higher dosages in the past which resulted in some flat affect, but hardly a zombie state. I'm sure some people do react badly to lithium, but to deny yourself lithium treatment might prevent you from ever getting well. If it is not the right drug for you, it will become obvious very quickly. If so, then discontinue it and move on.
- Scott
Posted by zonked on October 1, 2011, at 1:00:16
In reply to Effexor...is there hope, posted by mellow on September 28, 2011, at 21:31:53
True story: I once met a dude, BP 1 w/ psychotic features, who was stabilized on Clozaril of all things (nothing else worked).
He needed 150mg effexor to fight off depression; but his psychiatrist refused to go above 75 for fear of mania. But his GP understood, so he got one script of 75 from his psychiatrist and another 75 from his GP.
Never saw him manic but didn't know him very long. Poor guy suffered a lot in his life before finally coming to his magic combo.
I used to think Effexor was a sort of joke-pill until I met him and one other lady in real life who responded beautifully to it.
-z
> Hey guys...been gone a few weeks. Feeling absolutely horrible. I want to scream and cry but I can't. I'm a ball of emotion stuck in my skull. I just kind of shake and have a knot in my gut. I can't really describe my symptoms other than having a crummy outlook on life and being really sensitive to rejection. I swing back in forth all day between wanting to jump off a building and being able to cope with my anxiety and anhedonia. It's like I can't find any joy at all. I've gone to buddhist ceremonies and meditated. I read self help. I play with my dog etc. and I just can't get going for more than an hour or so. I never touch my guitars anymore. I haven't put on my running shoes in 8 weeks.
>
> I feel stuck in therapy. I actually brought my therapist close to tears last week b/c she doesn't understand why I don't see how "wonderful a person I am"...But as we all know it doesn't make a difference to hear that stuff when you feel depersonalized and isolated from the rest of the world.
>
> Anyhow pdoc started me on Effexor 37.5 today. Said it should take two week and I should be skeptical (assume I am manic) if it comes on too fast. Told me to be careful. I have read that it is not approved for bipolar associated depression for this reason but I am on stabilizers so I may be ok. He also mentioned that we may need to discontinue it because I might get my usual spring time hypomania in the new year and Effexor may really complicate that. This really concerns me because I have heard Effexor is nearly impossible to taper. He warned of brain zaps. He does not plan to go above 37.5 however. He says lower doses are more serotogenic rather than effecting the norepinephrine components of the brain.
>
> All in all this puts me on four drugs and I am worried about this just making me more unstable, but it beats the alternative of going on like I have been. I have been getting progressively more depressed and anxious for 5 months. So if anyone has any kind words or experience with Effexor or other NRI's in a cocktail please please post.
>
> Dx: Bipolar II Cyclothymic
>
> Cocktail:
> Effexor 37.5
> Risperidone 1.5
> Lamotrigine 150
> Topiramate 50
>
> Fish oil 2000
> Mega B stress
> High Energy Multi
> D3 1000
>
> 6-8 cups of coffee daily (And no I can't quit!)
>
> Thanks, mellow
Posted by floatingbridge on October 1, 2011, at 1:07:20
In reply to Re: Effexor...is there hope » mellow, posted by zonked on October 1, 2011, at 1:00:16
Z, effexor worked for me really well years. Helped with ADD and all. It's the real deal, as you now know.
Posted by floatingbridge on October 14, 2011, at 1:14:12
In reply to Effexor...is there hope, posted by mellow on September 28, 2011, at 21:31:53
I was wondering how things are going for you with Effexor.fb
This is the end of the thread.
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