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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 15 of 15. This is the beginning of the thread.
Posted by jerseygal111 on July 23, 2012, at 16:50:12
Are TCAs less potent than SSRIs and SNRIs? I've been through all the SSRIs and am trying the last SNRI which is cymbalta. If cymbalta doesn't work, I'll have to move on to another class of antidepressants. My doctor said that TCAs are not as potent as SSRIs and SNRIs so he didn't think they were worth trying. He wants me to go to an MAOI. I'm reluctant to start an MAOI because of all the dietary restrictions. If there's a chance that a TCA could work, I'd rather try that first.
Posted by bleauberry on July 23, 2012, at 17:08:08
In reply to TCAs, posted by jerseygal111 on July 23, 2012, at 16:50:12
Statistically speaking, TCA's and SSRIs share approximately the same efficacy rate, though clinically the general impression is TCAs are better. Not sure where your doc got his opinion from but I don't think it is correct. He sounds like a real good doc though, considering maois.
Comparing TCAs and SSRIs is like comparing apples and oranges. They're different. TCA's used to be king of hill, but when ssri's came along they took over, a combination of a supposedly better side effect profile and marketing by the pharm companies for newer meds. The better side effect profile actually isn't accurate, because some people find the side effects of tca's better than ssri's. Each has different kinds of side effects, so again it is not easy to compare. For example we can reliably predict a likelihood of sexual side effects on ssris, and we can reliably predict a likelihood of dry mouth on tca's.
You would probably love reading the stuff by Dr Gillman at psychotropical.com. I agree with him on most issues. Long story short, the best success comes not from tca or ssri, but a combination of both. That is because that is the only way to get a true SNRI. You have not tried an SNRI. Effexor might be called one for marketing purposes, but its ratio of serotonin to norepinephrine is 30:1. Cymbalta is 9 to 1. They are both almost completely SSRI. Savella is 2 to 3, and Clomipramine is about 1 to 1.
I like the maoi idea. I can understand wanting to try something else first. In that case, prozac+nortriptyline, zoloft+nortriptyline, maybe desipramine instead of nortriptyline, savella.
If your doc could give you maybe 2 pills of ritalin, 2 pills of adderall, and 2 pills of vicodin, that would allow you the opportunity to zero in on what chemistry you need to work with, take some of the guess work out of it. For example, according to a study, response to ritalin predicts a more likely response to nortriptyline, where a response to adderall points to desipramine. Either way, they work fast so it doesn't require a long trial. Couple days will tell you a lot. I know it sounds weird, but in just one week these kinds of experiments can give you enough clues and hints to avoid months or years of guessing.
Maybe you don't respond to either, and that is helpful too. Vicodin is to see if there is an opioid connection. People feel one of 3 ways of vicadin....tired crappy....euphoric.....normal. Me, it can make me feel just plain normal, not high, not drugged, not anything, just plain normal. So I know my opioid system is involved in my symptoms. That is helpful when choosing future meds, herbs, or supplements.
> Are TCAs less potent than SSRIs and SNRIs? I've been through all the SSRIs and am trying the last SNRI which is cymbalta. If cymbalta doesn't work, I'll have to move on to another class of antidepressants. My doctor said that TCAs are not as potent as SSRIs and SNRIs so he didn't think they were worth trying. He wants me to go to an MAOI. I'm reluctant to start an MAOI because of all the dietary restrictions. If there's a chance that a TCA could work, I'd rather try that first.
Posted by linkadge on July 23, 2012, at 18:04:21
In reply to TCAs, posted by jerseygal111 on July 23, 2012, at 16:50:12
TCAs are more potent. There may be more side effects, but they are more potent.
Posted by Phillipa on July 23, 2012, at 18:22:51
In reply to Re: TCAs, posted by linkadge on July 23, 2012, at 18:04:21
Besides being more potent they seem to cause a great deal of weight gain in short periods of time. Based on when worked in psych and what I saw. Phillipa
Posted by papillon2 on July 23, 2012, at 18:27:39
In reply to Re: TCAs, posted by Phillipa on July 23, 2012, at 18:22:51
TCAs are more potent.
Posted by papillon2 on July 23, 2012, at 18:32:08
In reply to TCAs, posted by jerseygal111 on July 23, 2012, at 16:50:12
Your doctor being adamant that they are more potent than TCAs would make me want to run to the hills and get a second opinion.
The only advantage to SSRIs and SNRIs is that the side effects are generally more tolerable.
Posted by linkadge on July 23, 2012, at 19:24:09
In reply to Re: TCAs, posted by papillon2 on July 23, 2012, at 18:32:08
Am I right in saying that it is a younger doctor?
Linkadge
Posted by jerseygal111 on July 24, 2012, at 16:52:57
In reply to Re: TCAs, posted by linkadge on July 23, 2012, at 19:24:09
Thanks for everyone's feedback. Phillipa, did you notice that certain TCAs caused more weight gain than others? I'm already on remeron which caused me to gain about 20 pounds so I really don't want to gain more weight. And Linkadge, my doctor is actually 65 so he's not a young doctor. He's been pretty good about letting me choose the treatment options that he recommends to me. He didn't think it was worth trying cymbalta because I had been on pristiq and it didn't work. But I wanted to try cymbalta to exhaust all my options before moving to a different class of med. So he was willing to go along with it. I'm currently weaning off of zoloft which didn't work and then I'll start the cymbalta
Posted by Emily Elizabeth on July 24, 2012, at 20:46:55
In reply to Re: TCAs, posted by jerseygal111 on July 24, 2012, at 16:52:57
Have you tried an atypical antipsychotic in addition to an antidepressant? Like Abilify? I found it to be extremely helpful and had many fewer side effects than the TCA I tried (desipramine). I also just wanted to throw out there that I tend to be pretty tolerant of side-effects, but TCA side effects were awfully bad.
If you haven't tried Abilify yet, I might try that even before the cymblata.
Best,
EE
Posted by jono_in_adelaide on July 24, 2012, at 21:55:43
In reply to TCAs, posted by jerseygal111 on July 23, 2012, at 16:50:12
Amitriptyline is generaly considered more potent, but it also has more side effects.
I think that controlled studies of 150mg/day in severely depressed inpatients showed it to be superior.
A cocktail that is easier to take but very effective is Nortriptyline 75-100mg at night, and Zoloft 50-100mg in the morning, giving you the best of both worlds
Posted by SLS on July 25, 2012, at 4:55:14
In reply to Re: TCAs, posted by jono_in_adelaide on July 24, 2012, at 21:55:43
> Amitriptyline is generaly considered more potent, but it also has more side effects.
>
> I think that controlled studies of 150mg/day in severely depressed inpatients showed it to be superior.
>
> A cocktail that is easier to take but very effective is Nortriptyline 75-100mg at night, and Zoloft 50-100mg in the morning, giving you the best of both worldsFor me, Effexor 300 mg/day worked better in combination with nortriptyline than did Zoloft at 200 mg/day. Of course, Effexor would be harder to discontinue were that to become necessary.
To really explore the combination you suggest, I would first establish nortriptyline treatment by using blood tests as a guideline to determine dosage. Too much nortriptyline can be as ineffective as too little. It's window of efficacy lies between blood levels of 50 - 150 ng/ml. My blood level at a dosage of 150 mg is about 125 ng/ml if I remember correctly. I would add the Zoloft only if the nortriptyline fails to produce results after 3 - 4 weeks at the therapeutic dosage. If Zoloft is tolerated well, I can't think of any reason why administering it at a dosage of 200 mg/day would be disadvantageous should the lower dosages not produce results.
- Scott
Posted by jerseygal111 on July 25, 2012, at 20:42:35
In reply to TCAs, posted by jerseygal111 on July 23, 2012, at 16:50:12
Unfortunately, my doctor didn't suggest taking nortriptyline in combination with zoloft. I was taking 200 mg. of zoloft and it didn't do anything for me. That's why I'm moving onto cymbalta. I wonder if we would've added the nortriptyline to the zoloft if it would've made a difference in my response to the zoloft. I guess I'll never know because I'm already weaning off the zoloft before I begin cymbalta. My doctor doesn't seem to be a fan of combining too many medications. I'm currently taking klonopin, remeron, lamictal, and will be taking cymbalta. He seems to limit the number of medications that he puts people on to 4. I don't know if this is a good strategy or not but I'll see what happens with the cymbalta and go from there. In answer to adding abilify to my meds, I did try zyprexa which my doctor said is similar to using abilify. It didn't help.
Posted by Phillipa on July 25, 2012, at 23:43:34
In reply to Re: TCAs, posted by jerseygal111 on July 25, 2012, at 20:42:35
I used cymbalta at one time found it covered back pain. I didn't have to wean off a med to start another then. Seems like more docs are weaning before trying another now. All mine were direct switch overs. I find the last two pdocs I had were leaning in the direction of less and lower doses of meds.
Posted by papillon2 on July 26, 2012, at 0:46:28
In reply to Re: TCAs, posted by jerseygal111 on July 24, 2012, at 16:52:57
> Thanks for everyone's feedback. Phillipa, did you notice that certain TCAs caused more weight gain than others? I'm already on remeron which caused me to gain about 20 pounds so I really don't want to gain more weight.
I gained weight weight at the rate of 1kg (2.2lbs) / wk when on Remeron. I have not had any weight gain on Nortriptyline. I lost some of the excess weight just coming off Remeron, despite eating more and exercising less. That stuff does weird things to your metabolism. If you are wanting to avoid further weight gain stay the hell away from atypical anti-psychotics. Especially Zyprexa.
I am inclined to agree with your doctor, btw, that Cymbalta isn't likely to do much if Pristiq isn't. I'd go to a different class of anti-depressant, either a TCA or MAOI, if I were in your position. I'd try a TCA first.
Posted by phidippus on July 26, 2012, at 22:31:56
In reply to TCAs, posted by jerseygal111 on July 23, 2012, at 16:50:12
Clomipramine is a TCA that is far more effective than most SSRIs. TCAs are no less powerful than SSRIs or SNRIs.
Eric
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