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Dr. Bob is Robert Hsiung, MD,
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Posted by ChicagoKat on September 16, 2012, at 14:02:31
In reply to Re: Need out of the box suggestions, posted by gilmourr on September 15, 2012, at 18:52:06
> Sounds like you have a doc that will really go out on a limb for you with meds. In that case, if you can get this it should work well at hopefully.
>
> - MAOI (Nardil 45 mg) - base drug
> - Vyvanse - Long acting stimulant (or another)
> ** titrate up very slowly
> - Add a TCA, nortryptiline
>
> MAOI + TCA + Stim is VERY powerful.
>
> If you still have anxiety, you can use stelazine 1-2 mg/daily. And that's about it.
>
> If I could get a doctor to prescribe all this, I'd do it in a second.Thanks Gilmourr, I'll ask my doc about the combo and see what he says when I see him next Tues.
And you're right; he really is willing to go out on a limb for me...and he really knows his stuff PLUS he's a very kind person. I got really lucky when I found him. :)
Thanks again,
Kat
Posted by phidippus on September 16, 2012, at 14:12:09
In reply to Re: Need out of the box suggestions, posted by gilmourr on September 15, 2012, at 18:52:06
I wouldn't do nortryptaline. Too much norepenephrine when combined with the Vyvanse. Go for the best TCA, Clomipramine.
Eric
Posted by ChicagoKat on September 16, 2012, at 18:17:39
In reply to Re: Need out of the box suggestions » gilmourr, posted by phidippus on September 16, 2012, at 14:12:09
> I wouldn't do nortryptaline. Too much norepenephrine when combined with the Vyvanse. Go for the best TCA, Clomipramine.
>
> EricHi Eric,
I'm curious...what makes Clomipramine the best TCA?
Kat
Posted by Lou Pilder on September 16, 2012, at 20:33:10
In reply to Lou's response- » chicagokat, posted by Lou Pilder on September 10, 2012, at 11:10:42
> > Hi all,
> > I suffer from treatment-resistant depression and I see my pdoc tomorrow afternoon and I am searching for ideas to suggest to him. I have tried all the basic things, and they've all either stopped working for me or had intolerable side effects. This includes:
> > SSRIs
> > SNRIs
> > TCAz
> > Atypical antipsychotics
> > Mood stabilizers (lithium, lamictal)
> > MAOIs (ensam, Nardil Marplan) I should mention that Nardil worked GREAT for my depression and anxietty, but at doses above 45mg it gave me ataxia and I suffered falls...and NO, this was not due to orthostatic hypotension)
> > and atypical antidepressants like trazodone and remeron.
> > I've also tried ECT, which only made me feel worse.
> >
> > Right now I'm on Ritalin, and it, too, is giving out on me; I was gonna see how tomorrow goes then give the Ritalin a holiday to see if it will work for me again. I'm aalso on Lyrica for anxiety,, for which it works, but it seems to worsen my depression.
> > I was thinking of going back on Lexapro; I was on it last spring, but stopped b/c it wasn't helping my depression, but it occurred to me that it may well have been helping my anxiety, which has come back in force since I stopped the Lexapro.
> >
> > So does anyone have any other ideas? I've given my pdoc info on Tramadol, but he seems very hesitant to prescribe it.
> >
> > Thanks for any ideas,
> > Kat
>
> Kat,
> You wrote,[...I am searching for ideas to suggest to him (the psychiatrist)..intolerable side effects... does anyone have any other ideas?...Thanks for any ideas...].
Now looking at what you wrote here,I see that you are open to {other ideas}. And I have other ideas. These ideas have been revealed to me. The revelation shows me what the mind is, what one can do about that mind, and how one could have a new mind so that all things become new. That would mean that old things would pass away, even the old mind that could have been harmed by mind-altering drugs. And the revelation shows that healing can be given to the one with an injured mind. This healing comes from a Jewish perspective and there is a prohibition posted to me by Mr Hsiung that prevents me from posting what could give you a new mind and with the stripes of a Sun, you could be healed. This Sun brings a healing liht, the light of the world that is a light to your path. This light will dispel the darkness and reveal to you the origin of the light. Then you could be made free, free from depression, free from axiety, free from addiction, free from death. This light will illuminate your understanding.
Here is a video that I think could illuiminate your mind in some respects to help you make a more informed decision as to seek mind-altering drugs to stop any depression/anxiety that you may have. This video is by a doctor that explains aspects of psychotropic drugs and you could make up your own mind as to if you want to continue to go to your doctor for another drug and another and another. When one does that, chances are (redacted by respondent).
Lou
To see this video by Dr Moira Dolan:
A. Pull up Google
B. Type in:
[youtube, Psychiatry vs Physical Medicine part II]
time is 7 min posted on April 29 2007 you will see her picture.
Posted by schleprock on September 16, 2012, at 21:14:58
In reply to Lou's response-Dr Dolan-psindhaweal, posted by Lou Pilder on September 16, 2012, at 20:33:10
> > > Hi all,
> > > I suffer from treatment-resistant depression and I see my pdoc tomorrow afternoon and I am searching for ideas to suggest to him. I have tried all the basic things, and they've all either stopped working for me or had intolerable side effects. This includes:
> > > SSRIs
> > > SNRIs
> > > TCAz
> > > Atypical antipsychotics
> > > Mood stabilizers (lithium, lamictal)
> > > MAOIs (ensam, Nardil Marplan) I should mention that Nardil worked GREAT for my depression and anxietty, but at doses above 45mg it gave me ataxia and I suffered falls...and NO, this was not due to orthostatic hypotension)
> > > and atypical antidepressants like trazodone and remeron.
> > > I've also tried ECT, which only made me feel worse.
> > >
> > > Right now I'm on Ritalin, and it, too, is giving out on me; I was gonna see how tomorrow goes then give the Ritalin a holiday to see if it will work for me again. I'm aalso on Lyrica for anxiety,, for which it works, but it seems to worsen my depression.
> > > I was thinking of going back on Lexapro; I was on it last spring, but stopped b/c it wasn't helping my depression, but it occurred to me that it may well have been helping my anxiety, which has come back in force since I stopped the Lexapro.
> > >
> > > So does anyone have any other ideas? I've given my pdoc info on Tramadol, but he seems very hesitant to prescribe it.
> > >
> > > Thanks for any ideas,
> > > Kat
> >
> > Kat,
> > You wrote,[...I am searching for ideas to suggest to him (the psychiatrist)..intolerable side effects... does anyone have any other ideas?...Thanks for any ideas...].
> Now looking at what you wrote here,I see that you are open to {other ideas}. And I have other ideas. These ideas have been revealed to me. The revelation shows me what the mind is, what one can do about that mind, and how one could have a new mind so that all things become new. That would mean that old things would pass away, even the old mind that could have been harmed by mind-altering drugs. And the revelation shows that healing can be given to the one with an injured mind. This healing comes from a Jewish perspective and there is a prohibition posted to me by Mr Hsiung that prevents me from posting what could give you a new mind and with the stripes of a Sun, you could be healed. This Sun brings a healing liht, the light of the world that is a light to your path. This light will dispel the darkness and reveal to you the origin of the light. Then you could be made free, free from depression, free from axiety, free from addiction, free from death. This light will illuminate your understanding.
> Here is a video that I think could illuiminate your mind in some respects to help you make a more informed decision as to seek mind-altering drugs to stop any depression/anxiety that you may have. This video is by a doctor that explains aspects of psychotropic drugs and you could make up your own mind as to if you want to continue to go to your doctor for another drug and another and another. When one does that, chances are (redacted by respondent).
> Lou
> To see this video by Dr Moira Dolan:
> A. Pull up Google
> B. Type in:
> [youtube, Psychiatry vs Physical Medicine part II]
> time is 7 min posted on April 29 2007 you will see her picture.
>
>WARNING: VERY SCARY SOUND AT START OF LOU'S VIDEO; PROCEED WITH CAUTION!!!!
Posted by Phillipa on September 16, 2012, at 21:46:19
In reply to Re: Lou's response-Dr Dolan-psindhaweal, posted by schleprock on September 16, 2012, at 21:14:58
Got it don't watch any of them. Phillipa
Posted by phidippus on September 16, 2012, at 21:58:34
In reply to Re: Need out of the box suggestions » phidippus, posted by ChicagoKat on September 16, 2012, at 18:17:39
I would say its a word of mouth thing. It also kicks *ss in studies.
Eric
Posted by SLS on September 17, 2012, at 7:23:41
In reply to Re: Need out of the box suggestions » phidippus, posted by ChicagoKat on September 16, 2012, at 18:17:39
> > I wouldn't do nortryptaline. Too much norepenephrine when combined with the Vyvanse. Go for the best TCA, Clomipramine.
> I'm curious...what makes Clomipramine the best TCA?
Clomipramine seems to produce a greater number of therapeutic responses than any other TCA. However, this difference might not be so significant as to make this drug your first choice. Clomipramine has a greater load of side effects than the other TCAs, so it may not be as tolerable as nortriptyline or desipramine. Because of this, I would recommend that you look at nortriptyline first before moving on to clomipramine. With nortriptyline, you can use blood-levels to arrive at a dosage that is therapeutic. Slow metabolizers generally require 75 mg/day while rapid metabolizers need 150 mg/day. It is almost as if intermediate dosages are ineffective due to the therapeutic window nortriptyline is known to exhibit.
If there is an OCD or intrusive thoughts thing going on, then clomipramine makes sense to try first.
- Scott
Posted by gilmourr on September 17, 2012, at 15:42:02
In reply to Re: Need out of the box suggestions » gilmourr, posted by phidippus on September 16, 2012, at 14:12:09
> I wouldn't do nortryptaline. Too much norepenephrine when combined with the Vyvanse. Go for the best TCA, Clomipramine.
>
> Eric
I said Nardil, Nortryp and Vyvanse..If you're saying clomip with Nardil he will die.
Clomipramine is not stronger than this combo.
Nardil is incredibly strong but weaker in NE. Vyvanse will raise NE and D levels for him, and Nortryptiline can be taken at night to help him sleep with antihistamine in it. It's a good combo.
Posted by phidippus on September 17, 2012, at 15:45:23
In reply to Re: Need out of the box suggestions » ChicagoKat, posted by SLS on September 17, 2012, at 7:23:41
I experienced very few side effects while on the Clomipramine-those I did suffer went away within weeks.
Eric
Posted by phidippus on September 17, 2012, at 16:14:37
In reply to Re: Need out of the box suggestions, posted by gilmourr on September 17, 2012, at 15:42:02
If the dosage of clomipramine is modest, he should be fine.
I don't mind Nortryptaline, only the blood monitoring. Something as effective as Nortryptaline (Ki 3.4 NET) without the TCA side effects would be Straterra (Ki 5.0 NET) or Reboxetine(Ki 1.1 NET)-the lower the Ki the stronger the effect on norepenephrine. (Reboxetine is a potent, selective, and specific noradrenergic reuptake inhibitor. It has a superior pharmacological selectivity to existing tricyclic antidepressants and selective serotonin reuptake inhibitors when tested in a large number of in vitro and in vivo systems).
I have no arguments against the Vyvanse.
Eric
Posted by SLS on September 17, 2012, at 16:55:02
In reply to Re: Need out of the box suggestions » gilmourr, posted by phidippus on September 17, 2012, at 16:14:37
Did I not understand you?
Nardil and clomipramine together?
> If the dosage of clomipramine is modest, he should be fine.
No way, man.
No way.
- Scott
Posted by SLS on September 17, 2012, at 17:00:42
In reply to Re: Need out of the box suggestions » SLS, posted by phidippus on September 17, 2012, at 15:45:23
> I experienced very few side effects while on the Clomipramine-those I did suffer went away within weeks.
>
> EricI took clomipramine, too. My experience with it was quite different than yours. However, I did not remain on it beyond 8 weeks. It is a very dirty drug. This might make it more efficacious, but also makes it less tolerable. I hated it. It was worse than imipramine. Plus, you get sexual side effects with clomipramine that you don't get with any other TCA (although amoxapine can reduce libido).
- Scott
Posted by phidippus on September 17, 2012, at 17:53:19
In reply to Re: Need out of the box suggestions » phidippus, posted by SLS on September 17, 2012, at 17:00:42
I should have mentioned I did suffer anorgasmia, one of the most frustrating sexual side effects ever.
Eric
Posted by phidippus on September 17, 2012, at 17:56:05
In reply to Re: Need out of the box suggestions » phidippus, posted by SLS on September 17, 2012, at 16:55:02
Why?
Eric
Posted by SLS on September 17, 2012, at 23:21:38
In reply to Re: Need out of the box suggestions » SLS, posted by phidippus on September 17, 2012, at 17:56:05
> Why?
When one is taking a MAOI, just sniffing a SRI will produce serotonin toxicity (syndrome). This is the opinion of the overwhelming majority of people in the field. Clomipramine is as potent a serotonin reuptake inhibitor as the SSRIs are; having a Ki of less than 1.0 nM. There is no safe dosage.
My experiment with Parnate and Effexor has me convinced of the danger of combining these drugs. Adding a tiny piece of a 75mg IR tablet to Parnate was enough to pin me to my bed with muscle rigidity and being altered to the point of incoherence. This episode lasted for about an hour. I had chosen Effexor because of its short half-life. Unfortunately, my parents had to witness this. When I gained sufficient coherence, I asked them to take my body temperature. Fortunately, it was only about a degree higher than it usually is. I don't recall sweating.
I was desperate.
- Scott
Posted by phidippus on September 18, 2012, at 17:45:36
In reply to Re: Need out of the box suggestions » phidippus, posted by SLS on September 17, 2012, at 23:21:38
I need to learn more about MAOIs and what drugs can be taken with them.
Eric
Posted by ChicagoKat on September 19, 2012, at 12:32:15
In reply to Re: Need out of the box suggestions » SLS, posted by phidippus on September 18, 2012, at 17:45:36
> I need to learn more about MAOIs and what drugs can be taken with them.
>
> EricIf you find out which drugs can be safely taken with MAOIs, please let me know. Saw the pdoc yesterday, and since the Tramadol was a disaster, we are not going through a washout and then restarting Nardil. I told him that you guys had talked about takiing TCAs while on an MAOI, and he was aware that it was done but had never done so himself. He was curious if you were on the TCA first, or it you started it once you were stable on yourr MAOI.
Fortunately, my pdoc gave me lots of goodies, benzos, gabapentin, and ambien to help me through the washout. And he said I could keep taking Ritalin until a few days before I start Nardil since it has such a short half life. Wish me luck,and let me know if you have any answers to my questions.
Kat
P.S. the he is a she ;)
Posted by brynb on September 19, 2012, at 13:21:43
In reply to Re: Need out of the box suggestions, posted by ChicagoKat on September 19, 2012, at 12:32:15
Hi Kat,
Being that you do well with Ritalin, have you tried the MAOI selegline? Apparently, it's a stimulant derivative (as I learned here). It comes in a patch form, Emsam. I think a few people here have done well with it, and I believe it has less side effects than other MAOIs. It was too stimulating for me, and I don't know much about MAOI's, but, just a thought...
-b
Posted by ChicagoKat on September 19, 2012, at 15:48:56
In reply to Re: Need out of the box suggestions, posted by brynb on September 19, 2012, at 13:21:43
> Hi Kat,
>
> Being that you do well with Ritalin, have you tried the MAOI selegline? Apparently, it's a stimulant derivative (as I learned here). It comes in a patch form, Emsam. I think a few people here have done well with it, and I believe it has less side effects than other MAOIs. It was too stimulating for me, and I don't know much about MAOI's, but, just a thought...
>
> -b
>
>Hi Bryn...I really appreciate your suggestion, but I've tried Ensam and it made me really agitated...I just couldn't tolerate it. Too bad there aren't any MAO-A reversible inhibitors in the US, as there are in Europe. Seems like something like that would really help. Oh well, someday, maybe. For the meantime, I'll give Nardil another try, albeit at a lower dose (prob 45mg a day) so that it doesn't cause the ataxia I got the first time I tried it. At that dose my anxiety was completely blown away, and it may eventually help my depression somewhat.
Sorry to babble so much, I'm on my Ritalin :D
Hope you are well,
Kat
Posted by SLS on September 19, 2012, at 18:57:57
In reply to Re: Need out of the box suggestions » brynb, posted by ChicagoKat on September 19, 2012, at 15:48:56
> Too bad there aren't any MAO-A reversible inhibitors in the US, as there are in Europe.
Just a quick FYI:
The RIMAs don't seem to work nearly as well as the irreversibles. They tend to poop-out quickly. Moclobemide underwent clinical trials in the US for social anxiety 20 years ago, but was abandoned for lack of efficacy. Having a few irreversible inhibitors of MAO-A would be nice. Clorgyline worked very well, but was not developed because the patent had expired. Perhaps a new indication would bring it back. It seems to be therapeutically active in fungal infections and heart failure.
Brofaromine was available for a short period of time in a few countries in Europe. It probably worked better than moclobemide, but perhaps not good enough. Maybe there was a safety issue. Maybe a business decision. I don't know. If I remember correctly, brofaromine was a serotonin reuptake inhibitor in addition to being a RIMA. This is not a good combination.
- Scott
Posted by ChicagoKat on September 19, 2012, at 19:20:18
In reply to Re: Need out of the box suggestions » ChicagoKat, posted by SLS on September 19, 2012, at 18:57:57
> > Too bad there aren't any MAO-A reversible inhibitors in the US, as there are in Europe.
>
> Just a quick FYI:
>
> The RIMAs don't seem to work nearly as well as the irreversibles. They tend to poop-out quickly. Moclobemide underwent clinical trials in the US for social anxiety 20 years ago, but was abandoned for lack of efficacy. Having a few irreversible inhibitors of MAO-A would be nice. Clorgyline worked very well, but was not developed because the patent had expired. Perhaps a new indication would bring it back. It seems to be therapeutically active in fungal infections and heart failure.
>
> Brofaromine was available for a short period of time in a few countries in Europe. It probably worked better than moclobemide, but perhaps not good enough. Maybe there was a safety issue. Maybe a business decision. I don't know. If I remember correctly, brofaromine was a serotonin reuptake inhibitor in addition to being a RIMA. This is not a good combination.
>
>
> - ScottThanks for the info Scott!
Posted by phidippus on September 19, 2012, at 22:34:38
In reply to Re: Need out of the box suggestions, posted by ChicagoKat on September 19, 2012, at 12:32:15
SSRIs are contraindicated with concomitant use of MAOIs (monoamine oxidase inhibitors). This can lead to increased serotonin levels which could cause a serotonin syndrome.
Overall, it appears from the literature that the combination of MAOIs and TCAs can be relatively safe and effective in the treatment of patients whose depression is treatment-resistant. On the other hand, the risks associated with MAOI and TCA treatment have made this strategy relatively unpopular.
What you want to avoid is serotonin syndrome-combining serotogenic antidepressants with MAOI presents a risk.
For me the one time I was on an MAOI it was started at the same time I started a TCA-both were raised slowly.
I think you can take Ritalin and Nardil together.
Eric
Posted by SLS on September 20, 2012, at 0:43:07
In reply to Re: Need out of the box suggestions » SLS, posted by ChicagoKat on September 19, 2012, at 19:20:18
I would just add to Eric's list of drugs to avoid while taking a MAOI anything that is a serotonin reuptake inhibitor. This includes the SNRIs. It also includes the TCAs imipramine and clomipramine. The other TCAs are probably okay, although I have my doubts about protriptyline. It might be too noradrenergic and anticholinergic. I would worry about cardiovascular side effects. I know someone who did well on Nardil + doxepin. Trimipramine should not be a problem theoretically, but I don't know anyone who has taken this drug in combination with a MAOI. I would recommend desipramine and nortriptyline as first choices. They are secondary amines that are milder in anticholinergic effects and have little or no serotonin reuptake inhibition.
When taking TCA + MAOI, the two drugs can be started together. If one is already taking TCA, the MAOI can be added gradually. If one is already taking MAOI, adding a TCA is discouraged. I don't know why. I have done this on a few occasions and had no problem with it. I think the main concerns are cardiovascular and would include a hypertensive reaction or tachycardia. One's heart rate will almost always be increased by TCA. However, a resting rate above 120 beats per minute should raise concern. Perhaps one can use propranalol to control this, but I have never seen it done. TCAs are contraindicated if there is heart-block conductance pathology. If you are worried about this, you can get a ECG before treatment and then after you begin treatment. Desipramine is a bit harsher than nortriptyline. However, there are people who respond to one drug but not the other.
Other drugs to avoid because of serotonin reuptake inhibition during MAOI treatment are meperidine (Demerol) and dextromethorphan. Personally, I would stay away from ziprasidone (Geodon) and tramadol. Direct-acting noradrenergic agonists must be avoided, too. This would include decongestants (phenylpropanolamine and pseudoephedrine). So, too, are epinephrine and norepinephrine. I'm sure you can find a more comprehensive list on the Internet.
With MAOI, one can take Wellbutrin, amphetamine, and methylphenidate, even though these drugs are contraindicated. Since hypertensive reactions are possible, this should be done cautiously. I recommend taking your first dose of a stimulant in the doctor's office so that your blood pressure can be monitored. Dopamine agonists are also okay. I once took together Parnate, desipramine, Dexedrine, and bromocriptine. I have also added Wellbutrin to Parnate.
I think you should use my statements here as a guideline for you to do further research on your own rather than to assume their accuracy.
- Scott
Posted by phidippus on September 20, 2012, at 8:41:15
In reply to Re: Need out of the box suggestions » ChicagoKat, posted by SLS on September 20, 2012, at 0:43:07
Preliminary trials of low-dose amphetamine and MAOIs being administered together are in progress. However, this is to be done only under strict supervision of the prescribing parties.
Indirectly acting sympathomimetic amines, such as amphetamines, ephedrine and MAOI with amphetamine-like properties, can be potentiated, because they may release increased amounts of nor-adrenaline from sympathetic nerve endings after MAO inhibition.
Combining stimulants with monoamine oxidase inhibitors: a review of uses and one possible additional indication
by
Feinberg SS.
From the Department of Psychiatry,
Albert Einstein College of Medicine, Bronx, N.Y.
J Clin Psychiatry. 2004 Nov;65(11):1520-4ABSTRACT
BACKGROUND: Among antidepressant augmentation strategies, the addition of a stimulant to a monoamine oxidase inhibitor (MAOI) has received little attention in the literature in recent years because of the diminished clinical use of the latter and concerns of precipitating a hypertensive crisis or other serious complication. Despite that fact, experienced clinicians continue to use this combination for a variety of indications after other options have failed. This article reviews these reported uses and presents a case suggesting another possible indication. METHOD: A MEDLINE search was conducted for articles published from 1962 to December 2003 using relevant search terms (psychostimulant, stimulant, amphetamine, dextroamphetamine, pemoline or methylphenidate, atomoxetine, bupropion, monoamine oxidase inhibitor, and selegiline). A manual search was conducted of cross-references and other relevant recent psychiatric sources (2000-2003). RESULTS: The described uses of the MAOI-stimulant combination have included treatment of refractory depression and the MAOI-related side effects of orthostatic hypotension and daytime sedation. No documented reports were found in the recent literature of hypertensive crises or fatalities occurring when the stimulant was cautiously added to the MAOI. Also presented here is another possible indication for this therapeutic regimen: treatment of attention-deficit/hyperactivity disorder in an adult patient whose major depression had uniquely responded to the MAOI tranylcypromine. CONCLUSION: As in other fields of medicine, potentially hazardous medication combinations are utilized in psychiatry after cautiously weighing the danger of the treatment against the morbidity and risk of not adequately addressing the illness. Particularly, as the potential arrival of the apparently safer transdermal selegiline may increase the use of MAOIs, we feel this combination deserves additional controlled study.
Eric
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Dr. Bob is Robert Hsiung, MD,
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