![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 20 of 20. This is the beginning of the thread.
Posted by jono_in_adelaide on January 17, 2013, at 0:27:45
Dont worry, I'm not stalking you!
After reading what treatments have and havent worked for you in the past, it seems as though you have had some sucsess with Zoloft, so, before going down the path of ECT, could i suggest that you
- Go back on Zoloft, and push the dose above the "usual" 50mg to 100-200mg/day
- Augment the Zoloft with either Nortriptyline or Welbutrin, both of these hot noradrenalin, which is especialy indicated in endrogenous depression. Nortriptyline helps anxiety to some extent as well, because of its activity at the 5HT2A receptor. Welbutrin might be more "activating" and give you kick start if you need it.
I would definatly urge you to try either of these stratergies before having ECT (or try both, pick one and give it a decent trial, if that doesnt work, trial the other)
Posted by gilmourr on January 17, 2013, at 13:32:08
In reply to Gillmore (again), posted by jono_in_adelaide on January 17, 2013, at 0:27:45
> Dont worry, I'm not stalking you!
>
> After reading what treatments have and havent worked for you in the past, it seems as though you have had some sucsess with Zoloft, so, before going down the path of ECT, could i suggest that you
>
> - Go back on Zoloft, and push the dose above the "usual" 50mg to 100-200mg/day
>
> - Augment the Zoloft with either Nortriptyline or Welbutrin, both of these hot noradrenalin, which is especialy indicated in endrogenous depression. Nortriptyline helps anxiety to some extent as well, because of its activity at the 5HT2A receptor. Welbutrin might be more "activating" and give you kick start if you need it.
>
> I would definatly urge you to try either of these stratergies before having ECT (or try both, pick one and give it a decent trial, if that doesnt work, trial the other)I'm not sure about wellbutrin, I feel like it would just make me wired and anxious. So nortrypiltine would be my first bet.
Have you googled magnetic seizure therapy? Tell me what you think about it. I have an option for that or rTMS in a few weeks. If I do one, I believe I won't be able to do the other for a couple months or maybe a year, which is why I don't like the idea of doing rTMS (because it's less effective).
Posted by jono_in_adelaide on January 17, 2013, at 16:58:57
In reply to Re: Gillmore (again), posted by gilmourr on January 17, 2013, at 13:32:08
Well, my bet would be to start out with Zoloft 25mg at night and Nortriptyline 25mg at night for 4 nights, then go to 50mg of each at night, then eventualy get to 100mg of Zoloft and 75-100mg of nortriptyline (even upto 150mg - its best to get a blood test for nortriptyline blood levels to make sure you're in "the zone")
You should hit this dose after say 2 weeks, and give it a fair trial (say 6 weeks at full doseage) before deciding wether it has worked or not.
If it doesnt, you still have the option of magnetic seizure therapy, but if it does work, a daily pill is a lot easier than regular sessions of MST thriouhgout your life.
So - startof with 25mg of Zoloft and 25mg of nortriptyline at night
Slowly push to 100mg Zoloft and 75mg of nortriptyline at night, then get your blood levels of nortriptyline measured, and adjust dose based on this
Stay at thereputic dose for 6 weeks before making a decision
Hope this (or the MST)works for you bud.
Posted by jono_in_adelaide on January 17, 2013, at 17:06:49
In reply to Re: Gillmore (again), posted by jono_in_adelaide on January 17, 2013, at 16:58:57
And sorry, i realy know very little about MST so dont want to comment.
The only thing I will say is that if it works, its unlikely to work for ever, that you will likely need regular treatments over time, so if you 8can* find a simple daily pill that works, it will be a lot cheaper and more convenient in the long term
Posted by jono_in_adelaide on January 17, 2013, at 17:10:07
In reply to Re: Gillmore (again), posted by jono_in_adelaide on January 17, 2013, at 16:58:57
Scott,have you got any clinical pearls you can suggest to gillmore beyond my suggestion of zoloft plus an NARI based on his prior experiences detailed on the thread above, before he goes down the path of ECT?
You're the master of the art!
Posted by SLS on January 17, 2013, at 22:55:11
In reply to Re: Gillmore (again) SLS, posted by jono_in_adelaide on January 17, 2013, at 17:10:07
> Scott,have you got any clinical pearls you can suggest to gillmore beyond my suggestion of zoloft plus an NARI based on his prior experiences detailed on the thread above, before he goes down the path of ECT?
I will need to review the thread. Unfortunately, it is getting late.It is true that many people find Wellbutrin to be too activating and anxiogenic. However, there are some for whom it is exactly the right drug to regain energy and vigilance, but not always drive and motivation. Adding a serotonergic drug can act as an adjunct to Wellbutrin and help to brighten mood and recover interest and desire to initiate activities. Unfortunately some people will find one SSRI or another to produce apathy and amotivation as unwanted effects. I know of no way to predict which of these drugs will produce these effects for any one person. I think Zoloft has the reputation for having milder side effects. The combination of Wellbutrin and Zoloft is sometimes referred to as "Welloft". Effexor or Pristiq can be great adjuncts to use with Wellbutrin. A friend of mine felt moderately better using a combination of Wellbutrin and Lexapro. It wasn't until she switched from Lexapro to Pristiq that she finally attained remission.
I guess every doctor will have his favorite psychotropic drug treatments. Every patient will have his favorites, too. Psychiatry is an art trying very hard to be a science. It is not quite there yet. I haven't been following Gilmourr's story, so I really can't comment on his approach towards recovering mental wellness at this point. However, as Jono has suggested, I think it generally makes sense to try several polypharmacy drug combinations before undergoing ECT. A severe, suicidal, melancholic depression might qualify for the immediate application of ECT. Even here, there is not always agreement between doctors as to the protocol suggesting where to place the electrodes, the frequency and power of the current used, time of seizure, percentage of motor threshold, etc.
Since it is on my mind, I would offer that Paxil is a powerful SSRI that some people require to achieve a robust therapeutic response. It works. Unfortunately, it is prohibited from being used by women during pregnancy. It is teratogenic and can lead to fetal heart valve defects. Weight gain is often a problem, and if the drug must be discontinued, withdrawal effects can be difficult to manage.
- Scott
Posted by gilmourr on January 18, 2013, at 4:35:56
In reply to Re: Gillmore (again), posted by jono_in_adelaide on January 17, 2013, at 16:58:57
This sounds like essentially what I was thinking of as I've already worked up to 100 mg of Zoloft and I've been on it for 2 weeks now and 50 mg for a few days before that.
Like I said (or think I said) is that MST or rTMS (whichever I choose) is in <30 days, and I CAN'T adjust my meds because it's a trial.
I can do this after the procedure, but I wanted to try Nardil again after whichever procedure I get.
I just wanted to take a break from Nardil for 60 days because the 3rd time I used it it was less effective and had more side effects at my "good" dose.
Basically, the only thing I can do atm is choose between rTMS or MST. And I'm currently looking at MST more because of its remission rates. And this is not as bad side effect wise as ECT.
Apparently, nobody has reported any cognitive slowing, but I think only 100 people have used the treatment.
> Well, my bet would be to start out with Zoloft 25mg at night and Nortriptyline 25mg at night for 4 nights, then go to 50mg of each at night, then eventualy get to 100mg of Zoloft and 75-100mg of nortriptyline (even upto 150mg - its best to get a blood test for nortriptyline blood levels to make sure you're in "the zone")
>
> You should hit this dose after say 2 weeks, and give it a fair trial (say 6 weeks at full doseage) before deciding wether it has worked or not.
>
> If it doesnt, you still have the option of magnetic seizure therapy, but if it does work, a daily pill is a lot easier than regular sessions of MST thriouhgout your life.
>
> So - startof with 25mg of Zoloft and 25mg of nortriptyline at night
>
> Slowly push to 100mg Zoloft and 75mg of nortriptyline at night, then get your blood levels of nortriptyline measured, and adjust dose based on this
>
> Stay at thereputic dose for 6 weeks before making a decision
>
> Hope this (or the MST)works for you bud.
Posted by gilmourr on January 18, 2013, at 4:39:15
In reply to Re: Gillmore (again), posted by gilmourr on January 18, 2013, at 4:35:56
BTW, it's off topic but my hands are almost cold all the time and so are my feet and I'm colder in general.
I've never been like this but is it most likely my anxiety? Since coming off Nardil my anxiety is awful.
I'm guessing it's either that or lack of serotonin, but I've been on Zoloft for like 18 days so I don't think there's an issue there.
I'm just cold and clammy, and I didn't have that on Nardil. (though I did have 24/7 shivers, which I think was just caused by noradrenaline overload, however my hands were warm.)
Posted by SLS on January 18, 2013, at 6:30:45
In reply to Re: Gillmore (again), posted by gilmourr on January 18, 2013, at 4:35:56
I like Jono's plan.
Regarding Nardil, it is likely that you will experience some kind of brief response to it after having been off it for more than three months. The problem is, it will poop-out again rather quickly. I think you should look to augment it with something from the beginning or very soon after starting it. If you opt for going with a TCA, I recommend nortriptyline. It is the mildest with respect to anticholinergic/noradrenergic side effects. There is also lithium, Lamictal, Abilily, Latuda, and even Wellbutrin. Before abandoning the Zoloft, though, I would try adding nortriptyline or Wellbutrin or Abilify to it. In fact, you could begin treatment with Abilify and Lamictal before discontinuing the Zoloft.
One possible plan. There are things you can do first before going for ECT or TMS. If it is an emergency, ECT can be considered, but I might first try Zyprexa as an intervention.
Optimize your dosage of Zoloft to 100 - 200 mg/day
1. Add Wellbutrin.
2. Add Abilify.
3. Add Lamictal.
4. Discontinue Wellbutrin.
5. Add nortriptyline.
6. Discontinue Zoloft.
7. Add Nardil.
8. Add lithium.
9. Discontinue Abilify.
10. Add LatudaYou will modify this schedule depending on your reactions along the way.
Now is the wrong time to ask, of course, but what is your diagnosis?
What are your major symptoms?
Did you ever rapid cycle? (4 or more episodes per year)
Do you ever have racing thoughts?
Is there any history of mania or hypomania?
How old were you when you became ill?
What evidence is there in your family history of mental illness?
- Scott
Posted by gilmourr on January 18, 2013, at 15:24:54
In reply to Re: Gillmore (again) » gilmourr, posted by SLS on January 18, 2013, at 6:30:45
> I like Jono's plan.
>
> Regarding Nardil, it is likely that you will experience some kind of brief response to it after having been off it for more than three months. The problem is, it will poop-out again rather quickly. I think you should look to augment it with something from the beginning or very soon after starting it. If you opt for going with a TCA, I recommend nortriptyline. It is the mildest with respect to anticholinergic/noradrenergic side effects. There is also lithium, Lamictal, Abilily, Latuda, and even Wellbutrin. Before abandoning the Zoloft, though, I would try adding nortriptyline or Wellbutrin or Abilify to it. In fact, you could begin treatment with Abilify and Lamictal before discontinuing the Zoloft.
>
> One possible plan. There are things you can do first before going for ECT or TMS. If it is an emergency, ECT can be considered, but I might first try Zyprexa as an intervention.
>
> Optimize your dosage of Zoloft to 100 - 200 mg/day
>
> 1. Add Wellbutrin.
> 2. Add Abilify.
> 3. Add Lamictal.
> 4. Discontinue Wellbutrin.
> 5. Add nortriptyline.
> 6. Discontinue Zoloft.
> 7. Add Nardil.
> 8. Add lithium.
> 9. Discontinue Abilify.
> 10. Add Latuda
>
> You will modify this schedule depending on your reactions along the way.
>
> Now is the wrong time to ask, of course, but what is your diagnosis?
>
> What are your major symptoms?
>
> Did you ever rapid cycle? (4 or more episodes per year)
>
> Do you ever have racing thoughts?
>
> Is there any history of mania or hypomania?
>
> How old were you when you became ill?
>
> What evidence is there in your family history of mental illness?
>
>
> - ScottThanks for the medication advice, I'm definitely going to look at these combinations after I get MST. From everything I've looked at there should be no long term memory/cognitive effects. And I want to try it because of it being quite safe.
I have major depression, panic disorder + mild agoraphobia.
I became ill when I was 20.
Mom has panic disorder (remission)
Dad depression (untreated/alcohol)
Cousin (bipolar)
other cousins/aunts = depression/fibroI am 100% sure I'm not bipolar as I have no highs, racing thoughts, or cycles. Even being on meds I've never been like in remission from depression. For the most part I consider this a 2 year episode.
SLS have you looked at magnetic seizure therapy? I'm sure if you checked it out you'd probably agree that even for how invasive it is, the side effects are minimal it seems and the efficacy is strong.
Posted by SLS on January 19, 2013, at 5:26:17
In reply to Re: Gillmore (again), posted by gilmourr on January 18, 2013, at 15:24:54
Hi G.
I will definitely keep MST in mind. Thanks. I think it is a reasonable choice for depression. Is there any evidence that it is effective for anxiety disorders?
Imipramine is one of the best-studied drugs for panic disorder with agoraphobia. It works for a great many people.
Good luck with the MST.
- Scott
Posted by gilmourr on January 19, 2013, at 10:10:12
In reply to Re: Gillmore (again) » gilmourr, posted by SLS on January 19, 2013, at 5:26:17
> Hi G.
>
> I will definitely keep MST in mind. Thanks. I think it is a reasonable choice for depression. Is there any evidence that it is effective for anxiety disorders?
>
> Imipramine is one of the best-studied drugs for panic disorder with agoraphobia. It works for a great many people.
>
> Good luck with the MST.
>
>
> - ScottI believe so. They've been testing it a lot for OCD and it's kind of like a weaker version of ECT. So if ECT can help people with severe anxiety (which I've read reports that it can for some and has) then there is a chance this may work. But I'm more so convinced that if I can get this to solve the depression aspect then I can use Nardil.
Hopefully it works. I think I used expired Nardil last time so maybe that was why. It will basically be a 2 month break from Nardil, maybe 3 months.
I forget if I asked you SLS but what do you think about clonidine and Nardil? Basically instead of lithium to lower norepinephrine? I'm just trying to augment Nardil to get maybe a bit more serotonin, a bit less NE and the same D and GABA-T action.
Only things I can think of are lithium, clonidine, amitryptiline.
Posted by SLS on January 19, 2013, at 13:02:20
In reply to Re: Gillmore (again), posted by gilmourr on January 19, 2013, at 10:10:12
> I forget if I asked you SLS but what do you think about clonidine and Nardil?
I think using clonodine would be a bad idea for two reasons:
1. Combined with Nardil, you might experience severe hypotension.
2. Clonodine is known to cause depression, even in healthy individuals.> Basically instead of lithium to lower norepinephrine?
If you feel that you want to reduce NE activity, you could try prazosin. It has not produced dizziness for me in combination with Parnate except when I first started taking it. You could try propranalol or atenolol, but I am concerned with hypotension as a side effect.
> I'm just trying to augment Nardil to get maybe a bit more serotonin, a bit less NE and the same D and GABA-T action.
I know I have asked this of you before, but what is your rationale for concluding that you have too much NE?
- Scott
Posted by gilmourr on January 19, 2013, at 14:25:26
In reply to Re: Gillmore (again) » gilmourr, posted by SLS on January 19, 2013, at 13:02:20
> > I forget if I asked you SLS but what do you think about clonidine and Nardil?
>
> I think using clonodine would be a bad idea for two reasons:
>
> 1. Combined with Nardil, you might experience severe hypotension.
> 2. Clonodine is known to cause depression, even in healthy individuals.
>
> > Basically instead of lithium to lower norepinephrine?
>
> If you feel that you want to reduce NE activity, you could try prazosin. It has not produced dizziness for me in combination with Parnate except when I first started taking it. You could try propranalol or atenolol, but I am concerned with hypotension as a side effect.
>
> > I'm just trying to augment Nardil to get maybe a bit more serotonin, a bit less NE and the same D and GABA-T action.
>
> I know I have asked this of you before, but what is your rationale for concluding that you have too much NE?
>
>
> - ScottI believe I got too much NE because I had shivers, cold intolerance, urinary retention, constipation it even causes ejac issues. Which I believe are all adrenergic side effects.
shivers I think are related to hyperreflexia because I'd be sensitive to sounds and would jump a lot.
On Parnate which is even stronger on NE, I was like freezing cold, almost hypothermic.
So yeah, just based on that I think it's NE. As I don't get any of these side effects on SERT based meds.
And you might be wondering, well why do I want to go back on Nardil, well it's because my usual dose (the first two times I used it) I only had constipation at 45 mg which was getting better. At 60 mg I had all the previously listed side effects.
But the third time I used Nardil I had all the 60 mg side effects at 45 mg. Might be because I used some expired nardil, might be because my B6 levels were 4 times elevated, or maybe it was because I restarted it in 14 days. There was a sh*t tonne wrong and I need to test it agian.
Posted by SLS on January 19, 2013, at 19:09:01
In reply to Re: Gillmore (again), posted by gilmourr on January 19, 2013, at 14:25:26
> > > I forget if I asked you SLS but what do you think about clonidine and Nardil?
> >
> > I think using clonodine would be a bad idea for two reasons:
> >
> > 1. Combined with Nardil, you might experience severe hypotension.
> > 2. Clonodine is known to cause depression, even in healthy individuals.
> >
> > > Basically instead of lithium to lower norepinephrine?
> >
> > If you feel that you want to reduce NE activity, you could try prazosin. It has not produced dizziness for me in combination with Parnate except when I first started taking it. You could try propranalol or atenolol, but I am concerned with hypotension as a side effect.
> >
> > > I'm just trying to augment Nardil to get maybe a bit more serotonin, a bit less NE and the same D and GABA-T action.
> >
> > I know I have asked this of you before, but what is your rationale for concluding that you have too much NE?
> >
> >
> > - Scott
>
> I believe I got too much NE because I had shivers, cold intolerance, urinary retention, constipation it even causes ejac issues. Which I believe are all adrenergic side effects.
>
> shivers I think are related to hyperreflexia because I'd be sensitive to sounds and would jump a lot.
>
> On Parnate which is even stronger on NE, I was like freezing cold, almost hypothermic.
>
> So yeah, just based on that I think it's NE. As I don't get any of these side effects on SERT based meds.
>
> And you might be wondering, well why do I want to go back on Nardil, well it's because my usual dose (the first two times I used it) I only had constipation at 45 mg which was getting better. At 60 mg I had all the previously listed side effects.
>
> But the third time I used Nardil I had all the 60 mg side effects at 45 mg. Might be because I used some expired nardil, might be because my B6 levels were 4 times elevated, or maybe it was because I restarted it in 14 days. There was a sh*t tonne wrong and I need to test it agian.I know what it is like to feel like you've made a mistake and need to revisit a particular treatment.
Good luck.
- Scott
Posted by gilmourr on January 19, 2013, at 19:32:00
In reply to Re: Gillmore (again), posted by SLS on January 19, 2013, at 19:09:01
> > > > I forget if I asked you SLS but what do you think about clonidine and Nardil?
> > >
> > > I think using clonodine would be a bad idea for two reasons:
> > >
> > > 1. Combined with Nardil, you might experience severe hypotension.
> > > 2. Clonodine is known to cause depression, even in healthy individuals.
> > >
> > > > Basically instead of lithium to lower norepinephrine?
> > >
> > > If you feel that you want to reduce NE activity, you could try prazosin. It has not produced dizziness for me in combination with Parnate except when I first started taking it. You could try propranalol or atenolol, but I am concerned with hypotension as a side effect.
> > >
> > > > I'm just trying to augment Nardil to get maybe a bit more serotonin, a bit less NE and the same D and GABA-T action.
> > >
> > > I know I have asked this of you before, but what is your rationale for concluding that you have too much NE?
> > >
> > >
> > > - Scott
> >
> > I believe I got too much NE because I had shivers, cold intolerance, urinary retention, constipation it even causes ejac issues. Which I believe are all adrenergic side effects.
> >
> > shivers I think are related to hyperreflexia because I'd be sensitive to sounds and would jump a lot.
> >
> > On Parnate which is even stronger on NE, I was like freezing cold, almost hypothermic.
> >
> > So yeah, just based on that I think it's NE. As I don't get any of these side effects on SERT based meds.
> >
> > And you might be wondering, well why do I want to go back on Nardil, well it's because my usual dose (the first two times I used it) I only had constipation at 45 mg which was getting better. At 60 mg I had all the previously listed side effects.
> >
> > But the third time I used Nardil I had all the 60 mg side effects at 45 mg. Might be because I used some expired nardil, might be because my B6 levels were 4 times elevated, or maybe it was because I restarted it in 14 days. There was a sh*t tonne wrong and I need to test it agian.
>
> I know what it is like to feel like you've made a mistake and need to revisit a particular treatment.
>
> Good luck.
>
>
> - ScottYeah, it's questionable whether I'll be able to get Nardil to work for me again. I just need to try because last time was so... irregular.
It's just going to bother me unless I give it one last trial within normal parameters.
Posted by gilmourr on January 20, 2013, at 11:19:24
In reply to Re: Gillmore (again), posted by gilmourr on January 19, 2013, at 19:32:00
BTW, prazosin seems like a good drug but it's half life is 2-3 hours. Wouldn't I have to take it like every 12 hours then at least?
Is there another adrenergic blocker that might help?
Posted by SLS on January 20, 2013, at 13:27:03
In reply to Re: Gillmore (again), posted by gilmourr on January 20, 2013, at 11:19:24
> BTW, prazosin seems like a good drug but it's half life is 2-3 hours. Wouldn't I have to take it like every 12 hours then at least?
>
> Is there another adrenergic blocker that might help?I take prazosin 3 times a day. It's no big deal, really. You could probably get a way with twice a day.
I am wondering if the rather unique ability of prazosin to block NE alpha-1b receptors in the amygdala and subgenual cingulate contributes to its anti-PTSD and antidepressant effects.
- Scott
Posted by jono_in_adelaide on January 20, 2013, at 18:03:35
In reply to Re: Gillmore (again) » gilmourr, posted by SLS on January 20, 2013, at 13:27:03
Gillmore, can I beg you to give nortriptyline a try before you abandon Zoloft?
You could take Zoloft, nortriptyline and prazocin for the triple whammy, hitting three different systems fior a potent effect.
Posted by gilmourr on January 21, 2013, at 17:14:42
In reply to Re: Gillmore (again), posted by jono_in_adelaide on January 20, 2013, at 18:03:35
> Gillmore, can I beg you to give nortriptyline a try before you abandon Zoloft?
>
> You could take Zoloft, nortriptyline and prazocin for the triple whammy, hitting three different systems fior a potent effect.
I'll see if I'm allowed. Not sure whether I can with MST coming up soon, but I don't have the exact date yet so maybe I can still add nortryptiline.If I added it, how long do you think until it kicks in? I've been on Zoloft for 20 days and I feel apathetic and just meh. My sleep is much better and I don't hit severe lows where I stay up all night, but I'm still really depressed and don't enjoy anything.
This is the end of the thread.
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