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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 8 of 8. This is the beginning of the thread.
Posted by antennastoheaven on May 29, 2013, at 23:22:20
Hello,
Short version: I've been taking Emsam (the selegiline patch) for two weeks, and since then I've felt fatigued most of the time. I've been sleeping a lot (as much as 14 hours a day) and have had trouble focusing. Sometimes I even feel more anhedonic than usual. I've missed a few days of work, have been leaving early, and have been unproductive on the days I am there. I was on Wellbutrin and occasional Adderall before this, and was functional although not feeling great. Diagnoses: depression, anxiety (not currently an issue), schizoid PD, and bipolar (only because mania was an SSRI side effect for me).
The drug is hurting my work performance and is making me feel worse, and I can only take another week or two of this before I'll need to officially take medical leave at work. I'm wondering if others think worth it to continue taking Emsam? Should I try to add something else? Switch to another MAOI, or maybe another kind of drug (TCA?)? Go back to Wellbutrin?
(read on for long version)
I have been depressed for a very long time, with my primary complaints being anhedonia and lack of motivation. I was prescribed Emsam after asking for it. I was previously on Wellbutrin for about a year, then stopped ten days before starting Emsam. I was also prescribed Adderall for ADD (inattentive), which I used occasionally (about 3 days a week on average). I've also had anxiety issues (stress or drug abuse induced) for which I occasionally take Xanax or etizolam. I'm diagnosed bipolar but this is based solely on SSRI-induced hypomanic episodes. My medical record also indicates a diagnosis of schizoid personality disorder although I have never been told about this diagnosis otherwise.
I wanted to try something new because the Wellbutrin+Adderall combination wasn't doing enough for me (at 300 mg Wellbutrin XL and 20 mg Adderall XR). Despite struggling to get out of bed, I was able to go to work most days and was generally productive, but it wasn't really addressing anhedonia very well. My depression grew worse as I became more bored and began to feel sad. Additionally, the constant elevated heart rate and slight increase in anxiety was annoying. Before giving up Wellbutrin, I'd had the following added on: Zoloft (made me feel OK but caused me to not care about work and made me spend a lot of money), Abilify (slight improvement in motivation at first, but not lasting and not worth side effects, and I like 5HT receptor agonists), lithium (made me worse due to physical side effects, so bad I missed some days of work), Lamictal (gave me even worse anhedonia and made me suicidal), and marijuana (worked for anhedonia and mood for months, but eventually started to cause anxiety).
So about a month ago I asked for Emsam, and after being referred to a psychiatrist who has patients using it, received a prescription for the 6mg/24h patch. I spent a few days taking 150 mg Wellbutrin XL, then ten days with no Wellbutrin, and then, two weeks ago I started taking Emsam. I didn't notice anything the first day, but the next day I had more trouble waking up than usual and have felt that way ever since. At worst I've laid in bed 2-3 hours before getting up. During the day I've been sleepy most of the time - on the weekends I've been taking naps, and during the week sometimes took a nap after getting home from work. My blood pressure has been slightly lower than it was while on Wellbutrin, but not particularly low - generally around 110/70 vs the 120/80 I'd typically see on Wellbutrin. The worst problem is that focusing on anything has been extremely difficult. I work in a mentally demanding job so this has made me very unproductive in the past two weeks.
I've tried changing the dosing around a bit - I applied the patch in the morning at first, then switched to at night. I even tried leaving two patches on at once to see if that would make a difference. No difference noted.
At times I actually do feel a little happier, but being so tired negates any antidepressant benefit. I was feeling better overall while on Wellbutrin, and even during the ten day period during which I wasn't using any drugs.
So now I'm trying to figure out what to do next. Am I just being impatient? Will the fatigue go away in another week? I can't go much longer like this, or else I won't be able to work anymore. It's not so much a problem of money, but not working means I sit at home all day and this just makes me more depressed.
Could a higher dose help? I've already been leaving two patches on at once... Is 6mg/24hr enough to inhibit MAO-A? Because more norepinephrine seems like it would help. And maybe increased l-(meth)amphetamine metabolite?
I know it's safe to take stimulants at careful doses despite the contraindication, but don't want to be dependent on them. I'd be willing to try Wellbutrin with Emsam, but it seems unlikely that this combination would be prescribed. Provigil/Nuvigil sounds more likely but I don't really like them.
I'm thinking about maybe asking for another MAOI - Parnate seems to be not as sedating. Of course there are more dietary restrictions. There are also many other potential medications I have yet to try, although I've mostly been prescribed the easy/common ones (SSRIs, stimulants, Wellbutrin, antipsychotics, mood stabilizers...). Tricyclics?
Posted by g_g_g_unit on May 30, 2013, at 2:05:08
In reply to Fatigued on Emsam (selegiline patch) - next steps?, posted by antennastoheaven on May 29, 2013, at 23:22:20
wish i could help you (we don't get EMSAM here), but just wanted to cool userhandle.. that album rocks
Posted by Phillipa on May 30, 2013, at 9:51:10
In reply to Fatigued on Emsam (selegiline patch) - next steps?, posted by antennastoheaven on May 29, 2013, at 23:22:20
Sounds like you did better with wellbutrin? Would you return to this if you decide to discontinue Emsam? Phillipa
Posted by antennastoheaven on May 30, 2013, at 12:31:34
In reply to Re: Fatigued on Emsam (selegiline patch) - next steps? » antennastoheaven, posted by Phillipa on May 30, 2013, at 9:51:10
> Sounds like you did better with wellbutrin? Would you return to this if you decide to discontinue Emsam? Phillipa
I will go back to Wellbutrin if no other medications are offered. Really hoping to try something else new, though.
Posted by antennastoheaven on May 31, 2013, at 11:22:25
In reply to Re: Fatigued on Emsam (selegiline patch) - next steps? » Phillipa, posted by antennastoheaven on May 30, 2013, at 12:31:34
So maybe things are turning around. It seems excess sleep has turned into insomnia - got only three hours of sleep or night despite spending seven hours in bed.
I think I'll keep trying for a little longer.
Posted by psychlover on May 31, 2013, at 13:30:22
In reply to Re: Fatigued on Emsam (selegiline patch) - next steps?, posted by antennastoheaven on May 31, 2013, at 11:22:25
Emsam worked well for me 5 years ago, at least for the first few months, then I felt like it stopped working. Not sure why.
I started it again last week and have had 5 major hypertensive incidents since then, so I am pretty scared about more of these or more serious ones.
psychlover
Posted by antennastoheaven on June 6, 2013, at 3:49:42
In reply to Fatigued on Emsam (selegiline patch) - next steps?, posted by antennastoheaven on May 29, 2013, at 23:22:20
Hello,
I think I want to give up on Emsam (still waiting on a call from my nurse practitioner for her advice, and want to be prepared for the conversation; she doesn't have any experience with the drug, but the psychiatrist with a MD that she works with does.)Things have gotten worse. Last week I developed insomnia for a few days and ended up getting a few hours of broken sleep each night, and was prescribed Ambien. That made me sleep, but I felt miserable during the day with headaches, low energy, nausea, etc. So far I've missed four days of work and am looking into going onto medical leave and possibly entering a partial hospitalization program (that is for anohter post)
When I was taking Wellbutrin, I was doing relatively well. I didn't feel good most of the time, but I was functional and able to go to work and be productive. I could just go back do that (presumably after waiting a few days after stopping Emsam, but I'm not particularly feeling risk-averse right now.) But there's no reason not to expect the same downsides as before - increased anxiety / heart rate, mainly. Still, being able to function at work would be a major improvement and alleviate my worries about my employment situation.
On the other hand I wanted to switch from Wellbutrin to something else for a reason in the first place. I want something that will make me feel better, not just functional. Could another MAOI be worth a try? Parnate?
My therapist has recommended partial hospitalization and I posted about it in this thread: http://www.dr-bob.org/babble/psycho/20130309/msgs/1044771.html
If I do end up doing partial hospitalization, I'll be seeing a different psychiatrist who may be seeing things differently.
Posted by creepy on April 1, 2020, at 18:44:46
In reply to Fatigued on Emsam (selegiline patch) - next steps?, posted by antennastoheaven on May 29, 2013, at 23:22:20
ask your doc if you can add desipramine. I have been on welbutrin more times than I can count and every time I had problems waking up. its the wellbutrin (or the lack of it, in the AM) that causes it.
My solution was to move to desipramine and take it before bedtime.
This is the end of the thread.
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