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Dr. Bob is Robert Hsiung, MD,
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Posted by ed_uk2010 on January 24, 2015, at 16:19:59
In reply to feeling like im out of options, posted by hello123 on January 24, 2015, at 16:02:14
I assume you're treating chronic depression?
I'm not at all convinced that selegiline is especially useful, particularly at low doses. I do not believe it's at all comparable with the classical MAOIs such as Nardil and Parnate. Since you feel you're out of options, I guess you've already tried these meds? If you have not already tried both, you need to.
Posted by ed_uk2010 on January 24, 2015, at 16:29:15
In reply to feeling like im out of options, posted by hello123 on January 24, 2015, at 16:02:14
Low doses of selegiline are fairly MAO-B selective. This strategy has not shown good efficacy in depression at all. As for high doses of oral selegiline... well, I think it would be a much better idea to take an MAOI proven to be of use in severe depression.
Moclobemide, a selective MAO-A inhibitor has, unlike low dose selegiline, shown efficacy in trials. Unfortunately, experience in treatment-resistant patients is that it doesn't work well in practice.
In all honesty, only classical non-selective MAOIs appear useful in treatment resistant depression. Emsam is unimpressive in comparison, as far as I can tell, and is highly expensive.
Posted by hello123 on January 24, 2015, at 17:02:25
In reply to Re: feeling like im out of options, posted by ed_uk2010 on January 24, 2015, at 16:29:15
Am I wrong to make the assumption that id likely experience a very unpleasent emotional numbing effect from an MAOI that targets Serotonin, since thats all ive experienced from Reuptake Inhibitors that target Serotonin? Ive tried Lexapro, Zoloft, Prozac and Paxil. As well as SNRI's that id describe as making me feel numb and disconnected. but yes, Selegiline is the only MAOI ive tried.
Also, in the past ive responded very well to Adderall and somewhat well to Mirapex. Its like they put my good emotion at a 10, and do away with and Depression. but Chronic use at prescribed doses (never any abuse problems) of each only made my abillity to feel pleasure worse. and taking long breaks from them didnt help any. is like they chronically made my Dopamine System unresponsive. and this is what caused me to be stuck in bed staring out the window. Cyproheptadine was what helped me after this. ive read about Cypro's effects at Receptors, and came to the conclusion it likely helped by basically "disinhibitting" Dopamine, making it able to release in response to normally pleasurable experiences. Basically, ive figured i have a huge Dopamine problem.
Posted by hello123 on January 24, 2015, at 17:10:13
In reply to Re: feeling like im out of options, posted by hello123 on January 24, 2015, at 17:02:25
i think at least part of the reason ive had such a severe, longterm reaction to some meds stems from the Encephalitis Brain Infection I had when i was 13 in 2001, that resulted in a 5 day Coma. After the Coma i was so weak i was drooling on myself and couldnt lift a finger. but i gradually got my strength back and basically got back to my normal self. But i think the infection may have caused problems that predisposed me to reacting very badly to certain Psych Meds.
Posted by ed_uk2010 on January 24, 2015, at 17:40:01
In reply to Re: feeling like im out of options, posted by hello123 on January 24, 2015, at 17:02:25
> Am I wrong to make the assumption that id likely experience a very unpleasent emotional numbing effect from an MAOI that targets Serotonin, since thats all ive experienced from Reuptake Inhibitors that target Serotonin? Ive tried Lexapro, Zoloft, Prozac and Paxil. As well as SNRI's that id describe as making me feel numb and disconnected.
Yes, you are incorrect to assume that MAOIs 'feel' like SSRIs. Bear in mind, MAOIs do not affect serotonin in the same way as SSRIs. MAOIs make more serotonin available for release whereas SSRIs sort of trap serotonin in the synapse after it has been released. The effect on neurotransmission is not the same. Classical MAOIs also affect dopamine and NE directly. Dopamine is metabolised both by MAO-A and -B, not just B. Classical MAOIs therefore have a different effect on dopamine neurotransmission to low dose selegiline.
>Also, in the past ive responded very well to Adderall and somewhat well to Mirapex. Its like they put my good emotion at a 10, and do away with and Depression. but Chronic use at prescribed doses (never any abuse problems) of each only made my ability to feel pleasure worse.
I've never heard of anyone obtaining prolonged/sustained relief of depression from dopamine agonists like Mirapex. The benefit is seemingly transient.
Amphetamines like Adderall can provide a temporary boost but do not generally improve depression in the long run... and can readily make it worse.
I'd suggest Parnate for you since Nardil is more likely to be sedating. People respond differently though so you need to be open to trying both without too many preconceived ideas about what will work and why. Both drugs are proven treatments against severe depression.... naltrexone, oral low dose selegiline etc are not.
>Cyproheptadine was what helped me after this. ive read about Cypro's effects at Receptors, and came to the conclusion it likely helped by basically "disinhibitting" Dopamine, making it able to release in response to normally pleasurable experiences.
Possibly, but even the top neuroscientists don't understand all the details. You might perhaps find cyproheptadine of some use if you experience insomnia on an MAOI.
>Basically, ive figured i have a huge Dopamine problem.
The major neurotransmitters are all interconnected. You will not have a problem affecting dopamine in isolation. It's always worth bearing in mind that we do not really understand the cause/s of depressive illness at all.... we do have an idea what treatments may help though. Theories about what might be wrong with our brain function on a biochemical level are often highly simplistic ideas about a phenomenon more complex that we will ever understand.
I think you should speak to your doctor about stopping both selegiline and naltrexone, then starting Parnate after a short wash out. You will of course have to be careful about dietary and drug interactions. A lot of self-education is required.
Posted by ed_uk2010 on January 24, 2015, at 17:41:11
In reply to Re: feeling like im out of options, posted by hello123 on January 24, 2015, at 17:10:13
> i think at least part of the reason ive had such a severe, longterm reaction to some meds stems from the Encephalitis Brain Infection I had when i was 13 in 2001, that resulted in a 5 day Coma.
Perhaps this illness has been a contributing factor to your depression just as much or more than it has affected your response to certain meds?
Posted by hello123 on January 24, 2015, at 18:06:36
In reply to Re: feeling like im out of options, posted by ed_uk2010 on January 24, 2015, at 17:41:11
thats the first conclusion many make. but i see myself as a very functional person with Mild Depression (compared to now) before i ever took any kind of Psychiatric Med. i could go into detail abou my whole experience with meds, but it would be a lomg story.
My family sees how much i changed for the worst from then to how i became about 2 months after starting them. it was a big change. i think undetectable effects caused by the Encephalitis on my brain, changed my brain to where it reacts so severely. the the Encephalitis i had may have played a part in the mild Depression i had before taking meds, though
Posted by hello123 on January 24, 2015, at 18:14:26
In reply to Re: feeling like im out of options » hello123, posted by ed_uk2010 on January 24, 2015, at 17:40:01
and yeah. i understand the brain is like an ecosystem. effects on one part of it is very likely effects on other systems of it. thats how blocking off certain Serotonin Receptors can cause an increase in Dopamine, as i was referring to when i came to the conclusion on how Cyproheptadine benefitted me. this is just very isolated understanding on how i understand the effects of antagonisn of these receptors, of course.
Posted by ed_uk2010 on January 24, 2015, at 18:23:11
In reply to Re: feeling like im out of options, posted by hello123 on January 24, 2015, at 18:14:26
>this is just very isolated understanding on how i understand the effects of antagonisn of these receptors, of course.
That's what I mean. I'm not trying to criticise you in any way... but I was concerned that your ideas about brain chemistry might be preventing you from trying meds (like Parnate) which could potentially make a real difference.
..............
If you feel that taking, and then stopping amphetamine is responsible for many of your symptoms... the are two types of meds which could potentially help, although I imagine you've already tried both: noradrenergic TCAs like nortriptyline... and bupropion (Wellbutrin).
Posted by Tomatheus on January 24, 2015, at 18:50:06
In reply to feeling like im out of options, posted by hello123 on January 24, 2015, at 16:02:14
Hello123,
I can say that the feeling that I've exhausted my options -- or at least every option that I'd consider to be worth trying -- for the treatment of my chronic fatigue, or persistent clinical depression, is a familiar one. Having first sought help in the form of talk therapy and then having tried antidepressants and other psychiatric medications, I started to find that the treatments that brought me some relief only did so on a short-term basis. I think that I've mentioned to you previously that it was almost two years ago when I went to an orthomolecular treatment center, where they ordered several tests and found that, among other things, my vitamin D level was low. I've been taking vitamin D3 steadily for almost a year now, and I can say that over the last two months or so, I've noticed what seems to be some gradual improvement in my energy and concentration. I still have other symptoms to contend with, and I'm still not sure if what I'm noticing now will persist into the longer term, but for the first time in about 15 years, I'm starting to feel like I might be seeing the light at the end of the long tunnel of fatigue that I've been in for so long.
I'm not saying that seeing an orthomolecular doctor is necessarily the best choice for everyone, but I do think that seeing a doctor who might order some tests for abnormalities that are relevant to clinical depression would be a good idea. As I was just saying on another thread earlier today, tests that might be relevant to clinical depression include those that measure for thyroid disorders, anemia, and deficiencies of vitamin B12, folic acid, and vitamin D. If you haven't had these tests done, then talking to a doctor about possibly getting them done might point you toward a treatment option that you might not have previously thought to explore. I know that I was reluctant to take any form of vitamin D in the long run because one attempt at supplementation when I wasn't taking any medications for my psychotic/perceptual problems seemed to worsen my psychosis. But I still did try vitamin D3 again, albeit reluctantly, with Abilify after the test found my vitamin D level to be low, and as I've said, I do seem to be noticing good results from D3 supplementation. So, if I wouldn't have had my vitamin D level tested, I most likely wouldn't be taking vitamin D3 right now. The test made the difference.
At any rate, I just thought I'd put the idea of getting some tests done out there since the trial-and-error approach that mainstream psychiatrists take doesn't seem to have produced lasting results for you, at least up to this point. I wish you luck with everything and hope that you can reach a point where things will improve for you.
Tomatheus
Posted by ed_uk2010 on January 24, 2015, at 19:25:51
In reply to Re: feeling like im out of options, posted by hello123 on January 24, 2015, at 18:14:26
>Cyproheptadine...
I forgot to ask, how do you respond to mirtazapine (Remeron)? It shares the 5-HT2 receptor blocking effect of cyproheptadine, but has an action at alpha-2 receptors as well.
Posted by hello123 on January 24, 2015, at 20:13:53
In reply to Re: feeling like im out of options » hello123, posted by Tomatheus on January 24, 2015, at 18:50:06
getting some tests done to try to pinpoint a problem will likely be something i'll ask my pdoc about at my appointment on the 26th. ive been looking into supplements lately, mainly because ive been trying to do something about my cavities, but ive been hoping to find something good for my mood as well. so far, no luck. i dod have a blood test a couple of years ago when i told my medical doc about my mood problems, but she didnt find anything that was off with the test, other than high triglicerides. ive been hoping there is a better, more thorough test i can do. ive also had an MRO and PET scan done that didnt detect anything.
Posted by hello123 on January 24, 2015, at 20:22:11
In reply to Re: feeling like im out of options, posted by ed_uk2010 on January 24, 2015, at 19:25:51
Remeron did no good for me. back when i had first started taking Cyproheptadine, it actually made me more depressed while it was in my system during the first few weeks of taking it. but after some time, my mood was made much stronger and this effect went away, and i only felt benefits from it. but since ive regressed so much since then, im back to feeling like that when i take anything with an antihistamine effect, including Benadryl and Remeron. my mood just cant handle an antihistamine very well. but yah, no benefit from Remeron.
Posted by Tomatheus on January 24, 2015, at 20:32:35
In reply to Re: feeling like im out of options)) Tomatheus, posted by hello123 on January 24, 2015, at 20:13:53
I wish you luck with seeing if you can get some more thorough testing than what you've had in the past done. Looking into supplements might not be such a bad idea, although I'll say that in my case I couldn't seem to get lasting results from any supplements other than vitamin D3. Still, others respond more favorably to supplements than I do, and a few supplements have some evidence to back up their use in alleviating the symptoms of mood disorders. I also think that Parnate and Nardil, which Ed suggested, would be worth considering.
Good luck with your upcoming pdoc appointment, and of course, with any treatment changes that may be offered and prescribed.
Tomatheus
Posted by Phillipa on January 24, 2015, at 21:38:45
In reply to Re: feeling like im out of options » hello123, posted by Tomatheus on January 24, 2015, at 20:32:35
Hello123 I remember you as the encephalitis stuck in my memory. Only thing I forgot what it was from. Would you find refreshing my memory? Thanks Phillipa
Posted by ed_uk2010 on January 25, 2015, at 5:09:09
In reply to Re: feeling like im out of options)) Tomatheus, posted by hello123 on January 24, 2015, at 20:13:53
Hi again,
So, given your problems with SSRIs, how have you done on non-serotongergic ADs such as Wellbutrin, nortriptyline and desipramine?
Posted by Lou Pilder on January 25, 2015, at 8:59:42
In reply to Re: feeling like im out of options, posted by ed_uk2010 on January 24, 2015, at 16:19:59
> I assume you're treating chronic depression?
>
> I'm not at all convinced that selegiline is especially useful, particularly at low doses. I do not believe it's at all comparable with the classical MAOIs such as Nardil and Parnate. Since you feel you're out of options, I guess you've already tried these meds? If you have not already tried both, you need to.
ed,
You wrote,[...If you have not already tried both (Nardil and Parnate), *you need to*...]
Your statement here could be acted on by the poster as some type of advocating these drugs and die or get a life-ruining condition from the drug(s). If you could post answers to the following, then I could respond accordingly.
True or false:
A.I am an un licensed mental-health professional, Lou
B. The authority that I use to tell the poster that he/she needs to take those drugs comes from the Bible.
C. I will have nothing in my conscience, Lou, if the poster dies from taking those drugs.
D. Since I told that poster that he/she needs to take those drugs, then the doctor that has been treating him/her would be wrong to treat the poster differently by not prescribing to the poster those drugs.
E. I will assume all liability if the poster kills themselves after taking these drugs, Lou.
Lou
Posted by ed_uk2010 on January 25, 2015, at 10:00:16
In reply to Lou's response-prakmed » ed_uk2010, posted by Lou Pilder on January 25, 2015, at 8:59:42
Good day,
>A.I am an unlicensed mental-health professional
I am not familiar with the concept of an unlicensed mental-health professional.
>B. The authority that I use to tell the poster that he/she needs to take those drugs comes from the Bible.
Nothing I say is likely to come from the Bible.
>C. I will have nothing in my conscience, Lou, if the poster dies from taking those drugs.
That would be terrible, but is fortunately highly improbable if the poster was educated on how to avoid interacting foods and medications.
Everything in life is a risk Lou. I took a risk getting out of bed this morning. I could have fallen and broken a bone. Similarly, I could have taken the risk of staying in bed all day - I may have developed a DVT. MAOIs are also a risk, like all potent medications. The decision to take the medication depends on an assessment of whether one's depression or anxiety is sufficiently severe to make taking a risk worthwhile.Effective treatment of depression could be life-saving, Lou. Perhaps I would feel more pain in my conscience if the poster came to harm due to not getting effective treatment?
>D. Since I told that poster that he/she needs to take those drugs, then the doctor that has been treating him/her would be wrong to treat the poster differently by not prescribing to the poster those drugs.
This is an internet forum Lou. My suggestion of a particular medication is nothing more than a suggestion, even if it was phrased like an instruction, it isn't and cannot be... MAOIs are prescription-only drugs; the decision whether or not to prescribe one is the right and responsibility of the treating psychiatrist. Similarly, the decision whether or not to take a prescribed MAOI belongs to the patient. So no, I am not responsible, I can only advise based on what I believe may be helpful.
>E. I will assume all liability if the poster kills themselves after taking these drugs, Lou.
That's bizarre. People can kill themselves for all manner of reasons regardless of what meds they are on. I could never assume liability, nor would it be possible for me to do so.
Thank you for your unique input on this issue.
Posted by ed_uk2010 on January 25, 2015, at 10:05:42
In reply to Lou's response-prakmed » ed_uk2010, posted by Lou Pilder on January 25, 2015, at 8:59:42
Lou,
As the board's greatest proponent of clarification, I have made the decision to clarify my previous post (especially for you) by means of an re-phrase...
'Nardil and Parnate... If you have not already tried both, you need to.'
....has now been reworded as....
'If you've not already tried both, you need to consider doing so.'
Does that help? :)
Posted by europerep on January 25, 2015, at 10:17:07
In reply to feeling like im out of options, posted by hello123 on January 24, 2015, at 16:02:14
Hey there...
I can really only echo what Ed has already said. Irreversible MAOIs like tranylcypromine and phenelzine are definitely one of the things to look at for treating refractory depression.
And I can also confirm from experience that MAOIs are in no way to be considered stronger SNRIs or something like that. Trancylpromine and phenelzine affected me in a way entirely different from venlafaxine (up to a dose of 600mg/d), or any other antidepressant for that matter. Incidentally, this was not in a positive sense, as I experienced strong side effects and an actual worsening in depression, but at least that second part is actually really rare. The forum here is full of positive and even life-saving experiences with irreversible MAOIs.
By the way, tranylcypromine also has a weak but not negligible stimulant component. I definitely felt it when I took my first dose of the day, it kind of reminded me of methylphenidate. So if you have felt some benefit from stimulants, tranylcypromine might be preferable to phenelzine as a first choice.
But, in essence, I really agree that MAOIs are probably worth exploring in your case. Of course there are things you must learn about them and of which you are already aware, namely risks for drug-drug and food-drug interactions, but these should really not be blown out of proportion. I mean, those things that you have to avoid on MAOIs you *definitely* do have to avoid, without any ambiguity, but it's really not that difficult to build a diet around the restrictions that will be perfectly safe.
I hope this helps...
Posted by hello123 on January 25, 2015, at 16:02:05
In reply to Re: feeling like im out of options, posted by Phillipa on January 24, 2015, at 21:38:45
tbe Encephalitis was caused by a sick cat that scratched my thumb. the scratch wasnt really any worse than a paper cut, but it sure caused some problems. It started outwith a swollen Lymph-node under my arm. my mom took me to my doctor about this, and we were told it would go away in time. i cant remember how long he said, but i do remember hating that id have to go all that time with that weird looking lump. my mom asked if i needed an Antibiotic and he said "no". so we went back home and i think it was within about a week later (i dont remember this part) i developed a high fever and was talking "out of my head", so my parents rushed me to the closest hospital. and from there i was taken by ambulance to a better Childrens Hospital. and during this time i went into the Coma.
after some tests, they found that about 75% of my brain was infected and told my family they would know with in 5 days if id live or die. and after 5 days i woke from the coma. my body was completely exhausted of all its strength, but i slowly but surely got itvall back and was goid to leave after about 2 weeks after the Coma.
None of this was really at all a tragic exoerience for me like it was for my family. like i said, i dont even remember the really bad parts.
Posted by hello123 on January 25, 2015, at 16:24:31
In reply to Re: feeling like im out of options » hello123, posted by europerep on January 25, 2015, at 10:17:07
Ed,i actually felt the opposite effect of what most experience from Wellbutrin. bad effects on motivation and libido. but i havent tried the other two. ive been nervous about trying a med with the main action of increasing Norepinephrine. while i did well for a short while on Adderall even tho it increases NE, it seems every other med with a strong action on NE like Wellbutrin, Effexor and Fetzima. their negative effects were much different than the numb feeling SSRI's give me, so i figured it was from the Norepinephrine. they made me feel way worse by making me just disconnected feeling as well. My pdoc mentioned he was considering Strattera at my last appointment. Do you think the two you mentioned would likely be a better option than Strattera? ive gotten much more willing to try an NRI lately.
Posted by hello123 on January 25, 2015, at 16:28:21
In reply to Re: feeling like im out of options » hello123, posted by europerep on January 25, 2015, at 10:17:07
thats good to hear the effects from MAOI's feel much different than Reuptake Inhibitors for you. Thanks and it makes me feel more hopeful about trying them
Posted by Lou Pilder on January 25, 2015, at 16:48:13
In reply to Re: Lou's response-prakmed » Lou Pilder, posted by ed_uk2010 on January 25, 2015, at 10:05:42
> Lou,
>
> As the board's greatest proponent of clarification, I have made the decision to clarify my previous post (especially for you) by means of an re-phrase...
>
> 'Nardil and Parnate... If you have not already tried both, you need to.'
>
> ....has now been reworded as....
>
> 'If you've not already tried both, you need to consider doing so.'
>
> Does that help? :)
>
> ed,
You wrote,[...does that help?...]
> I am unsure as to who it helps. Who do of the following does it help?
A. The drug companies that make those drugs.
B. The psychiatrist/doctor that prescribes the drugs
C. The pharmacy that sells the drugs
D. The taker of the drug(s)
E. something else
Lou
Posted by ed_uk2010 on January 25, 2015, at 16:57:32
In reply to Re: feeling like im out of options ED_UK, posted by hello123 on January 25, 2015, at 16:24:31
> Ed,i actually felt the opposite effect of what most experience from Wellbutrin. bad effects on motivation and libido.
Wellbutrin's mechanism of action is not well understood.... it's not like nortriptyline or desipramine though, that much is clear.
>every other med with a strong action on NE like Wellbutrin, Effexor and Fetzima.Effexor is a weak norepinephrine reuptake inhibitor but a potent serotonin reuptake inhibitor. Wellbutrin isn't a potent NRI either, it's a weak NRI, a very weak DRI and has other poorly understood actions, for example at nicotinic receptors. Neither drug is particularly similar to tricyclic antidepressants.
It could be that you'd find the tricyclic NRIs such as nortriptyline intolerable, but you won't know unless you try... You might respond well.
>i figured it was from the Norepinephrine...
It certainly could have been, but it's not definitely the case. I think you need to be cautious if you try nortriptyline or desipramine. Start with a very low dose if you choose to try one. Strattera was not effective against depression in clinical trials, I wouldn't particularly recommend it for this purpose when NRIs proven to be effective against depression are available. Tricyclics are dangerous in overdose which is one reasons that some pdocs may not wish to prescribe.
Desipramine is a potent and relatively selective NRI. Nortriptyline has more additional effects - it might be better if you suffer from anxiety or trouble sleeping. Nortriptyline possibly has slightly more evidence to support its use in severe depression... on the other hand it may cause more dry mouth and initial drowsiness (which tends to wear off quite quickly).
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