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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 13 of 13. This is the beginning of the thread.
Posted by legm82 on June 8, 2015, at 16:09:48
Hello,
I have bipolar depression and insomnia, I've tried almost all the AAPs except Saphris and Latuda, they don't sell them in my country, so If I would like to try them I would have to buy them overseas.
I have tried the mood stabilizers Trileptal and Tegretol and had asthma problems, also tried Lamictal gives me pruritus and worsen the insomnia, also Valproate that makes me feel more depressed.
Not tried Lithium, my pdoc consider it to be too toxic.
My question is this:
My pdoc says that in the pharmacology area, we are run out of options, so he is telling me to consider intensive CBT to combat my depression.
Would you say that it is worth to make an effort economically and also commiting myself to the therapy, to get some results that might be very poor ?
Do you think that CBT could be worth the effort ?
Thanks in advance for your responses.
Posted by SLS on June 9, 2015, at 10:48:53
In reply to CBT vs Seroquel or Abilify or Latuda, posted by legm82 on June 8, 2015, at 16:09:48
> Hello,
>
> I have bipolar depression and insomnia, I've tried almost all the AAPs except Saphris and Latuda, they don't sell them in my country, so If I would like to try them I would have to buy them overseas.
>
> I have tried the mood stabilizers Trileptal and Tegretol and had asthma problems, also tried Lamictal gives me pruritus and worsen the insomnia, also Valproate that makes me feel more depressed.
>
> Not tried Lithium, my pdoc consider it to be too toxic.
>
> My question is this:
>
> My pdoc says that in the pharmacology area, we are run out of options, so he is telling me to consider intensive CBT to combat my depression.
>
> Would you say that it is worth to make an effort economically and also commiting myself to the therapy, to get some results that might be very poor ?
>
> Do you think that CBT could be worth the effort ?
>
> Thanks in advance for your responses.I like the idea of using psychotherapy, especially when used as an adjunct to medication. I have a hard time believing that you have run out of pharmacological alternatives. Of course, I don't know everything that you have tried so far.
How have you reacted to the following drugs AND at what dosages?
1. bupropion (Wellbutrin)
2. venlafaxine (Effexor)
3. nortriptyline (Pamelor)
4. mirtazapine (Remeron)
5. paroxetine (Paxil)
6. topiramate (Topamax)
7. amphetamine
8. methylphenidateSeroquel is a better choice than Abilify for insomnia. I'm sorry lamotrigine (Lamictal) produced intolerable pruritis. I wonder if the antihistaminic properties of Seroquel would resolve that. I really don't know. Psychiatric researchers swear that Seroquel has antidepressant properties when treating bipolar depression. I'm not so sure. I have read that combining Lamictal and Abilify has a robust antidepressant effect in bipolar disorder.
I find lithium at the low dosage of 300 mg/day helps me in the treatment of chronic bipolar depression. Lithium toxicity is dosage-dependent. Such a low dosage is rarely toxic.
Is rTMS (repetitive transcranial magnetic stimulation) available in your country? I am thinking of doing that myself. My medication with and without psychotherapy only helps me partially. You can stay on your medication during rTMS. Someone here on Psycho-Babble received more benefit from right side stimulation at 1Hz than the more common left side stimulation at 10 Hz.
- Scott
Posted by legm82 on June 9, 2015, at 11:39:17
In reply to Re: CBT vs Seroquel or Abilify or Latuda » legm82, posted by SLS on June 9, 2015, at 10:48:53
Hi Scott
You are currently using Lithium 300mg/day, is that enough to reach the 0.6 in blood required to be effective?
My pdoc has told me that Lithium is the only possible drug we haven't tried, but he warned me about its toxicity and also about renal damage and also thyroid damage. He also said that it's important not to get dehydrated because it elevates lithium's concentration in blood, that even a diarrhea could cause the lithium to become toxic.
What do you think about my pdoc says about lithium?
Posted by legm82 on June 9, 2015, at 14:12:02
In reply to Re: CBT vs Seroquel or Abilify or Latuda » legm82, posted by SLS on June 9, 2015, at 10:48:53
Scott
In your post you asked about nortriptyline (Pamelor). It's a TCA, what is it good for? Depression?. What about the risk of going hypomaniac with it? Does it help with insomnia?
Posted by SLS on June 9, 2015, at 15:21:50
In reply to Re: CBT vs Seroquel or Abilify or Latuda » SLS, posted by legm82 on June 9, 2015, at 14:12:02
> Scott
>
> In your post you asked about nortriptyline (Pamelor). It's a TCA, what is it good for? Depression?. What about the risk of going hypomaniac with it? Does it help with insomnia?Nortriptyline by itself has been known to be effective as an antidepressant. In addition to NE reuptake inhibition, it also blocks 5-HT2a receptors, which might help make it less "harsh" than desipramine. Just about every antidepressant can induce a switch into mania, but the TCAs are considered particularly liable in this regard. How often do you experience hypomania? Is it spontaneous, or does it happen only in response to medication? Is it a mixed state with persistent depressive symptoms or irritability, or is it more pleasantly energizing with expansive thinking or delusions of grandeur?
What has been your experience with MAOIs?
- Scott
Posted by legm82 on June 9, 2015, at 15:35:08
In reply to Re: CBT vs Seroquel or Abilify or Latuda » legm82, posted by SLS on June 9, 2015, at 15:21:50
> Nortriptyline by itself has been known to be effective as an antidepressant. In addition to NE reuptake inhibition, it also blocks 5-HT2a receptors, which might help make it less "harsh" than desipramine. Just about every antidepressant can induce a switch into mania, but the TCAs are considered particularly liable in this regard. How often do you experience hypomania? Is it spontaneous, or does it happen only in response to medication? Is it a mixed state with persistent depressive symptoms or irritability, or is it more pleasantly energizing with expansive thinking or delusions of grandeur?
>
> What has been your experience with MAOIs?
>
>
> - ScottThe hypomania I experience is with depressive symptoms and irritability, it's mostly induced by medication like antidepressants or stimulants.
Do you consider nortriptyline to be better than doxepin or surmontil?
Posted by SLS on June 9, 2015, at 22:38:10
In reply to Re: CBT vs Seroquel or Abilify or Latuda » SLS, posted by legm82 on June 9, 2015, at 15:35:08
> > Nortriptyline by itself has been known to be effective as an antidepressant. In addition to NE reuptake inhibition, it also blocks 5-HT2a receptors, which might help make it less "harsh" than desipramine. Just about every antidepressant can induce a switch into mania, but the TCAs are considered particularly liable in this regard. How often do you experience hypomania? Is it spontaneous, or does it happen only in response to medication? Is it a mixed state with persistent depressive symptoms or irritability, or is it more pleasantly energizing with expansive thinking or delusions of grandeur?
> >
> > What has been your experience with MAOIs?
> >
> >
> > - Scott
> The hypomania I experience is with depressive symptoms and irritability, it's mostly induced by medication like antidepressants or stimulants.
>
> Do you consider nortriptyline to be better than doxepin or surmontil?
If you are prone to manic switches, most doctors would not suggest taking a tricylic without a mood stabilizer or anti-manic agent. Perhaps Seroquel? Of the TCAs, Surmontil makes an interesting choice. It is not a reuptake inhibitor and helps normalize sleep architecture. I don't know the extent to which mania is a liability with Surmontil. Perhaps it is lower. Doxepin is also an interesting choice for you. It is a potent antihistamine and will help with sleep. I have seen someone who suffered from bipolar depression with infrequent hypomanias do well with Nardil + doxepin. She had had a wonderful response to lithium monotherapy for quite a few years, but a new doctor had her discontinue it. She relapsed within a month. Restarting lithium did not help. She hasn't felt well since.In my experience, Depakote and Zyprexa have made the best "emergency" antimanic agents for me. My manias are severe and are triggered by medication. They have been infrequent. I think it has happened four times, all in association with MAOIs with and without TCAs.
By the way, my lithium blood level is at or below 0.4. It won't have antimanic properties at such a low level, but it can still exert antidepressant effects. Also, 150 mg/day of lithium will help prevent Alzheimer's Dementia. For me, 300 mg/day serves both functions, and is unlikely to affect thyroid or renal function. You can always have blood tests to monitor these. If I go higher in dosage with lithium, I experience flat affect and a feeling of greater depression.
- Scott
Posted by legm82 on June 9, 2015, at 22:52:49
In reply to Re: CBT vs Seroquel or Abilify or Latuda » legm82, posted by SLS on June 9, 2015, at 22:38:10
> By the way, my lithium blood level is at or below 0.4. It won't have antimanic properties at such a low level, but it can still exert antidepressant effects. Also, 150 mg/day of lithium will help prevent Alzheimer's Dementia. For me, 300 mg/day serves both functions, and is unlikely to affect thyroid or renal function. You can always have blood tests to monitor these. If I go higher in dosage with lithium, I experience flat affect and a feeling of greater depression.
>
>
> - Scott
>Hi Scott
Do you have tremors with Lithium? What side effects do you have to face in order to continue your therapy with Lithium? It is a very stigmatized drug, and really scares me a lot.
Posted by SLS on June 9, 2015, at 23:31:04
In reply to Re: CBT vs Seroquel or Abilify or Latuda » SLS, posted by legm82 on June 9, 2015, at 22:52:49
> > By the way, my lithium blood level is at or below 0.4. It won't have antimanic properties at such a low level, but it can still exert antidepressant effects. Also, 150 mg/day of lithium will help prevent Alzheimer's Dementia. For me, 300 mg/day serves both functions, and is unlikely to affect thyroid or renal function. You can always have blood tests to monitor these. If I go higher in dosage with lithium, I experience flat affect and a feeling of greater depression.
> >
> >
> > - Scott
> >
>
> Hi Scott
>
> Do you have tremors with Lithium? What side effects do you have to face in order to continue your therapy with Lithium? It is a very stigmatized drug, and really scares me a lot.Your reluctance to take lithium is understandable. It is a drug with a narrow therapeutic index (the range of dosages that helps without hurting). Some researchers think lithium should be used first. I think it depends on the type of bipolar disorder being treated. At 300 mg/day, I experience absolutely no tremors. The dosage is too low. I start getting tremors at 900 mg/day. I have taken as much as 1500 mg/day during a period of mania. It seems to me that most people using lithium as a mood stabilizer (prevents both mania and depression) end up at 1200 mg/day.
Some work was done at Harvard about 15 years ago that found that lithium at low dosages helped when added to fluoxetine (Prozac). The average effective dosage was 450 mg/day (300 - 600 mg/day). Interestingly, they found that increasing the dosage of fluoxetine to 60 mg/day without taking any lithium helped even more.
- Scott
Posted by legm82 on June 10, 2015, at 11:08:03
In reply to Re: CBT vs Seroquel or Abilify or Latuda » legm82, posted by SLS on June 9, 2015, at 23:31:04
> Your reluctance to take lithium is understandable. It is a drug with a narrow therapeutic index (the range of dosages that helps without hurting). Some researchers think lithium should be used first. I think it depends on the type of bipolar disorder being treated. At 300 mg/day, I experience absolutely no tremors. The dosage is too low. I start getting tremors at 900 mg/day. I have taken as much as 1500 mg/day during a period of mania. It seems to me that most people using lithium as a mood stabilizer (prevents both mania and depression) end up at 1200 mg/day.
>Hi Scott
I have appointment with my pdoc tomorrow, I will tell him about Low Dose Lithium to improve my bipolar depression, do you take it at night?
What do you suggest me to talk with my pdoc regarding the Lithium?I have another concern, the Lithium will not help to combat my insomnia, it will remain uncovered.
Do you have any suggestions? Last night I took Seroquel 25mg and it helped me with sleep but caused me to have asthma.
Posted by SLS on June 10, 2015, at 15:52:30
In reply to Re: CBT vs Seroquel or Abilify or Latuda » SLS, posted by legm82 on June 10, 2015, at 11:08:03
> > Your reluctance to take lithium is understandable. It is a drug with a narrow therapeutic index (the range of dosages that helps without hurting). Some researchers think lithium should be used first. I think it depends on the type of bipolar disorder being treated. At 300 mg/day, I experience absolutely no tremors. The dosage is too low. I start getting tremors at 900 mg/day. I have taken as much as 1500 mg/day during a period of mania. It seems to me that most people using lithium as a mood stabilizer (prevents both mania and depression) end up at 1200 mg/day.
> I have appointment with my pdoc tomorrow, I will tell him about Low Dose Lithium to improve my bipolar depression, do you take it at night?
Because I take lithium carbonate, which is the inexpensive version of lithium, I take it twice a day. There are controlled-release versions like Lithobid that you only have to take once a day. I need to take other medication three times a day anyway, so I have no issue with divided dosing.
> What do you suggest me to talk with my pdoc regarding the Lithium?
I would ask him if he has had any patients do well when low-dose lithium was added to an antidepressant. You can also ask him how many of his patients had to discontinue lithium because of renal or thyroid toxicity.
> I have another concern, the Lithium will not help to combat my insomnia, it will remain uncovered.
> Do you have any suggestions? Last night I took Seroquel 25mg and it helped me with sleep but caused me to have asthma.Have you been diagnosed as having asthma in the past? What are your symptoms when you take Seroquel?
Do you have trouble falling asleep? Do you have trouble staying asleep? What time of day is your depression at its worst?
- Scott
Posted by legm82 on June 10, 2015, at 16:18:20
In reply to Re: CBT vs Seroquel or Abilify or Latuda » legm82, posted by SLS on June 10, 2015, at 15:52:30
> I would ask him if he has had any patients do well when low-dose lithium was added to an antidepressant. You can also ask him how many of his patients had to discontinue lithium because of renal or thyroid toxicity.
He might tell me that the patients he has on Lithium take the terapeutic dosage and he will respond me about the renal or thyroid toxicity based on those patients.
> Have you been diagnosed as having asthma in the past? What are your symptoms when you take Seroquel?
Yes, when I was child I was diagnosed with Asthma, then it go away when I was 15years or so, not completely, but I have to be careful anyways.
> Do you have trouble falling asleep? Do you have trouble staying asleep? What time of day is your depression at its worst?
I have trouble falling sleep more than staying asleep. My depression is worst at morning.
Do you have suggestions for my sleep issue?
Posted by SLS on June 10, 2015, at 21:02:11
In reply to Re: CBT vs Seroquel or Abilify or Latuda » SLS, posted by legm82 on June 10, 2015, at 16:18:20
> > Do you have trouble falling asleep? Do you have trouble staying asleep? What time of day is your depression at its worst?
> I have trouble falling sleep more than staying asleep. My depression is worst at morning.In the past, it was believed that early morning awakenings and feeling worse in the morning indicated the use of tricyclics. Again, tricylics are thought to be more liable to trigger manias than most other drugs.
> Do you have suggestions for my sleep issue?It might be worth exploring combining mirtazapine (Remeron) with venlafaxine (Effexor). Remeron is often given for sleep, and in combination Effexor, sometimes produces improvements in depression when other treatments have failed. Even though Remeron is very antihistaminic (like Seroquel), I couldn't find any reports of asthma on Medline. However, the manufacturer mentions it as an infrequent side effect.
- Scott
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