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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 19 of 19. This is the beginning of the thread.
Posted by Tabitha on August 22, 2016, at 12:29:42
So my dx is bipolar II. In the last few years I've done this:
- Lamictal 150
==> good for a few months, depression relapse
- Lamictal 150 + SNRI (cymbalta)
==> good for several months, then some depression relapse plus got tired of sexual side effects & sleep disruption
- Lamictal 150 + SNRI (fetzima)
==> good for a few months, depression relapse
- Lamictal 150 + SNRI (fetzima) + lithium 300
==> good, tapered off the fetzima since I had relapsed on it anyway, while increasing lamictal
- Lamictal 200 + lithium 300
==> slow depression relapse, pdoc wanted me to ramp up the lithium
- Lamictal 200 + lithium 900
==> agitated, miserable, horrible depression, joint pain, constant sweating. In desperation I dropped lithium back to 300 and dug up my old cymbalta
- Lamictal 200 + lithium 300 + SNRI (cymbalta)
==> feeling markedly better after 4 days. I see pdoc next week.From this I've concluded I really need a serotonin drug. The lamictal + lithium just doesn't cut it for me. My concern though is that I always relapse with depression. I've tried every flavor of AD (except MAOI), I've responded to all of them, but none last more than 6 months to a year.
Has anyone else had this pattern? Did you find a solution? I wondered if just swapping different ADs every six months would help.
Posted by Christ_empowered on August 22, 2016, at 13:21:14
In reply to Many Trials, Always Relapse, posted by Tabitha on August 22, 2016, at 12:29:42
hi. Sorry about all the trials. Can get frustrating, I'm sure.
Have you ever tried adding remeron or wellbutrin? I read a tiny abstract on PubMed or something about Remeron+Cymbalta. It works, although apparently it sometimes pushes people into (hypo)mania :-( .
Other than that...Symbyax? Or zyprexa+whatever dose prozac your doc deems appropriate...I guess there's no need to go for the pre-mixed combo. Or do you not want a neuroleptic? TD is a very real issue, though you wouldn't think so with everybody and their mama being given atypicals.
Have you ever added buspirone (BuSpar) to the mix? Not that great by itself, but I've read that it can help you get more mileage out of an antidepressant.
I don't know what symptoms are involved in your flavor depression, but...for me, Trileptal+Lamictal has helped control the agitation and general misery of my depressions. I take 1200mgs/Trileptal, but I would think you could do with considerably less.
there's also abilify to consider, if you're willing to go the AP/AAP route. I think with most depressive states lower doses are better, but if you get a lot of agitation and such, you might benefit from a somewhat higher dose. Of course...Seroquel...supposedly good for highs, lows, and I think mixed states. Makes my depression worse, but...a lot of people seem to benefit.
Ummm...I don't know your doctor's rules on controlled substances, but Provigil or Nuvigil help some people. The many flavors of Ritalin or Focalin...an amphetamine of some sort...
OK. I'm done now. I hope you and your prescriber can find a winning combination.
Posted by Tabitha on August 22, 2016, at 14:17:39
In reply to Re: Many Trials, Always Relapse, posted by Christ_empowered on August 22, 2016, at 13:21:14
Thanks for all the suggestions. I don't really know much about use of AP's for depression. I used Seroquel briefly and found it really sedating.
I've wondered about provigil since I have so much fatigue. I'll bring it up with the pdoc.
Posted by linkadge on August 23, 2016, at 16:33:21
In reply to Re: Many Trials, Always Relapse » Christ_empowered, posted by Tabitha on August 22, 2016, at 14:17:39
Hey,
I hear your comments and concerns. I have similar problems (i.e. frequent relapse into depression). It seems to help me to keep changing medications.
Sometimes the addition of certain supplements helps me (inositiol, folic acid and omega 3).
I've given up on the idea that I can take the same meds regularly and stay well.
Linkadge
Posted by Tabitha on August 23, 2016, at 18:57:26
In reply to Re: Many Trials, Always Relapse » Tabitha, posted by linkadge on August 23, 2016, at 16:33:21
> I hear your comments and concerns. I have similar problems (i.e. frequent relapse into depression).
Sorry to hear you're also in the continuous relapse boat.
> It seems to help me to keep changing medications.
I'm going to discuss that with my pdoc. I wonder if we can just pro-actively switch things up every 6 months or so
A question for you: have you had success switching meds within the same family? Like swapping one SSRI for another SSRI?
>
> I've given up on the idea that I can take the same meds regularly and stay well.Yes, unfortunately that's what I'm starting to think
Posted by linkadge on August 24, 2016, at 10:37:25
In reply to Re: Many Trials, Always Relapse » linkadge, posted by Tabitha on August 23, 2016, at 18:57:26
Hi Tabitha,
Yes, I would frequently switch one SSRI for another (or SNRI). Sometimes a drug holiday in between helped to some extent.
Paxil feels very different (to me) than say Prozac or Zoloft.
Not sure if it's an actual biochemical response, or just the novelty of trying something new.
Linkadge
Posted by Tabitha on August 24, 2016, at 13:39:13
In reply to Re: Many Trials, Always Relapse » Tabitha, posted by linkadge on August 24, 2016, at 10:37:25
Posted by SLS on August 24, 2016, at 16:10:30
In reply to Re: thanks (nm) » linkadge, posted by Tabitha on August 24, 2016, at 13:39:13
If you do opt to try Paxil, be aware that it is probably the SSRI most likely fail to work once it is discontinued and restarted. If it is working, just leave it alone. I also suspect that Paxil can cause cross-tolerance to other SSRIs. Because of this, I would try Lexapro and Zoloft first, and reserve Paxil as a second-line or third-line antidepressant. How high did you go with Effexor, and did you add Wellbutrin, nortriptyline, or Remeron to it?
You might consider low-dosage lithium - maybe 300 mg/day to add in the background. A low dosage avoids toxic or irreversible effects on thyroid and kidneys. I'm taking lithium because it helps to a mild degree with depression, and is possibly a treatment to prevent Alzheimer's Dementia, which occurs at a significantly higher rate with people with severe depression.
- Scott
Posted by Tabitha on August 24, 2016, at 16:52:46
In reply to Re: thanks » Tabitha, posted by SLS on August 24, 2016, at 16:10:30
> If you do opt to try Paxil, be aware that it is probably the SSRI most likely fail to work once it is discontinued and restarted. If it is working, just leave it alone. I also suspect that Paxil can cause cross-tolerance to other SSRIs. Because of this, I would try Lexapro and Zoloft first, and reserve Paxil as a second-line or third-line antidepressant.
Thanks, I didn't know that. Paxil is probably the last one I would try since it's notorious for weight gain anyway.
> How high did you go with Effexor, and did you add Wellbutrin, nortriptyline, or Remeron to it?
I don't even recall the dosage. And no, we never tried multiple ADs. I don't think I've ever done that. Generally I end up with an AD + mood stabiliser combo.
>
> You might consider low-dosage lithium - maybe 300 mg/day to add in the background. A low dosage avoids toxic or irreversible effects on thyroid and kidneys. I'm taking lithium because it helps to a mild degree with depression, and is possibly a treatment to prevent Alzheimer's Dementia, which occurs at a significantly higher rate with people with severe depression.Yes, I've been using lithium 300 mg for a while now. The most recent experiment was increasing to 900 mg, but it wasn't doing anything for my depression and I felt generally awful on it. I also was really averse to going high enough to require regular blood work.
I didn't know that depression increases risk of Alzheimer's. I guess that's one good reason to stay on the lithium.
Posted by Horse on August 25, 2016, at 3:00:09
In reply to Many Trials, Always Relapse, posted by Tabitha on August 22, 2016, at 12:29:42
Hi Tabitha, depression is relentless, isn't it? If you haven't tried Provigil or Nuvigil, it's a great idea. I don't do very well without a simulant, and I tolerate Nuvigil (or Provigil) very well, and it's made a significant difference. No cure, but you know.
I find thyroid and vit d help, as does sublingual vit b12, and they work synergistically for me. Have you ever tried cytomel (t3)? That helps some people even if they do not have a thyroid problem.
My dx is bpll and it sucks sucks sucks along with fatigue profound enough to have a bunch of tests for cfs. I send a virtual hug if that's ok and a dose of courage. Sunlight, too, which reminds me of lightboxes. Have you tried one?
Posted by Tabitha on August 25, 2016, at 12:43:36
In reply to Re: Many Trials, Always Relapse » Tabitha, posted by Horse on August 25, 2016, at 3:00:09
> Hi Tabitha, depression is relentless, isn't it? If you haven't tried Provigil or Nuvigil, it's a great idea. I don't do very well without a simulant, and I tolerate Nuvigil (or Provigil) very well, and it's made a significant difference. No cure, but you know.
I've considered it. I brought it up with my pdoc once but he wanted to try something else. I'll try again in the future if my fatigue doesn't improve once I get my depression under control again.
>
> I find thyroid and vit d help, as does sublingual vit b12, and they work synergistically for me. Have you ever tried cytomel (t3)? That helps some people even if they do not have a thyroid problem.Yes, I used cytomel for a couple years after first getting it as an augment to AD. It helped my energy and clarity of thinking. I couldn't get a reputable doctor to keep me on it though. My pdoc quit using it due to safety concerns.
>
> My dx is bpll and it sucks sucks sucks along with fatigue profound enough to have a bunch of tests for cfs. I send a virtual hug if that's ok and a dose of courage. Sunlight, too, which reminds me of lightboxes. Have you tried one?
>Thanks for the encouragement. I tried a light visor once, didn't notice much effect. Fatigue is miserable, isn't it? I feel like I'm lucky to have 3-4 hours per day when I can accomplish anything.
The pdoc just put me back on cymbalta, which helps pain, so I plan to start exercising again. I think that helped quite a bit when I was doing it.
Posted by Horse on August 25, 2016, at 23:11:20
In reply to Re: Many Trials, Always Relapse » Horse, posted by Tabitha on August 25, 2016, at 12:43:36
I wasn't able to tolerate cytomel, but my house was very clean. The clarity of thought was good, too.
May I ask at what dosage of cymbalta you're taking? I've been noticing my pain medication is losing efficacy, an before I speak to my doctor, I wanted to find out about minimum doses for pain relief with the thought of maybe adding it to my trintellix.
Posted by Tabitha on August 25, 2016, at 23:58:29
In reply to Re: Many Trials, Always Relapse » Tabitha, posted by Horse on August 25, 2016, at 23:11:20
> I wasn't able to tolerate cytomel, but my house was very clean. The clarity of thought was good, too.
I felt fine the whole time.
> May I ask at what dosage of cymbalta you're taking? I've been noticing my pain medication is losing efficacy, an before I speak to my doctor, I wanted to find out about minimum doses for pain relief with the thought of maybe adding it to my trintellix.
started at 30mg, going up to 60mg soon. I already got significant pain relief at 30mg. It's also a big help for hot flashes.
Posted by Horse on September 11, 2016, at 20:05:38
In reply to Re: Many Trials, Always Relapse » Horse, posted by Tabitha on August 25, 2016, at 23:58:29
Thanks Tabitha :)
Posted by Tabitha on September 18, 2016, at 11:07:04
In reply to Re: Many Trials, Always Relapse » Tabitha, posted by Horse on September 11, 2016, at 20:05:38
So, initially I wrote that I always relapse. I told my pdoc this, and asked him about pre-emptively changing my meds, and he said that can make them stop working permanently. He looked through my history, and said that the cymbalta hadn't pooped out, rather I'd wanted to switch due to side-effects. I realized he was right. My memory was a little fuzzy, and typical of depression, I'd put it into a story of hopelessness.
Anyway, we decided to continue the cymbalta and go up to 60mg, since that was the AD that had helped the most. It's been almost a month, and I've experienced gradual, major improvement. Everything is better, even physical symptoms I didn't associate with depression.
I always find the ramp-up interesting, and wish I could remember it for later. I experienced something I don't recall from previous times. In between feeling utterly miserable and feeling much better, I felt numb for a week or so. Food tasted really bad. I could detect all the separate flavors of it, but they didn't blend into an appealing whole. I think what happened was, my senses were getting sharper, yet I still wasn't feeling pleasure. So everything was clearer yet still unpleasant. I was afraid it might be permanent, but it was still better than the previous misery.
Gradually I felt little flashes of enthusiasm and enjoyment, then there were several per day. I started to feel motivated to do things that, while depressed, I thought I had just lost interest in doing. Once I started doing them I was sad that I'd turned away from them.
My loved ones and other people seemed more interesting. I quit putting negative interpretations on their actions.
I started retrieving memories I haven't thought of in years. Just random things from long ago. I still have trouble remembering last week though (middle-aged brain syndrome, I think).
I'm still having fatigue every day, but it's improved somewhat. Just like last time, this stuff really helps with chronic pain. I've gone from basically my whole body hurting to just having occasional knee and back pain. I think pain and depression just feed off each other, or they're the same thing.
Anyway, I'm optimistic.
Posted by Horse on September 18, 2016, at 14:49:34
In reply to Re: Update, posted by Tabitha on September 18, 2016, at 11:07:04
Excellent news Tabitha! I'm very glad.
Posted by SLS on September 18, 2016, at 17:54:53
In reply to Re: Update, posted by Tabitha on September 18, 2016, at 11:07:04
Woohoo!
:-)
I'm glad you are improving in such significant ways.
Also...
Thank you for being such a good reporter and sharing your experiences. Your descriptions will be very important to others when they are having difficulties in interpreting what they may be experiencing early in treatment. I experience the onset of an antidepressant response in ways that are very similar to yours. I hope your improvement continues.
- Scott
Posted by jay_theoriginal1 on October 27, 2016, at 21:37:59
In reply to Many Trials, Always Relapse, posted by Tabitha on August 22, 2016, at 12:29:42
> So my dx is bipolar II. In the last few years I've done this:
>SNIP<
>
> From this I've concluded I really need a serotonin drug. The lamictal + lithium just doesn't cut it for me. My concern though is that I always relapse with depression. I've tried every flavor of AD (except MAOI), I've responded to all of them, but none last more than 6 months to a year.
>
> Has anyone else had this pattern? Did you find a solution? I wondered if just swapping different ADs every six months would help.Well, I think you need a good SNRI. I don't know which one is best. I will say after just using SSRI's and flooding my brain with serotonin for the past 6 months, I have become a numb monk. Sex drive, what is that? lol. I have become Autistic-like, disliking showers and brushing my teeth and shaving. Sure beats anxiety, but still have weird sensory problems. I gulp back clonazepam. I am hoping a trial of Pristiq goes well, as like you, at the start it is always kinda good. Cymbalta and Clomipramine failed me. I am trying to give my norepinephrine system a gentile kick in the butt, with some grace, though
lol. Fatzima is my next to-try drug if Pristiq fails completely. But, I am really going to give it the benefit of the doubt, since I did ao well on Effexor for years. And I too am so tired of the switching game between drugs. Good luck and best wishes...:)Jay
Posted by SLS on October 27, 2016, at 23:10:28
In reply to Re: Many Trials, Always Relapse » Tabitha, posted by jay_theoriginal1 on October 27, 2016, at 21:37:59
> > So my dx is bipolar II. In the last few years I've done this:
> >SNIP<
> >
> > From this I've concluded I really need a serotonin drug. The lamictal + lithium just doesn't cut it for me. My concern though is that I always relapse with depression. I've tried every flavor of AD (except MAOI), I've responded to all of them, but none last more than 6 months to a year.
> >
> > Has anyone else had this pattern? Did you find a solution? I wondered if just swapping different ADs every six months would help.> Well, I think you need a good SNRI. I don't know which one is best. I will say after just using SSRI's and flooding my brain with serotonin for the past 6 months, I have become a numb monk. Sex drive, what is that? lol. I have become Autistic-like, disliking showers and brushing my teeth and shaving. Sure beats anxiety, but still have weird sensory problems. I gulp back clonazepam. I am hoping a trial of Pristiq goes well, as like you, at the start it is always kinda good. Cymbalta and Clomipramine failed me. I am trying to give my norepinephrine system a gentile kick in the butt, with some grace, though
> lol. Fatzima is my next to-try drug if Pristiq fails completely. But, I am really going to give it the benefit of the doubt, since I did ao well on Effexor for years. And I too am so tired of the switching game between drugs. Good luck and best wishes...:)Good luck, Jay. I hope you do well with Pristiq. Please keep posting your progress.
If you receive partial benefit from Pristiq, you might be able to make it work better by adding Wellbutrin or Abilify to it rather than switching to Fatzima right away. I found Fatzima to be without effect. Of course, two people can have very different reactions to the same drug. Perhaps you can start a new thread asking for people's input regarding Fatzima. If I were being treated for the first time, I would choose Effexor or Cymbalta before moving to Fatzima. I have heard of only one person do well with it. If I remember, I'll ask my doctor what his impressions are of Fatzima.
Again, good luck.
- Scott
This is the end of the thread.
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