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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 18 of 18. This is the beginning of the thread.
Posted by Confusedcius on September 27, 2017, at 12:09:10
I'm 27 years old and struggling with cognitive impairment, no motivation, social anxiety, no libido (lost at about age 21 BEFORE going on an SSRI), no self confidence, irritability, etc.
The cognitive problems go all the way back to when I was a little child. Basically, I've always felt dumber than the average person. And lazier.. I would always want to stay home from school and play videogames. Which turned into staying on the computer and there I still am to this day.
It has gotten so bad that all I do all day is sit on my computer, still living in my parents house. My life is so hopeless that I've considered suicide.
I've tried lots of supplements and nothing helped.
Medications I've tried: Zoloft generic, Lexapro generic, Wellbutrin XL generic, Ritalin SR generic. The only one that helped was the Wellbutrin XL generic and only for the first 1-2 weeks on it and then I went back to how I was prior, even after staying on it for a few months and increasing the dosage to 450mg.
I've seen many mental health professionals including psychologists & psychiatrists which have all been ineffective (very hard to find a GOOD psychiatrist that accepts Medicaid). I was thinking of going back to one former psychiatrist and actually suggesting that I go on Adderall XR or Vyvanse since it seems like my problems are Dopamine/Norepinephrine related and because of the positive initial response to Wellbutrin.
Any suggestions are appreciated. Feel free to ask questions.
Posted by pedr on September 27, 2017, at 16:32:21
In reply to Cognitive Impairment, lack of motivation, etc., posted by Confusedcius on September 27, 2017, at 12:09:10
sorry you're having a rough time of it. Ostensibly you haven't tried many meds nor any combos so it's nowhere near time to give up yet. Regarding Adderall XR or Vyvanse - that's not a bad idea. I benefit from stimulants even though I've never been diagnosed with ADD.
HTH.
Posted by rjlockhart37 on September 29, 2017, at 16:00:20
In reply to Cognitive Impairment, lack of motivation, etc., posted by Confusedcius on September 27, 2017, at 12:09:10
adderal xr would be good choice to start, vyvanse is long acting also....they each last around 8 hours....they only thing else they would proably consider also is concerta or focalin.....
the others like dexedrine spansule, and older stimulant meds are not really considered first choice anymoore
Posted by porkpiehat on October 2, 2017, at 13:53:12
In reply to Cognitive Impairment, lack of motivation, etc., posted by Confusedcius on September 27, 2017, at 12:09:10
What were your responses to the SSRI's? Just "no change" or something different?
Two thoughts on stims:
-If you have a problem being on the computer all day this could be made worse.
-Stims can feel like a game changer but they can also turn on you after a few weeks.This may not be your experience...I've seen it in some other people and myself and it's something my doctor warned about.
Posted by baseball55 on October 2, 2017, at 18:19:43
In reply to Re: Cognitive Impairment, lack of motivation, etc. » Confusedcius, posted by porkpiehat on October 2, 2017, at 13:53:12
I've always had a paradoxical relationship to stims also. The first couple of times I take them, I feel good, but then I start to feel awful and enervated and can't wait for them to wear off.
> Two thoughts on stims:
> -If you have a problem being on the computer all day this could be made worse.
> -Stims can feel like a game changer but they can also turn on you after a few weeks.
>
> This may not be your experience...I've seen it in some other people and myself and it's something my doctor warned about.
>
>
Posted by phidippus on October 7, 2017, at 18:13:06
In reply to Cognitive Impairment, lack of motivation, etc., posted by Confusedcius on September 27, 2017, at 12:09:10
Um, you suffer from straight up depression. ADHD seems like a possibility, but Ritalin didn't help. How long were you on Lexapro and Zoloft?
Eric
Posted by Confusedcius on October 8, 2017, at 8:39:58
In reply to Re: Cognitive Impairment, lack of motivation, etc., posted by phidippus on October 7, 2017, at 18:13:06
> Um, you suffer from straight up depression. ADHD seems like a possibility, but Ritalin didn't help. How long were you on Lexapro and Zoloft?
>
> EricLexapro- 2 months
Zoloft- 1 monthI'm pretty sure I had ADHD as a child which progressed into Depression & Social Anxiety as an adolescent and became worse as an adult.
The Ritalin didn't help me when I took it a few years ago but I'm primarily inattentive and I've read that people in my subtype respond least to Ritalin of all ADHD meds.
Posted by phidippus on October 8, 2017, at 9:41:49
In reply to Re: Cognitive Impairment, lack of motivation, etc., posted by Confusedcius on October 8, 2017, at 8:39:58
You really should nail down an ADHD diagnosis-look up a neuropsychologist who will do testing.
ADHD can spawn depression and anxiety. Sometimes when you treat ADHD the anxiety and depression can lessen significantly.
If you do have ADHD and its primarily inattentive, it doesn't matter whether yoo take Ritalin or amphetamines, you just don't happen tto respond to Ritalin. Try dextroamphetamine and see how you respond.
Eric
Posted by Confusedcius on October 17, 2017, at 12:09:35
In reply to Re: Cognitive Impairment, lack of motivation, etc. » Confusedcius, posted by porkpiehat on October 2, 2017, at 13:53:12
> What were your responses to the SSRI's? Just "no change" or something different?
>
> Two thoughts on stims:
> -If you have a problem being on the computer all day this could be made worse.
> -Stims can feel like a game changer but they can also turn on you after a few weeks.
>
> This may not be your experience...I've seen it in some other people and myself and it's something my doctor warned about.
>
>Honestly, I don't think I gave the Zoloft a fair chance. I was either on 50mg or 100mg before tapering off but if I were to try it again, I'd take some supplements along with it like Omega 3 fish oils to improve it's efficacy. I would also go up to 200mg if need be, before tapering off.
The problem is that I'm not sure whether I should try Adderall XR/Vyvanse first or Zoloft first. My biggest problem is that I'm unmotivated. I stay at home all day, on my computer and I'm just not interested in life. I don't know which medication is more suitable to treat that main culprit.
Posted by Confusedcius on October 20, 2017, at 15:45:36
In reply to Cognitive Impairment, lack of motivation, etc., posted by Confusedcius on September 27, 2017, at 12:09:10
I've been thinking a lot about this lately and I'm pretty sure I have it nailed down: I have had ADHD since childhood that went undiagnosed and untreated. I developed Chronic Atypical Depression & Social Anxiety in adolescence and to this day I have all three conditions.
The question is: what is the best course of treatment for these 3 conditions? I'm thinking the only 3 meds approved for Social Anxiety (Zoloft, Paxil & Effexor) would be a good choice to try since SSRIs are also supposed to be helpful for Atypical Depression.
Then if those three don't work, I will have to try MAOIs.
Somewhere along in this, I'd have to address the ADHD problem but I assume it should be done after the Depression & Anxiety is under control. Unless anyone here thinks I should tackle the ADHD first?
Posted by phidippus on October 21, 2017, at 8:57:10
In reply to Re: Cognitive Impairment, lack of motivation, etc., posted by Confusedcius on October 20, 2017, at 15:45:36
I think you'll find if you address the ADHD, some of the depression and anxiety will come under control.
Eric
Posted by Confusedcius on October 23, 2017, at 12:28:21
In reply to Re: Cognitive Impairment, lack of motivation, etc., posted by phidippus on October 21, 2017, at 8:57:10
> I think you'll find if you address the ADHD, some of the depression and anxiety will come under control.
>
> EricI think so, too. Hopefully I can get started on Adderall XR or Vyvanse soon.
Posted by Confusedcius on March 12, 2018, at 8:46:34
In reply to Cognitive Impairment, lack of motivation, etc., posted by Confusedcius on September 27, 2017, at 12:09:10
UPDATE: After looking through some of Stahl's Essential's books, it seems that my problem is very much a 'reduced positive affect'. Poor motivation, poor self-confidence, poor attention, etc. all fall under that category. These are all likely due to a Dopamine/Norepinephrine dysfunction as I've suspected. My positive initial response to Wellbutrin XL also confirms that.
So, based on Stahl's recommendations and my own preferences to narrow them down, I've decided to go in this direction for possible combos:
Cymbalta
Cymbalta + Buspar
Cymbalta + Modafinil
Cymbalta + Wellbutrin XL
Wellbutrin XL + Buspar
Wellbutrin XL + Modafinil
Wellbutrin XL + Strattera
Strattera + Buspar
Strattera + Modafinil
Nardil
Nardil + ModafinilMy current med regimen: 60mg Duloxetine and 20mg Buspirone (10mg 2x day).
Since I've restarted my medication trials, I started on Cymbalta 30mg and then was increased to 60mg after 2 weeks and I've been on that dosage for many weeks. I did not notice an improvement so I requested to add on Buspar and my pdoc put me on 20mg and that's where I've been since 4-5 weeks ago. I will go back to my pdoc in a couple of weeks and my next step will either be A) Increase Buspar dose if no sufficient improvement by then, B) Discontinue Buspar and start Modafinil or C) Keep all dosages the same (best case scenario, would mean I've significantly improved by then).
I have noticed a possible, slight improvement with the Buspar so if I don't receive a significant improvement in the next couple weeks, I'm thinking of increasing the dosage but I'm not sure if higher doses of Buspar target more Serotonin and only lower doses target Dopamine. I don't want to spend weeks increasing the dose and then have it not work, especially since I've read (in Stahl's prescriber's guide) that doses above 20mg are more likely to cause sedation which is counterproductive for my situation.
Any insight is greatly appreciated.
Posted by SLS on March 28, 2018, at 13:14:02
In reply to Re: Cognitive Impairment, lack of motivation, etc., posted by Confusedcius on March 12, 2018, at 8:46:34
> UPDATE: After looking through some of Stahl's Essential's books, it seems that my problem is very much a 'reduced positive affect'. Poor motivation, poor self-confidence, poor attention, etc. all fall under that category. These are all likely due to a Dopamine/Norepinephrine dysfunction as I've suspected. My positive initial response to Wellbutrin XL also confirms that.
>
> So, based on Stahl's recommendations and my own preferences to narrow them down, I've decided to go in this direction for possible combos:
>
> Cymbalta
> Cymbalta + Buspar
> Cymbalta + Modafinil
> Cymbalta + Wellbutrin XL
> Wellbutrin XL + Buspar
> Wellbutrin XL + Modafinil
> Wellbutrin XL + Strattera
> Strattera + Buspar
> Strattera + Modafinil
> Nardil
> Nardil + Modafinil
>
> My current med regimen: 60mg Duloxetine and 20mg Buspirone (10mg 2x day).
>
> Since I've restarted my medication trials, I started on Cymbalta 30mg and then was increased to 60mg after 2 weeks and I've been on that dosage for many weeks. I did not notice an improvement so I requested to add on Buspar and my pdoc put me on 20mg and that's where I've been since 4-5 weeks ago. I will go back to my pdoc in a couple of weeks and my next step will either be A) Increase Buspar dose if no sufficient improvement by then, B) Discontinue Buspar and start Modafinil or C) Keep all dosages the same (best case scenario, would mean I've significantly improved by then).
>
> I have noticed a possible, slight improvement with the Buspar so if I don't receive a significant improvement in the next couple weeks, I'm thinking of increasing the dosage but I'm not sure if higher doses of Buspar target more Serotonin and only lower doses target Dopamine. I don't want to spend weeks increasing the dose and then have it not work, especially since I've read (in Stahl's prescriber's guide) that doses above 20mg are more likely to cause sedation which is counterproductive for my situation.
>
>
> Any insight is greatly appreciated.
Why do you not consider Effexor? Is there any evidence that Cymbalta works better than Effexor? Effexor + Wellbutrin works well for some people. I like Effexor + nortriptyline.
- Scott
Posted by ed_uk2010 on March 28, 2018, at 15:23:30
In reply to Re: Cognitive Impairment, lack of motivation, etc. » Confusedcius, posted by SLS on March 28, 2018, at 13:14:02
>I like Effexor + nortriptyline.
Hi Scott,
Do you think that would be better than nortriptyline plus an SSRI such as sertraline?
Posted by SLS on March 28, 2018, at 16:45:05
In reply to Re: Cognitive Impairment, lack of motivation, etc. » SLS, posted by ed_uk2010 on March 28, 2018, at 15:23:30
> >I like Effexor + nortriptyline.
>
> Hi Scott,
>
> Do you think that would be better than nortriptyline plus an SSRI such as sertraline?From what I read recently, SSRIs are better than SNRIs for anxiety disorders. For depression, I guess it depends on treatment history. For me personally, I respond better to venlafaxine (Effexor) than any of the SSRIs I've tried. This falls in line with some of the early work comparing venlafaxine to SSRIs in general. I respond even better when nortriptyline is added to the venlafaxine. I like sertraline (Zoloft) as a choice, even though I did not react well to it. I guess it makes sense to go with sertraline first unless there are reasons not to - if for no other reason than to avoid the more intense withdrawal symptoms of venlafaxine discontinuation. However, if venlafaxine works, and long-term treatment is indicated, it is likely that there will be no reason to discontinue it.
I have heard success stories involving the combining of bupropion (Wellbutrin) with sertraline. I know someone who achieved remission combining bupropion with desvenlafaxine (Pristiq).
Ed, how do you compare sertraline with escitalopram (Lexapro; Cipralex)? For awhile now, I think the first choice of American doctors has been escitalopram. It had been sertraline previously.
- Scott
Posted by ed_uk2010 on March 28, 2018, at 17:16:52
In reply to Re: Cognitive Impairment, lack of motivation, etc. » ed_uk2010, posted by SLS on March 28, 2018, at 16:45:05
Thanks Scott. Good summary.
Due to the strong tendency to favour generic drugs here, escitalopram never really caught on. That has remained the case even though it is now generic itself and extremely inexpensive.
Citalopram and sertraline were both extremely widely used, but there has been a strong shift to sertraline recently. It's mainly due to concern about QT prolongation with citalopram, especially because a lot of pts take multiple medications which could potentially do the same and interact. The same may apply to escitalopram to some extent. In addition, sertraline seems less toxic in overdose, and a good choice in cardiac disease too. So, sertraline has become favoured. Fluoxetine and paroxetine have so many more drug interactions, they aren't generally used first line. And of course, the tendency of paroxetine and venlafaxine to have difficult withdrawal has pushed them firmly into second/third line territory. Sertraline has come out of all this unscathed.
Posted by ed_uk2010 on March 28, 2018, at 17:17:59
In reply to Re: Cognitive Impairment, lack of motivation, etc. » ed_uk2010, posted by SLS on March 28, 2018, at 16:45:05
But if you ask me, escitalopram is generally quite a good medication. A lot of it boils down to prescribing patterns.
This is the end of the thread.
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