![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 6 of 6. This is the beginning of the thread.
Posted by MarkinBoston on September 19, 2000, at 3:59:56
I'm new here and am a little overwhelmed with how much cumulative experience I'm seeing in all the posts. I want to know what drug to try next and hoping for a flow chart, or at least some suggestions.
My story:
40yo single white male, 5'10", 260lbs., stage I hypertension, 20yr history of endogonous melancholic unipolar dysthymia with 6 major depressive episodes that have resolved with Effexor, sometimes + nortryteline. The major episodes usually followed long periods of job stress and have a SAD component. SSRI's initially worked on the major episodes, but no longer do. I go for meds when I feel a major approaching ( trouble working, memory problems, thinking problems). Dysthymia has not responded to anything and my chief complaints are suppressed affect, low motivation, no joy, no libido, ED, morning insomnia. I discontinue meds after the major resolves due to weight gain, apathy/demotivation, inorgasmia, evening insomnia, and excessive sweating.I've just gotten a full(ish) blood work up showing low testosterone, high estrogen, high cortisol (DMT suppression, though, and I felt GREAT after the dexamethasone). I feel good on testosterone supplimentation, but more depressed and PMS'y when my level is tried to be raised to normal median levels. I assume this is due to excessive estrogen from aromatization, but my endocrinologist refuses to give me any antagonists because the most effective antiaromatase and the favorite of body builders is classified as a breast cancer drug. I had to discontinue testosterone due to increased blood pressure and water gain (estrogen again) and withdrawl was hell. I later found out that bodybuilders solve that problem with Clomid (a FSH/LH raising fertility drug)that helps jump-start endogenous T production.
So, I'm viewing melancholic depression as creating HPA dysregulation with increased cortisol (stress hormone) levels and lower anabolic hormones. This promotes obesity and yet higher estrogen and lower androgens.
The following don't work: Prozac, Paxil, Zoloft, Lithium. Welbutrin gave me flu symptoms, and I could hardly stay awake over a 2 day period after a half tab of Remeron. 20mg of Ritalin in the AM has helped me get to work and sleep(yes!), but not think or remember better. Valium has been pleasant in the evening and aided in getting to sleep. Klonipin was too mild and didn't have the benefit of aiding an occational backache.
I've not tried MAOI's and prefer to take the safe kind - selective and reversable. L-Deprenyl is speedy and only FDA approved for Parkensons. Moclobromide would take a while to order over the internet. At this point, I don't care about the money if I can find long term relief for the dysthymia.
ECT seems really crude, though proven to improve endocrine function. I'd rather use it last.
Tonight I've started Serzone, though my pdoc thinks its one of the less effective meds. I was interested in its side effects of lowering blood presure, not increasing weight or impairing sexual function, and triggering Growth Hormone release (which promotes weight loss). In the AM I will be taking Effexor XR.
I'm not sure this is the best thing to try for the next 6 weeks, or there are drugs that work well for what I feel must be a pretty common form of depression. I was "happy" for a while ignoring the life of dysthymia, but turning 40 has made me realize I've wasted 20 years this way and its time to try again to "solve" the problem. Trying to find a good endocrinologist has been frustrating and more depressing than my baseline - neither one I went to is willing to even try giving me the minute dosages I need to correct excessive estrogen. Fortunately my pdoc is very up on research, shares her experience, and will give me anything I want to try.
I was interested in the talk here about Amatadine because my ACT/ACH liver numbers were somewhat above normal and I've had minor, chronic neck lymph tenderness/swelling. The current endo dismisses it as just fatty liver. I suppose I could ask him what the harm would be of a 2 week course of anti-virals to see if my numbers improve.
Comments? What meds work best for melancholics?
Thanks,
Mark
Posted by Ant-Rock on September 19, 2000, at 8:54:43
In reply to Newbie w/treat-res melancholic double depression, posted by MarkinBoston on September 19, 2000, at 3:59:56
> I'm new here and am a little overwhelmed with how much cumulative experience I'm seeing in all the posts. I want to know what drug to try next and hoping for a flow chart, or at least some suggestions.
>
> My story:
> 40yo single white male, 5'10", 260lbs., stage I hypertension, 20yr history of endogonous melancholic unipolar dysthymia with 6 major depressive episodes that have resolved with Effexor, sometimes + nortryteline. The major episodes usually followed long periods of job stress and have a SAD component. SSRI's initially worked on the major episodes, but no longer do. I go for meds when I feel a major approaching ( trouble working, memory problems, thinking problems). Dysthymia has not responded to anything and my chief complaints are suppressed affect, low motivation, no joy, no libido, ED, morning insomnia. I discontinue meds after the major resolves due to weight gain, apathy/demotivation, inorgasmia, evening insomnia, and excessive sweating.
>
> I've just gotten a full(ish) blood work up showing low testosterone, high estrogen, high cortisol (DMT suppression, though, and I felt GREAT after the dexamethasone). I feel good on testosterone supplimentation, but more depressed and PMS'y when my level is tried to be raised to normal median levels. I assume this is due to excessive estrogen from aromatization, but my endocrinologist refuses to give me any antagonists because the most effective antiaromatase and the favorite of body builders is classified as a breast cancer drug. I had to discontinue testosterone due to increased blood pressure and water gain (estrogen again) and withdrawl was hell. I later found out that bodybuilders solve that problem with Clomid (a FSH/LH raising fertility drug)that helps jump-start endogenous T production.
>
> So, I'm viewing melancholic depression as creating HPA dysregulation with increased cortisol (stress hormone) levels and lower anabolic hormones. This promotes obesity and yet higher estrogen and lower androgens.
>
> The following don't work: Prozac, Paxil, Zoloft, Lithium. Welbutrin gave me flu symptoms, and I could hardly stay awake over a 2 day period after a half tab of Remeron. 20mg of Ritalin in the AM has helped me get to work and sleep(yes!), but not think or remember better. Valium has been pleasant in the evening and aided in getting to sleep. Klonipin was too mild and didn't have the benefit of aiding an occational backache.
>
> I've not tried MAOI's and prefer to take the safe kind - selective and reversable. L-Deprenyl is speedy and only FDA approved for Parkensons. Moclobromide would take a while to order over the internet. At this point, I don't care about the money if I can find long term relief for the dysthymia.
>
> ECT seems really crude, though proven to improve endocrine function. I'd rather use it last.
>
> Tonight I've started Serzone, though my pdoc thinks its one of the less effective meds. I was interested in its side effects of lowering blood presure, not increasing weight or impairing sexual function, and triggering Growth Hormone release (which promotes weight loss). In the AM I will be taking Effexor XR.
>
> I'm not sure this is the best thing to try for the next 6 weeks, or there are drugs that work well for what I feel must be a pretty common form of depression. I was "happy" for a while ignoring the life of dysthymia, but turning 40 has made me realize I've wasted 20 years this way and its time to try again to "solve" the problem. Trying to find a good endocrinologist has been frustrating and more depressing than my baseline - neither one I went to is willing to even try giving me the minute dosages I need to correct excessive estrogen. Fortunately my pdoc is very up on research, shares her experience, and will give me anything I want to try.
>
> I was interested in the talk here about Amatadine because my ACT/ACH liver numbers were somewhat above normal and I've had minor, chronic neck lymph tenderness/swelling. The current endo dismisses it as just fatty liver. I suppose I could ask him what the harm would be of a 2 week course of anti-virals to see if my numbers improve.
>
> Comments? What meds work best for melancholics?
> Thanks,
> Mark
Hi Mark.
Sorry to hear of your struggles. one thing we have in common is low-testosterone, but I also have low-cortisol, which may sound good but really isn't. My endo says these readings are both due to my longstanding depression. I do have one idea you can check out regarding the testosterone/estrogen connection. A substance I just read about at (antiaging-systems.com)called Di-Indolylmethane converts estrogen-estradiol to "lesser" estrogens & their metabolites and is reccomended for users of testeosterone precursors such as their product called Pro-male. I am using this pro-male product currently and it has helped with the sexual side-effects due to my meds /depression.
Also, don't be so eager to discard the idea of MAOI's, they are powerful AD's, and the diet restrictions are not nearly as bad as you would think.
Hope this was of some help , Mark. If you check out that web-site it has some good info regarding hormone related meds.Good luck.
Sincerely,Anthony
Posted by stjames on September 19, 2000, at 11:06:02
In reply to Newbie w/treat-res melancholic double depression, posted by MarkinBoston on September 19, 2000, at 3:59:56
>
> I was interested in the talk here about Amatadine because my ACT/ACH liver numbers were somewhat above normal and I've had minor, chronic neck lymph tenderness/swelling. The current endo dismisses it as just fatty liver. I suppose I could ask him what the harm would be of a 2 week course of anti-virals to see if my numbers improve.James here....
Have you had a hepatitus a/b/c test ?
You will get better control if you stay on the AD's all the time. Your depression is here to stay
so it needs constant treatment or it will get worse as you get older.james
Posted by Racer on September 20, 2000, at 13:55:19
In reply to Newbie w/treat-res melancholic double depression, posted by MarkinBoston on September 19, 2000, at 3:59:56
This may sound nuts, but then, that's why I'm on meds, right? ;-)
Have you talked to your doctor about treating the cortisol/dex part separately? Yeah, nuts... I don't mean this as belittling your trouble, but my horse also suffers from raised cortisol, etc: it's a whole disease for her, Cushing's syndrome. The symptoms are different, since you're a human in the prime of life and she's an elderly equine, but the depression, weight changes, hormones, etc, are similar.
Treatments for Cushing's in horses are very limited, and expensive since they're based on human drugs at veterinary doses, but the drugs of choice are:
Periactin (cyproheptidine), which is an older anti-histimine, and can fix sleeplessness (though you'll be groggy the next morning) and temporarily fixes the anorgasmia from SSRIs. It's available generically, so the cost is negligible. The trouble, of course, is that it's also used to promote appetite...
Pergolide is a parkinson's drug, which has been shown to be very effective against Cushings. I used to know the thinking behind it, but I've got the icks today, and can hardly remember my own name (thanks Dr Bob for the forms knowing it for me, eh?), so I can't help there...
None of that is to say that I know anything much at all, just a suggestion for you. It sounds as though you've been through the wringer, so maybe this will help you and your doctor come up with a new idea which will maybe help.
A couple more thoughts, for what they're worth:
Have you had your thyroid tested?
Have you tried non-drug treatments for the SAD portion of your depression? Light, exercise, shaking your fist at the rain clouds? Can't hurt, right?
Have you had the cortisol tests done while you were NOT experiencing a depressive episode? I know, I know, but I'm back to my horse again. I know that she will go through periods when she gets sicker or more depressed, or just turns into the nasty-bitch-mare-from-hell for a few days. I wonder if you're suffering something like what she has?
Cushings in horses, by the way, (and dogs) is caused by a benign tumor on the pituitary gland which interupts the normal functioning of the feedback loop with the adrenal glands to produce cortisol and so on. Has anyone checked you for something similar? I know that the dex-sup test is used to diagnose it in horses...
Poor Mark, I know what hell it is to look for help without finding it, sure made me feel as though life wasn't worth living last time around (old timers on this board will remember and tell you about that!) I do hope you find relief soon.
Oh, and I'm leaning near to stjames: while I won't tell you to stay on ADs forever, I will suggest that you stay on them long enough to reset your chemistry. I've read that for recurrent depression, you should plan on staying on the drugs for 2 calendar years past the point they finally work. Same article said that going on and off a lot could make the drugs LESS effective over time. How long have you been staying on them?
Good luck.
Posted by JohnL on September 22, 2000, at 5:21:50
In reply to Newbie w/treat-res melancholic double depression, posted by MarkinBoston on September 19, 2000, at 3:59:56
> Comments? What meds work best for melancholics?
> Thanks,
> MarkMark,
So sorry to hear of your situation. You've come to the right place though. So many of us have been, or are, in exactly the same boat as you. And there are some real expert regulars here. And lots of desperate experimenters that discover wonderful things via unconventional methods.What meds work best for melancholics? Well, a review of all the literature would probably give the tricyclics a slight edge over everything else. Regardless, most statistics show that any of the psychiatric medications are basically similar in their ability to relieve melancholia. It's just that it varies so much from one person to the next. That leads me to my next comment...
It is my belief system that the dramatic variation we see from person to person is caused by unique chemistry imbalances. Each person has their own unique chemistry, genes, circumstances, metabolism, etc. There are many many chemical imbalances that cause melancholia. Yet they all have the same symptoms. Kind of like diarhhea...the causes are many, the symptoms are the same. So we need to target our own unique chemical/molecular root problem. We can only do that by trail and error.
I've also come to believe though that through trial and error we can gather clues to point us in the right direction. Every medication response we have--positive, negative, partial, whatever--provides clues as to what the underlying problem is. Doctors are not trained to look for these clues. Instead they try this and try that mainly by what has worked with other people, without giving much thought to why this or that didn't work. There are clues not be overlooked. But they are often overlooked because we aren't in the mindframe of seeking them.
As an example, let's say someone has tried several SSRIs, a couple tricyclics, and an MAOI. They worked a little bit, not enough, not very long, or not at all. To me that provides the clue that the underlying chemistry has nothing at all to do with neurotransmitter levels. The neurotransmitter levels in this example do not need to be increased. They are fine. The problem is something else. Perhaps the neurotransmitter levels need to be turbocharged, or maybe tamed. But not increased. That would lead us into completely different categories of medications for trial, from which addition clues are gathered. With some luck, the clue gathering phase will come to an abrupt end when we stumble onto the right medication match for the unique chemistry.
If you want to learn more about this method of anyalyzing, I would suggest buying a book (soft cover manual actually) called "The Successful Treatment of Brain Chemical Imbalance" by Dr Martin Jensen. You'll be amazed. A whole new world will open up to you in understanding why things you've tried didn't work, and where to look instead.
To get right down to bolts and nuts, I would suggest the possibility of acquiring two medications...Amisulpride (a French anitpsychotic that is excellent for melancholic depression with hardly any side effects) and Provigil (anti-narcoleptic). Why? Several reasons. 1)They target completely different chemistries that so far have been missed; 2)They have been proven clinically to be of value in treating the melancholic dysthymic anhedonic apathetic type of depression; 3)my history and type of depression is very much like yours, and these two medications work nearly 100% where all others failed. You can get a prescription for Provigil from your doctor. Or you can order it from International Antiaging Systems overseas. You can get Amisulpride from overseas pharmacies. Post a request to AndrewB for the location of Amisulpride. Or, do a search for Amisulpride posts going back about two months. There is a post with the pharmacy where you can order it without a prescription.
The real tip-off to me was your comment on Ritalin. There are powerful clues there. I think Amisulpride+Provigil stand a real good chance of working for you, with minimum dosing, minimum side effects, abolishment of melancholia, increase of energy and interest, and an increase in mental cognition. I suggest this not just based on the good response I've experienced, but rather by pondering the clues provided in your post. The clues are there. For dysthymic melancholic anhedonic apathetic depression, tricyclics probably have an edge over other antidepressants. But there side effects almost negate the good effects. Amisulpride and Provigil in my opinion are light years ahead in superiority. Try them alone or try them together. For me, 25mg Amisulpride (half the minimum) and 100mg Provigil (very low) work magic on my dysthymic anhedonic apathetic melancholic symptoms. Just about any medication you could name didn't work or left me incapacitated with torturous side effects. Consider the book, and these two medications. If nothing else, try Provigil alone. If you do try either or both of these, let me know. I'll be happy to share with you some tips in getting started.
John
Posted by MarkinBoston on October 11, 2000, at 1:46:57
In reply to Newbie w/treat-res melancholic double depression, posted by MarkinBoston on September 19, 2000, at 3:59:56
Thanks for all the info guys. I had some trouble finding my thread here and just stubled upon it now. Thought I'd give an update.
First, I am feeling better. I started titrating up on the serzone. I wanted to see what it did alone since it was new to me. I was up to 100mg AM and 200mg at 9PM, and then switched the morning drug to Effexor XR 150mg in the AM. In the several times I've used Effexor it had made me speedy. Paradoxically, I was zonked. The next morning I tried 37.5mg of the original stuff I had left over and had the same reaction, yet it continued way past the normal half-life. Called it quits with Effexor and the doc suggested dropping back a step on Serzone and re-titrate up again. I've been doing that. I also asked to get back on testosterone, and after nearly a week of 10mg/day Androgel and starting to feel better mentally, and my skin is just a touch oilier now. Even though Androderm is less convenient, I think it took effect sooner. It also has the benefit of releasing to match the normal daily high and low periods. The diuretic blood pressure medicine brought down my systolic by 30 points, but diastolic by 1 or 2. I feel the testosterone is starting to increase my BP now too. I'll get blood done in a week.
The interesting new thing that happened was titrating up on Serzone to 200mg pm and 100 am. I was zonked again during the day. 40mg of Ritalin didn't help a bit. Thinking, mood, and motivation were all good, but bad memory. Today in the AM I only took 50mg Serzone and 20mg Ritalin and my memory improved in the afternoon, I felt more up, and not zonked at all. So, I saw the pdoc today (ran out of Ritalin and caught her up on things). She wanted to write me up for Provigil, which while it sounds very good, I had a very good day today and want to titrate down on Serzone (even though I'm now at a sub-theraputic dose) and not change too many variables at once. I know the Ritalin and testosterone are both helping me and was relieved that my memory improved late day implicating Serzone, yet, I do think it is doing something for me and want to dose it right before switching dopamine agonists.
With 40mg of Ritalin not even denting my Serzone somanance, I was afraid that I had built tolarance. Today, I was also relieved to find out that it wasn't because 20mg on rising boosted me all day - to the point where I want to see if 10mg is enough.
I called Dr. Jensen's office and he is going to print soon with the 2nd Edition. I'll probably not wait and get the first now and that second when available.
Now, all I need is a libido (wasn't that in the Wizard of OZ?) which should be soon once the testosterone kicks in. I'm afraid I'll have to cut back due to blood pressure again though. I also hope I don't get the high estradiol. I feel like if I do, I'm going to have to tough it out for a couple days just to get blood showing it above "normal" in order to try and convince him to manage it. I wasn't impressed with this doc the last time I saw him. He didn't see the need for using Clomid when a guy goes off replacement therapy - "its only a couple weeks and Clomid has side effects", to which I replied "MD's are using anesthesia for surgery these days, arn't they?" He also wasn't open to check for what my gonads could do on their own when stimulated with Clomid or HGRH - "that's only done in research."
As to cushings syndrome. Its a typical trait of melancholics. Half show dex suppression, half don't. The problem with most cortisol antagonists is that they suppress other hormones too, so someone would need sex hormone replacement in combination. I'll look up the ones mentioned.
The doc actually had me get a brain MRI ($2000 my HMO's bill) and no pititary or other brain abnormalities were noticed. Didn't have any adrenal tests, though.Liver numbers: When the panels were done, I was neg for Hep A,B, and C. Havn't taken risks since my hiv- test a few years ago. My regular doc wanted another reading. I told him it would be a waste of money, because I'd had three and all were about the same readings. The first time I saw him I gave him copies of all the blood labs and the MRI report from when I went for a physical in May. The plan is to get new numbers after losing weight.
JohnL, thanks. We do seem to have similar chemistries going on and I'm watching the updates on your cocktail. I feel fairly good now and not pressured to rush into anything because I can't function. I think I have time to read the book, piece the clues together, do the remaining tests, and work on a better coctail and stay on maintenance.
Thyroid? Well, it (T4) was on the low end of normal one time and OK the second. I think the evidence now suggests dopamine difficientcy reguarding energy. It amazes me how T4 is screened, while T3 is the real active ingredient. Testing is sensitive enough now to measure it. Same goes for testosterone. Total is measured, while its only unbound and weakly bound T that are active.
One quirky thing about the anti-hypertensive I'm on, Triamterene 37.5mg/HCTZ 25mg caps. I don't sweat and get cold on it. Not what I'm used to at all and often have some face flush. The only other thing that had similar effect was when a herbal nutritionist had me take "Devil's Claw" for it many years ago. I kept it up that summer, then stopped taking it. I went EOD for a week on the diuretic so I could poop again and the sweating/warmth returned, so the other drugs weren't responsible. Feeling warm at least gives me some hope that my metabolic rate is high enough to support weight loss. Oh, well, just an anecdote.
Thanks for your support,
Mark
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.