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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 10 to 34 of 44. Go back in thread:
Posted by Maxime on November 13, 2009, at 13:30:23
In reply to Re: Stimulants for TRD » Maxime, posted by SLS on November 13, 2009, at 11:15:17
I tried Ritalin and Dexedrine first and both caused an awful crash in mood at night. I find the adderall xr to be very smooth in action. I've taken it with Parnate as well.
Posted by Maxime on November 13, 2009, at 13:31:34
In reply to Re: Stimulants for TRD » Maxime, posted by tensor on November 13, 2009, at 11:37:45
I used the XR version and took 30 mg a day. I had no crashes on this med unlike Ritalin and dexedrine which would make me crash so hard I wanted to die.
Posted by uncouth on November 13, 2009, at 14:41:36
In reply to Re: Stimulants for TRD » SLS, posted by Maxime on November 13, 2009, at 13:30:23
My guess is that in the short run, most people tend to respond similarly to stims -- short term, immediate mood lifting and activation.
My guess is that in the long run, stimulants can either be very good or very bad for people, depending on genetics and specifics of their disorder.
I think stimulants caused a permanent adjustment in my brain's reward system, such that my current default state has become apathy, anhedonia, amotivation. I am considering going back on stimulants, but hoping something else (bupropion and antipsychotics) can normalize. Not holding my breath though.
I sometimes wonder if God made me by design like this - to not derive much pleasure from this world. Sure makes it painful and hard to live in it though.
Posted by conundrum on November 13, 2009, at 14:59:31
In reply to Re: Stimulants for TRD, posted by uncouth on November 13, 2009, at 14:41:36
I'm the exact same way and prozac did it to me. Not a stimulant but it is a dopamine/norepinephrine releaser.
Even orgasms don't feel good and that is something that is hardwired to feel good. People think I'm whining when I say I don't enjoy things like I used to but when I say I get no pleasure from sex they seem to understand the seriousness of the situations.
Right now I'm trying to increase reward by boosting dopamine through 5HT1A agonism, 5HT2C antagonism, and alpha 2 adrenergic antagonism. I'm taking 15mg of buspar a day and 5mgs of prozac. The buspar seems to help a little bit with motivation, but not with pleasure. I know that sounds odd, since you would think pleasure and motivation would go hand in hand. Prozac seems to counter this positive effect, but I will continue the expirement.
I would also consider Remeron, which is a drug on should start on a higher dose like 30 mgs and work up to 45mgs.
Other options are Antipsychotics but the side effects profile of parkinson's like shaking and hyperglycemia seem a lot less safe than stimulants.
Some people respond to DA agonists like Mirapex and Requip, but they have their drawbacks as well.
It seems like once the reward system gets used to elevated dopamine it requires that amount to function normally. Do you have sexual anhedonia? Do you also have short term memory and concentration problems that you didn't have before you start treatment?
Posted by SLS on November 13, 2009, at 15:08:01
In reply to Re: Stimulants for TRD, posted by uncouth on November 13, 2009, at 14:41:36
> My guess is that in the short run, most people tend to respond similarly to stims -- short term, immediate mood lifting and activation.
>
> My guess is that in the long run, stimulants can either be very good or very bad for people, depending on genetics and specifics of their disorder.
>
> I think stimulants caused a permanent adjustment in my brain's reward system, such that my current default state has become apathy, anhedonia, amotivation. I am considering going back on stimulants, but hoping something else (bupropion and antipsychotics) can normalize. Not holding my breath though.
>
> I sometimes wonder if God made me by design like this - to not derive much pleasure from this world. Sure makes it painful and hard to live in it though.
Just a quickie:Parnate + Wellbutrin + Abilify.
I wish I had a citation to offer you that confirms the safety of combining Parnate with Wellbutrin. I tried it once and did not experience any side effects. It just didn't work.
My doctor and his colleagues have been combining Wellbutrin with Lamictal lately. He doesn't like using amphetamine for depression.
- Scott
Posted by bulldog2 on November 13, 2009, at 16:43:09
In reply to Re: Stimulants for TRD » bulldog2, posted by tensor on November 13, 2009, at 12:02:16
> > I've tried ritalin and adderall and they are good for the short term. Also the remission is not complete for montherapy. Just gets my head out of the water so to speak. The good part lasts several days and than goes down. If you keep chasing the euphoria the dose will escalate. For depression they probably need to be used as augmentation. Also need something to prevent tolerance as andrewb a former babbler found that memantine and adderall were his magic pills.
> > So I believe that stims have an important place in the p-docs tool box.
> > Before the advent of our new ads opiates and stims were the primary tools for depression. Have we found anything better in the last 50 years? At least opiates and stims didn't need three weeks to work. Now They don't work for everyone but I bet they would beat the 60% of the new ads.
>
> I agree, nothing really revolutionizing has happenened the last decades. Of course the newer meds have made the life easier but still.. On the other hand, older meds are tried and true, you know what you're up against, so to speak. Modafinil worked a long time, I wonder why it doesn't work anymore, anyway I will give my new combo some more time, then I will call my pdoc and ask for dexedrine.
> As you all know, it's frustrating watching the life pass by and have no energy, no impulses to do anything.
>
> /tensorYes I know what you mean. Most of the time I have the energy to get out of bed and force myself to do things. But also much of the time I derive no pleasure from life. I think this has gotten worse as I have gotten older. The color tv of my mind gets duller and duller. So I look for meds to get the color a bit brigter.
I remember as a young boy feeling happier after a teaspoon of codeine cough medicine. I didn't know what it was at the time so there was no placebo effect. So maybe I was born with a lack of pleasure endorphins. I always enjoyed my cough medicine when I was sick.
So maybe this was a vicious cycle. The cough medicine made me feel happy. But than after it wore off life seemed more dull. So I later pursued this happiness. But when off it I was even worse.
If you look at evolution and genetics there will be a variation in how many feel good endorphins one has. I've talked to people who say they get no effect from opiates. So are people who feel happier after a dose of opiates deficient in this substance?
If science could figure how how to conquer tolerance with stims and opiates you might have the best ads of the whole lot. The effect is immediate. Not perfect and not all respond to them. But I have a feeling the response rate might be better than the typical 60% of the other ads.
Posted by bulldog2 on November 13, 2009, at 16:54:45
In reply to Re: Stimulants for TRD » bulldog2, posted by conundrum on November 13, 2009, at 12:03:01
> When you said you feel good for a few days and then it decreases, do you mean you feel high for a few days and then normal levels of emotions?
>
> Can on still feel euphoric from normal life events once you have a bit of a tolerance or do you remain somewhat anhedonic?Yes for the first few days you have a bit of euphoria or if one's abusing the stims a lot of euphoria which I no longer enjoy. After several days the stim effect is still there but most of the mood effect is gone. This might be helpful for add but not for depression. Might be more helpful in combination with other meds.
As I mentioned before there are meds to counter the tolerance such as memantine but I could not tolerate this med.
Actually a combinaton of opiates and stims feels better than either. They seem synergistic. The opiates take the rough edge off the stims.
I might try low dose amitriptyline with the vyvanse. I know tcas can potentiate the effects of stims. I tried 10 mg amitriptyline with vyvanse. I can't find any research that they prevent tolerance. Bit it might be worth a shot. Keep the tca dose low.
Posted by floatingbridge on November 13, 2009, at 17:34:51
In reply to Re: Stimulants for TRD, posted by bulldog2 on November 13, 2009, at 11:41:15
> So I believe that stims have an important place in the p-docs tool box.
> Before the advent of our new ads opiates and stims were the primary tools for depression. Have we found anything better in the last 50 years? At least opiates and stims didn't need three weeks to work. Now They don't work for everyone but I bet they would beat the 60% of the new ads.
This sounds like what my pdoc said today re: my dexedrine. My depression did not remit much until the addition of dex.fb
Posted by Maxime on November 13, 2009, at 17:36:02
In reply to Re: Stimulants for TRD » uncouth, posted by SLS on November 13, 2009, at 15:08:01
My pharmacy wouldn't let me take the Wellbutrin with the Parnate. I hadn't planned on taking it, but they said no.
Posted by floatingbridge on November 13, 2009, at 17:37:12
In reply to Re: Stimulants for TRD » bulldog2, posted by tensor on November 13, 2009, at 12:02:16
Modafinil worked a long time, I wonder why it doesn't work anymore, anyway I will give my new combo some more time, then I will call my pdoc and ask for dexedrine.
> As you all know, it's frustrating watching the life pass by and have no energy, no impulses to do anything.
>
> /tensorTensor, have you read the thread(s) on generic vs. brand dexedrine and spansules vs. immediate release? I found them helpful.
fb
Posted by floatingbridge on November 13, 2009, at 17:43:44
In reply to Re: Stimulants for TRD, posted by uncouth on November 13, 2009, at 14:41:36
> My guess is that in the short run, most people tend to respond similarly to stims -- short term, immediate mood lifting and activation.
>
> My guess is that in the long run, stimulants can either be very good or very bad for people, depending on genetics and specifics of their disorder.
>
> I think stimulants caused a permanent adjustment in my brain's reward system, such that my current default state has become apathy, anhedonia, amotivation. I am considering going back on stimulants, but hoping something else (bupropion and antipsychotics) can normalize. Not holding my breath though.
>Uncouth, how long did you take stimulants for?
> I sometimes wonder if God made me by design like this - to not derive much pleasure from this world. Sure makes it painful and hard to live in it though.Please, Uncouth, I'm so sorry you feel this could be a possibility. (I have thought --and think--similar thoughts.) I'm glad that you posted and shared this, and I want to say that you were not made to suffer. Life is unfair, but there is a place in God's heart, or the universe, or however one would phrase it, for everyone--all of us. I try to remember this every day (w/ varying degrees of success).
many hugs,
fb
Posted by floatingbridge on November 13, 2009, at 17:57:11
In reply to Stimulants for TRD, posted by tensor on November 13, 2009, at 4:31:35
> Hi,
>
> what are your experiences with using stimulants as amphetamine for treatment-resistant depression? I used to take modafinil for a pretty long period of time but it simply does not work anymore. So I'm now looking at other options.
> I was thinking that I could take it monday-thursday and have a drug holiday friday-sunday as I did with modafinil to not develop tolerance, this way I would at least get things done four days a week as opposed to zero now. What do you think?
>
>
> Thanks.Hi Tensor,
Well, I've been taking Dexedrine for 8 months now, along w/ pristiq and various benzos (anxiety was a problem before the dex came on board. I've built up a tolerance, but not to the mood elevation--I mean, it is not the euphoria I first experienced, but it stills brightens me in a way nothing else has. I deal w/ the crash in various ways, and it's taken months to figure out a way to minimize the crash (which can be very ugly and painful). I am going to try the brand dexedrine spansules. I found out my insurance will cover them for not much extra. Generic IR and the Barr generic spansules do not last nearly as long as they should. The Barr spansules wear off after 4-5 hours! (The pamphlet says 10-12!) (I did not respond well to provigil.)
I've never taken drug holidays, so I cannot speak to that. I keep my daily dex consumption low and do not increase unless in an emergency.
Hope this was of some help. Do you take any other meds?
Posted by ColoradoSnowflake on November 13, 2009, at 18:33:05
In reply to Re: Stimulants for TRD » tensor, posted by floatingbridge on November 13, 2009, at 17:57:11
Hi all:
Dexedrine plus alcohol was the best combo I have ever had.......was wonderful and I had a ball for 20 years. Then they kicked my a**, I hit the wall, and it's been shades of awful ever since.
Parnate + Provigil + Nortrip has been the best since then, but doesn't compare to my old remedy!
hugs to everybody,
gayle
Posted by floatingbridge on November 13, 2009, at 18:34:10
In reply to Re: Stimulants for TRD » tensor, posted by floatingbridge on November 13, 2009, at 17:57:11
>
> Hope this was of some help. Do you take any other meds?Umm, sorry Tensor--bad memory. Just re-read your thread about your new combo. My bad.
Good Luck!
fb
Posted by southernsky on November 14, 2009, at 1:06:24
In reply to Stimulants for TRD, posted by tensor on November 13, 2009, at 4:31:35
It doesn't seem unreasonable to use drugs that enhance the dopamine system, imo. I'm not sure why it's more acceptable to target seratonin and noradreneline while ignoring dopamine...
Dextro helped me in that I didn't experience the horrible side effects from SSRIs that were worse than the depression itself. I never felt euphoria from dextro, but its affect has decreased after about a year on a low dose. Overall it does help and is much better for me than ssris.
There is a lot of research out there that TRD is a result of personality disorders, which point to characteristics that should be treated with therapy. One of the red flags of a personality disorder or comorbid personality disorder is repeated negative responses from psychotropic drugs.
As for me-i don't see the delineation between personality disorders (character disorders) and neurotic depression/disorders, its only seems to be a caterorgization used for treatment purposes, but it is something worth researching and learning about.
Posted by pingles on November 14, 2009, at 6:19:39
In reply to Stimulants for TRD, posted by tensor on November 13, 2009, at 4:31:35
Posted by SLS on November 14, 2009, at 6:27:12
In reply to Re: Stimulants for TRD, posted by southernsky on November 14, 2009, at 1:06:24
> It doesn't seem unreasonable to use drugs that enhance the dopamine system, imo. I'm not sure why it's more acceptable to target seratonin and noradreneline while ignoring dopamine...
I think the idea exists that anything that enhances dopaminergic neurotransmission through reuptake inhibition or synaptic release will produce addiction. Two very good antidepressants used in the 1980s were potent reuptake inhibitors of dopamine (DA). One of these, amineptine, displayed some addictive responses, but nothing to the degree of cocaine, another DA reuptake inhibitor. The other drug, nomifensine displayed no such addictive potential. There is also Wellbutrin, an antidepressant drug that is touted as being a DA reuptake inhibitor. So, things are not so simple as to be able to categorize all DA drugs as being addictive. Some of the new drugs in clinical stages of development are reuptake inhibitors of the three biogenic amines implicated in depression: serotonin (5-HT), norepinephrine (NE), and dopamine. Assigned the moniker "triple uptake inhibitors", I have not yet seen any indication that they display addictive properties.
> As for me-i don't see the delineation between personality disorders (character disorders) and neurotic depression/disorders,
What exactly is a neurotic depression?
- Scott
Posted by linkadge on November 14, 2009, at 9:19:43
In reply to Re: Stimulants for TRD » southernsky, posted by SLS on November 14, 2009, at 6:27:12
I have been using methylphenidate in combination with amitriptyline.
What I notice is that it does produce very fast and a very complete feeling of remission. I have been crashing though. Perhaps an evening dose would help that.
I don't feel so much euphoria as I do the drug moving me from internal to external. When I am depressed, all I feel is internal and nothing external means anything. The stim helps shift that ballance - at least temporarily.
Linkadge
Posted by tensor on November 14, 2009, at 9:29:11
In reply to Thanks alot for your input, very helpful! (nm), posted by pingles on November 14, 2009, at 6:19:39
LOL, pingles is actually a friend of mine and I was accidentally logged in as her when posting :-) So it's me, tensor, who is thanking.
Posted by floatingbridge on November 14, 2009, at 10:01:07
In reply to Re: Stimulants for TRD, posted by southernsky on November 14, 2009, at 1:06:24
> There is a lot of research out there that TRD is a result of personality disorders, which point to characteristics that should be treated with therapy. One of the red flags of a personality disorder or comorbid personality disorder is repeated negative responses from psychotropic drugs.
>
> As for me-i don't see the delineation between personality disorders (character disorders) and neurotic depression/disorders, its only seems to be a caterorgization used for treatment purposes, but it is something worth researching and learning about.southernsky,
I read something about this just yesterday (as I was contemplating my own trd) and found it very interesting, at least in my own case. I will not speak for others and their experience.
fb
Posted by bulldog2 on November 14, 2009, at 10:48:37
In reply to Re: Stimulants for TRD, posted by linkadge on November 14, 2009, at 9:19:43
> I have been using methylphenidate in combination with amitriptyline.
>
> What I notice is that it does produce very fast and a very complete feeling of remission. I have been crashing though. Perhaps an evening dose would help that.
>
> I don't feel so much euphoria as I do the drug moving me from internal to external. When I am depressed, all I feel is internal and nothing external means anything. The stim helps shift that ballance - at least temporarily.
>
> Linkadge
>
>
>
>
>
>There are longer timed formulations for ritalin and that includes a patch which can be removed when you wish to sleep.
Interesting your comment on moving the internal to external. When depressed I keep processing all my thoughts. Where in meditation you let them flow by in depression you latch onto them and experience emotions.I know I am coming out of depression when I become interested in external stimuli which includes becoming more sociable.
I am experimenting with 10 mg of amitriptyline with my vyvanse (50 mg). Seems to take the raw edges off. I want to see if it prolongs the vyvanse action and slows tolerance.
Posted by linkadge on November 14, 2009, at 12:50:18
In reply to Re: Stimulants for TRD » southernsky, posted by floatingbridge on November 14, 2009, at 10:01:07
>There is a lot of research out there that TRD is >a result of personality disorders
According to some I suppose. According to others TRD is a result of bipolar disorder.
Linkadge
Posted by southernsky on November 14, 2009, at 13:05:33
In reply to Re: Stimulants for TRD, posted by linkadge on November 14, 2009, at 12:50:18
sorry i meant to post this here instead of below.
yes Linkadge-many different theories out there.Here's a view from a professor at Columbia University about poor drug treatment response:
But in fact there is a body of literature that shows that when patients have a comorbid
personality disorder, its more difficult to treat their Axis I conditions. For example, if you have a patient who is depressed and who has narcissistic or borderline PD, that person is likely going to be difficult to treat. They may be failing various trials of meds, and knowing about their PD would be very helpful in understanding why. Or, a patient with panic disorder may not be responding to medication because they have a comorbid avoidant personality disorder. This is one reason drug companies exclude such patients from clinical trials, because they want the best response rate they can get.http://www.thecarlatreport.com/expertqa/diagnosing-personality-disorders
Hope it is helpful for some. I thought this interview was very interesting and informative.
Posted by southernsky on November 14, 2009, at 13:14:17
In reply to Re: Stimulants for TRD, posted by southernsky on November 14, 2009, at 13:05:33
I just reread that article/interview from my last post, and it seems the relevance of personality disorders may be more influential than I first realized.It will be interesting to see if the DSM is changed to reflect the growing clinical and researcher consensus about addressing the relevance of PDs.
"Now, most clinicians and researchers in personality disorders are saying it is time to move PDs to Axis I."
also from article:
So what do you think is likely to happen in DSM-V?
Its likely that personality disorders will be on Axis I. Moving disorders form Axis II to Axis I has happened before. When we went from DSM-III to III-R, the autism community wanted autism to be on Axis I, and so it was moved. Then, when
we went from DSM III-R to DSM-IV, the learning disorders community wanted learning disorders to go to Axis I, and we made that change. But the mental retardation community still liked the idea that MR was special, and they wanted it to stay on Axis II. Now, most clinicians and researchers in personality disorders are saying it is time to move PDs to Axis I.
Posted by SLS on November 14, 2009, at 13:15:30
In reply to Re: Stimulants for TRD, posted by southernsky on November 14, 2009, at 13:05:33
Would you say that most personality disorders are psychogenic or biogenic?
- Scott
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