Posted by Cam W. on October 4, 2001, at 11:24:12
In reply to Re: Will more Prozac help? » Cam W., posted by Marie1 on October 4, 2001, at 6:59:23
Marie - I don't really think that there is a clinical definition of "poop-out". It could be caused by several situations, to varying degrees. I have a paper that is 3 or 4 years old that talks about reasons for the loss of efficacy of antidepressants. If I remember correctly, the article listed causes and 7 potential strategies to counter what we on this board call poop-out (I'm not sure if the term was invented on PB or not, but a few of us here have big enough egos that we can claim it was). I would like to dig out the paper, but my files are still piled in 12 boxes in the garage (I gotta get a file cabinet or two). I believe that poop-out occurs most often in SSRIs, but has been seen in most all ADs.
I believe that they listed things like change in disease state (worsening of depression), changes in the kinetics of the AD &/or it's metabolites, changes in concentration of neurotransmitters &/or their receptors (not just serotonin, but possibly serotonin-induced changes in other NTs - like dopamine, GABA, acetylcholine, norepinephrine, etc - or neuroreceptors - for glucocorticoids, CRH, ACTH, etc.), age-related changes in physiology (menopause), thyroid hormone changes, etc.
I found it interesting that strategies to combat poop-out included lowering the antidepressant dose, as well as raising it. I would assume that lowering the dose may decrease secondary side effects, while maintaining AD effect. In other words, side effects such as cognitive blunting from cholinergic receptor blockade may resemble symptoms of depression, and when some of this blockade is removed through lowering of the dose, the AD appears to work again.
Anyway, back to your question. There is still a debate in the literature whether to augment an AD in treatment-resistant depression or to try a different AD (either within the same class or one with a different mechanism of action).
Most studies of augmentation of ADs are open-label, but there are some double-blind placebo controlled trials, as well (although, most of these are of short duration - eg. 6 - 12 weeks).
Dr.Mauricio Fava article, "Augmentation and Combination Strategies in Treatment-Resistant Depression" (p. 4-11), in the recent Eli Lilly-funded Journal of Clinical Psychiatry Supplemental (Vol.62, Suppl. 18, 2001), "Management of Treatment-Resistant Depression"
A) CLEAR EFFICACY:
a)lithium
b)liothyronine (thyroid hormone T3)B) SUGGESTED EFFICACY:
a) dopaminergic agents (pergolide, amantadine, pramipexole)
b) psychostimulants (methylphenidate, dextroamphetamine)
c) atypical antipsychotics (risperidone, olanzapine)
d) folate/methylfolate (methyltetrahydrofolate - MTHF)C) ANECDOTAL EFFICACY:
a) modafinil
b) anticonvulsants (VPA, carbamazepine, lamotrigine, gabapentin, topiramate)
c) opiates (oxycodone, oxymorphone, buprenorphine)
d) SAMe
e) DHEA
f) estrogensD) DISPUTED EFFICACY:
a) buspirone
b) pindolol
c) inositolAs for BuSpar™ (buspirone) augmentation of SSRIs, many earlier open-label, small studies showed significant improvement in treatment-resistant patients. More recently, the only double-blind, placebo-controlled trial have failed to replicate the findings of the earlier studies. There was no significant difference between the placebo or BuSpar when added to an SSRI in those with treatment-resistant depression.
The upside is that BuSpar does reverse the SSRI-induced sexual dysfunction in about 20% of those who try it.
As for you recommending BuSpar to those who have had SSRI poop-out, go for it! Tell your story and the doses you used. You may want to tell people that it doesn't work for everyone, but it worked for you. That's the difference between how most studies are read and clinical (real world) experience. We tend to forget the people in the negative studies that responded to the BuSpar + SSRI combination, and therefore, do not to use this augmentation strategy.
poster:Cam W.
thread:80214
URL: http://www.dr-bob.org/babble/20010927/msgs/80256.html