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Re: Was improving, now degrading?))SLS » dapper

Posted by SLS on January 9, 2009, at 8:08:25

In reply to Re: Was improving, now degrading?))SLS, posted by dapper on January 8, 2009, at 21:44:35

> SLS, your experiences with tri's? I have entered into that snowball effect. My depressive thoughts are building and I'm getting more and more uncomfortable. Wonder how long I can stay like this before something gives. Great to be back in this mental place.

It is a blessing that you understand so well the interaction (snowball effect) of depression with depression: with depression making depression worse making depression, making depression worse... etc. This insight might help you stay functional longer and reduce the painful descent into darkness.

With tricyclics, it is usually better to choose one of the secondary amines first, as they have milder side effects than the tertiaries. However, I wouldn't leave TCAs behind until you try imipramine at some point it is more potent than the others. In fact, just about the best drug for OCD is clomipramine (Anafranil) - imipramine with a chlorine atom attached. The two secondary amines are desipramine (Norpramin) and nortriptyline (Pamelor). They do not produce the magnitude of anticholinergic side effects that the others do. I am not sure which of the TCAs to try first. Nortriptyline is generally less activating than desipramine and is somewhat sedating, especially at first. It is a good drug, and I have had good luck with it. I had better luck with desipramine when it was combined with Parnate. It brought me to complete remission. It is a long story, but I no longer respond well to these two drugs without having to add a third and fourth.

It is a gamble to decide which drug to choose first. Some people do not respond to desipramine at all, who later go on to respond wonderfully to nortriptyline. The opposite is also true. These two drugs are each from a different series of compounds, so they are both worth trying. Unlike desipramine, which is a very selective NE reuptake inhibitor, nortriptyline adds some mild 5-HT reuptake inibition, 5-HT2a antagonism, and NE alpha-2 antagonism. I guess I just convinced myself that nortriptyline should be the first choice. You know, of course, that I don't have a crystal ball, and can give no guarantees. I think I would choose imipramine if nortriptyline doesn't work. It will give you a better chance of getting well than desipramine. If it works, you can then try to switch over to desipramine to mitigate the side effects. Actually, imipramine is broken down into desipramine (through desmethylation) in the body. Once equilibrium is established, there is usually significantly more desipramine flowing through your arteries than imipramine.

1. Nortriptyline
2. Imipramine

One step at a time. Depending on your reactions to these two drugs, it may or may not indicate investigating the other tricyclics.

There are lots of ideas floating around as to how to augment TCA and other antidepressants if monotherapy proves inadequate.


- Scott

 

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