![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 10 of 10. This is the beginning of the thread.
Posted by A0102 on February 1, 2002, at 5:08:57
Hi,
I have had problems with depression for about 7 years. Most antidepressants seem to work somewhat for me, but not enough to allow me to be able to function like a normal person would. ADs are basically enough to get rid of my suicidal ideations but don't help at all with the desire or drive to do anything productive. Even on ADs, I have a hard time just getting up in the morning and going to class. One of the biggest problems is that I have no energy to do anything most of the time. I still have really great friends and still enjoy things occasionally, but good times are hard to come by.
My experiences with ADs are like this:Paxil - made me apathetic, slightly effective
Imipramine - ineffective
Doxepin - ineffective
Remeron - helped with sleep and appetite, very slightly effective for depression
Celexa - very effective for the first couple weeks and after each dose increase. made me apathetic at higher doses. overall only moderately effective.
Wellbutrin - caused migraines, irritability, and lots of weight loss. slightly effective for depression
Prozac - ineffective (in all truth, I did not give this one a fair trial. I tried this one at a very bad time and only stuck with it for a few weeks)
Desipramine - caused all over achy flu-like feelings and very blurry vision. was not effective
Effexor - currently taking this one (on my 2nd week), seems similar to other SSRIs so far but too early to tell yet although I have been very sleepy
That is the current run down. I have also taken various combinations (Celexa + Remeron, Celexa + Provigil, Wellbutrin + Celexa, Wellbutrin + Provigil, Wellbutrin + Desipramine) and these have not done much more than give me 2 sets of side effects. go figure!
My next plan is to try to get my pdoc to prescribe Effexor + Remeron (very small dose!) + Dexedrine. With this combo, I hope that the Dexedrine will give me the energy to get my work done and get to class and also augment the Effexor. Remeron will combat the weight loss and insomnia that could result from Dexedrine. I particularly do not want to become addicted to stimulants, so I will encourage my doctor to be extra cautious (as if he won't be already). I'm happy to hear any advice! Thanks in advance and sorry for such a long post,
Adam
Posted by Elizabeth on February 2, 2002, at 12:18:35
In reply to Looking for advice for TRD / anergia (long), posted by A0102 on February 1, 2002, at 5:08:57
Hi. Sounds like you have the fairly common problem of SSRI-induced apathy as well as residual anergia that ADs haven't been helping with.
The idea of adding a stimulant sounds good. The Remeron might make the drowsiness worse -- at low doses it can be very sedating. You might want to add the Dexedrine alone and wait and see if you have insomnia problems from the Dexedrine or if the Effexor causes side effects that Remeron might alleviate. In general it's a good idea not to add medications until you know how the one you're taking is working, or to start multiple drugs at a time.
I don't think that addiction is a serious concern with Dexedrine, as long as you don't abuse it. If you find yourself wanting to take more than the amount prescribed, you should tell your doctor.
I notice that MAOIs (Nardil, Parnate, Marplan) aren't on your list, although you've tried several tricyclics. I think they're worth a try for someone like you (nonresponse to TCAs, apathy on SSRIs). Parnate is the one I'd recommend, as it tends to be the most stimulating (although it isn't always). If you're scared of the dietary restrictions or the risk of hypertensive crisis, that stuff has really been blown out of proportion -- there are very few foods that you actually need to avoid. Of course, you can't take MAOIs with most other ADs, and I think the Effexor/Dexedrine combination is worth trying (you should see how Effexor works by itself before adding Dexedrine, of course). But it might be a good next step if this doesn't work for you.
How much Effexor are you taking? Effexor isn't a SSRI (it's a norepinephrine reuptake inhibitor too, so it's not considered "selective") and it can often work for people who haven't found the SSRIs very helpful. I'm taking 225 mg/day, and it seems to be helping. My pdoc and I are planning on going up to 300 mg or more.
I hope this helps. Good luck with the Effexor. Oh, and welcome to Psycho-Babble!
-elizabeth
P.S. Your post isn't that long -- I've seen some *really* long ones on this board. So don't worry about it. :-)
Posted by petters on February 3, 2002, at 2:03:01
In reply to Re: Looking for advice for TRD / anergia, posted by Elizabeth on February 2, 2002, at 12:18:35
> Hi. Sounds like you have the fairly common problem of SSRI-induced apathy as well as residual anergia that ADs haven't been helping with.
>
> The idea of adding a stimulant sounds good. The Remeron might make the drowsiness worse -- at low doses it can be very sedating. You might want to add the Dexedrine alone and wait and see if you have insomnia problems from the Dexedrine or if the Effexor causes side effects that Remeron might alleviate. In general it's a good idea not to add medications until you know how the one you're taking is working, or to start multiple drugs at a time.
>
> I don't think that addiction is a serious concern with Dexedrine, as long as you don't abuse it. If you find yourself wanting to take more than the amount prescribed, you should tell your doctor.
>
> I notice that MAOIs (Nardil, Parnate, Marplan) aren't on your list, although you've tried several tricyclics. I think they're worth a try for someone like you (nonresponse to TCAs, apathy on SSRIs). Parnate is the one I'd recommend, as it tends to be the most stimulating (although it isn't always). If you're scared of the dietary restrictions or the risk of hypertensive crisis, that stuff has really been blown out of proportion -- there are very few foods that you actually need to avoid. Of course, you can't take MAOIs with most other ADs, and I think the Effexor/Dexedrine combination is worth trying (you should see how Effexor works by itself before adding Dexedrine, of course). But it might be a good next step if this doesn't work for you.
>
> How much Effexor are you taking? Effexor isn't a SSRI (it's a norepinephrine reuptake inhibitor too, so it's not considered "selective") and it can often work for people who haven't found the SSRIs very helpful. I'm taking 225 mg/day, and it seems to be helping. My pdoc and I are planning on going up to 300 mg or more.
>
> I hope this helps. Good luck with the Effexor. Oh, and welcome to Psycho-Babble!
>
> -elizabeth
>
> P.S. Your post isn't that long -- I've seen some *really* long ones on this board. So don't worry about it. :-)
Hi...The apathy from ssri is a quite common side effect. The reason is because the ssri reduce the dopamine level in the brain.
You can raise it again with meds like Wellbutrin or Mirapex, or why not Amantadine. This have helped many with similary problem as yours.
Sorry for my bad spelling. Not from U.S
Sincerely...//Petters
Posted by A0102 on February 3, 2002, at 6:27:14
In reply to Re: Looking for advice for TRD / anergia, posted by Elizabeth on February 2, 2002, at 12:18:35
Elizabeth,
Thanks for the advice! I'll give a little more insight now, but I didn't want to make my post but SO long. I am currently taking 75mg of Effexor XR daily. This is my 2nd week on it and I am increasing to 150mg next week. After that I have an appointment with my pdoc to decide where to go from there.I thought Dexedrine sounded like a good idea because of it's obvious "getting me out of bed" properties, but for other reasons as well. I have tried Adderall before (only 10mg) and found that it worked quite well at helping me find interest in life in general. It also helped me to focus on my school work much better. I'm not trying to say that I could be ADD but I noticed that I did spend much more time paying attention to what the professors were saying instead of daydreaming. I also found that it did almost nothing in the way of being physically stimulting. As odd as it seems, I found it calming in a way. You can see that I tried Provigil before to augment several of the other ADs, but it was pretty much worthless for me. I could take 400mg and still sleep 14 hours. Anyway, the 10mg of regular Adderall seemed to do well but I would prefer an all day dose. Would 20mg of Adderall XR or 15mg Dexedrine Spansules not provide similar action? (I don't know, I don't have too much experience here.)
I also wanted to add Remeron to insure that I don't have trouble falling asleep after taking a stimulant. I do take Sonata on occasion because a lot of the time I keep myself from going to sleep trying to figure out how to catch up on what I've missed during the day. My concern with continuing to take Sonata along with a stimulant is relying on them to regulate my sleep cycle and eventually building myself up to a crash. Also, Remeron works very well to increase my appetite which is another concern I have with stimulants.
I have not tried an MAOI yet due to the fact that my pdoc says I would likely have migraines with them similar to my experience with Wellbutrin. I'm not sure exactly how he came up with that or why he decided to go with Effexor. Effexor has a 25% rate of occurance of headache! Nonetheless, I am taking it now and don't really want to try to stop before I've given it a chance, as well as the withdrawl symptoms and my pdoc getting pissed for noncompliance.
So, that is where I stand right now. I'm hoping I won't have another post here in a few weeks asking for recommendations on a new pdoc. This one seems to be caught up in running through the list of every commonly used med before trying anything creative to target my specific symptoms. I'm not sure if that's good(i.e., patience) or bad(i.e., incompetence), but all I know is that while he's busy with that I'm dropping out of classes and losing my job.
Anyway, sorry for rambling on and thanks again Elizabeth and anyone else who wants to contribute!
Adam
> Hi. Sounds like you have the fairly common problem of SSRI-induced apathy as well as residual anergia that ADs haven't been helping with.
>
> The idea of adding a stimulant sounds good. The Remeron might make the drowsiness worse -- at low doses it can be very sedating. You might want to add the Dexedrine alone and wait and see if you have insomnia problems from the Dexedrine or if the Effexor causes side effects that Remeron might alleviate. In general it's a good idea not to add medications until you know how the one you're taking is working, or to start multiple drugs at a time.
>
> I don't think that addiction is a serious concern with Dexedrine, as long as you don't abuse it. If you find yourself wanting to take more than the amount prescribed, you should tell your doctor.
>
> I notice that MAOIs (Nardil, Parnate, Marplan) aren't on your list, although you've tried several tricyclics. I think they're worth a try for someone like you (nonresponse to TCAs, apathy on SSRIs). Parnate is the one I'd recommend, as it tends to be the most stimulating (although it isn't always). If you're scared of the dietary restrictions or the risk of hypertensive crisis, that stuff has really been blown out of proportion -- there are very few foods that you actually need to avoid. Of course, you can't take MAOIs with most other ADs, and I think the Effexor/Dexedrine combination is worth trying (you should see how Effexor works by itself before adding Dexedrine, of course). But it might be a good next step if this doesn't work for you.
>
> How much Effexor are you taking? Effexor isn't a SSRI (it's a norepinephrine reuptake inhibitor too, so it's not considered "selective") and it can often work for people who haven't found the SSRIs very helpful. I'm taking 225 mg/day, and it seems to be helping. My pdoc and I are planning on going up to 300 mg or more.
>
> I hope this helps. Good luck with the Effexor. Oh, and welcome to Psycho-Babble!
>
> -elizabeth
>
> P.S. Your post isn't that long -- I've seen some *really* long ones on this board. So don't worry about it. :-)
Posted by spike4848 on February 3, 2002, at 15:07:58
In reply to Re: Looking for advice for TRD / anergia » Elizabeth, posted by A0102 on February 3, 2002, at 6:27:14
> I have not tried an MAOI yet due to the fact that my pdoc says I would likely have migraines with them similar to my experience with Wellbutrin.Not true ... MAOI's can be used to treat migraine headaches. The only headache you would get is if your had a hypertensive reaction.
Spike
Posted by Denise528 on February 4, 2002, at 10:40:30
In reply to Re: Looking for advice for TRD / anergia, posted by petters on February 3, 2002, at 2:03:01
> > Hi Petters.
> >
>
> Can you explain? You say that SSRI induced apathy is caused by reduction of dopamine in the brain. If this is the case why do I feel less apathetic when taking Zyprexa, I thought Zyprexa reduces dopamine also.thx.....Denise
Posted by Elizabeth on February 4, 2002, at 12:33:50
In reply to Re: Looking for advice for TRD / anergia » Elizabeth, posted by A0102 on February 3, 2002, at 6:27:14
> I thought Dexedrine sounded like a good idea because of it's obvious "getting me out of bed" properties, but for other reasons as well.
Sure, since you've had past success with stimulants I think it's a fine idea. I think that you should give Effexor alone a chance to work, just so you'll know what's doing what. You may even find that you don't need a stimulant with the Effexor. I'm not sure about amphetamine doses; you'll need to work that out with your doctor. Concerta is another thing you might consider if you want something long-lasting.
> I also wanted to add Remeron to insure that I don't have trouble falling asleep after taking a stimulant.
A fine plan, but again, I think you should wait to see if you need it! When I was taking a stimulant (Cylert -- weaker than amphetamine, but lasts about 12 hours), I found that it helped me to regulate my sleep-wake cycle: I'd take it in the morning and be alert during the day, then gradually get tired just around the time I needed to go to sleep. Sleep regularity isn't something that comes easily to me, so this was pretty cool.
> I do take Sonata on occasion because a lot of the time I keep myself from going to sleep trying to figure out how to catch up on what I've missed during the day. My concern with continuing to take Sonata along with a stimulant is relying on them to regulate my sleep cycle and eventually building myself up to a crash.
Why do you think that wouldn't happen with Remeron too? I'm not sure about Sonata, but I know that Ambien often continues to work for a long time without tolerance (I took it just about every day when I was on Nardil and had no problems with tolerance or dependence).
> I have not tried an MAOI yet due to the fact that my pdoc says I would likely have migraines with them similar to my experience with Wellbutrin.
I don't see any reason to assume that. They're completely different drugs. As Spike pointed out, MAOIs are actually used to prevent migraines (or they used to be, anyway). It's *possible* you'll have migraines on them, but I think the risk of that is small. Obviously since you're trying Effexor, MAOIs aren't the thing to try right now, but it's an idea to keep on the back burner, and I think it's something you shouldn't rule out.
> I'm not sure exactly how he came up with that or why he decided to go with Effexor. Effexor has a 25% rate of occurance of headache!
Migraines are a very specific type of headache, not at all the same as the tension headaches that most people have from time to time. Anyway, headaches occur a lot in the general population, so placebo also has a high headache rate!
> This one seems to be caught up in running through the list of every commonly used med before trying anything creative to target my specific symptoms. I'm not sure if that's good(i.e., patience) or bad(i.e., incompetence), but all I know is that while he's busy with that I'm dropping out of classes and losing my job.
Patience is important (for both of you), but he also needs to choose medications rationally, with thought for your particular symptoms. Why not ask him why he chose Effexor in particular (and generally make a habit of asking for an explanation whenever he recommends a new med).
-elizabeth
Posted by Elizabeth on February 4, 2002, at 12:46:00
In reply to Re: Looking for advice for TRD / Peters, posted by Denise528 on February 4, 2002, at 10:40:30
Different people have different reactions to drugs. You feel less apathetic on Zyprexa, but a lot of people feel very sedated and "dull" or "flat" on antipsychotics. Some people become apathetic on SSRIs. This effects is hypothesized to be due to indirect effects on the dopaminergic system, but nobody really knows for sure (my guess is that it's not that simple). Also, Zyprexa has some fairly selective effects -- it doesn't decrease the amount of dopamine, but rather, it blocks dopamine receptors. There are different types of dopamine receptors that serve different functions, and Zyprexa doesn't block all of them with equal affinities. The receptors designated "D2" are the ones that are relevant in the antipsychotic action of Zyprexa, but blockade of the other dopamine receptor subtypes may have clinically relevant effects too. Zyprexa also blocks a particular subtype of serotonin receptor, and this may contribute as well.
I hope this answers your question.
Best,
-elizabeth
Posted by OldSchool on February 4, 2002, at 22:01:56
In reply to Looking for advice for TRD / anergia (long), posted by A0102 on February 1, 2002, at 5:08:57
> Hi,
> I have had problems with depression for about 7 years. Most antidepressants seem to work somewhat for me, but not enough to allow me to be able to function like a normal person would. ADs are basically enough to get rid of my suicidal ideations but don't help at all with the desire or drive to do anything productive. Even on ADs, I have a hard time just getting up in the morning and going to class. One of the biggest problems is that I have no energy to do anything most of the time. I still have really great friends and still enjoy things occasionally, but good times are hard to come by.
> My experiences with ADs are like this:
>
> Paxil - made me apathetic, slightly effective
>
> Imipramine - ineffective
>
> Doxepin - ineffective
>
> Remeron - helped with sleep and appetite, very slightly effective for depression
>
> Celexa - very effective for the first couple weeks and after each dose increase. made me apathetic at higher doses. overall only moderately effective.
>
> Wellbutrin - caused migraines, irritability, and lots of weight loss. slightly effective for depression
>
> Prozac - ineffective (in all truth, I did not give this one a fair trial. I tried this one at a very bad time and only stuck with it for a few weeks)
>
> Desipramine - caused all over achy flu-like feelings and very blurry vision. was not effective
>
> Effexor - currently taking this one (on my 2nd week), seems similar to other SSRIs so far but too early to tell yet although I have been very sleepy
>
> That is the current run down. I have also taken various combinations (Celexa + Remeron, Celexa + Provigil, Wellbutrin + Celexa, Wellbutrin + Provigil, Wellbutrin + Desipramine) and these have not done much more than give me 2 sets of side effects. go figure!
>
> My next plan is to try to get my pdoc to prescribe Effexor + Remeron (very small dose!) + Dexedrine. With this combo, I hope that the Dexedrine will give me the energy to get my work done and get to class and also augment the Effexor. Remeron will combat the weight loss and insomnia that could result from Dexedrine. I particularly do not want to become addicted to stimulants, so I will encourage my doctor to be extra cautious (as if he won't be already). I'm happy to hear any advice! Thanks in advance and sorry for such a long post,
> AdamI dont know, youve tried a lot of drugs like me. I think its rather unlikely any drug will fix you. Maybe an MAOI would be worth a shot if you havent tried that. I am of the opinion that if youve been thru the medicine merry go round with depression and nothing works, its unlikely that more SSRIs and tricyclics and similar conventional meds is going to fix you. The only med I have any confidence in for TRD is MAOIs. And many do not want to take those for obvious reasons.
The other possibility is ECT. ECT is effective for TRD. Basically thats my opinion about TRD. The only things really effective for TRD is MAOIs and old fashioned ECT. What a choice huh?
The medicine merry go round sucks, it gets old and it rarely works after youve been on so many psych meds.
Old School
Posted by Denise528 on February 5, 2002, at 6:10:22
In reply to Re: apathy + or - on Zyprexa » Denise528, posted by Elizabeth on February 4, 2002, at 12:46:00
> Different people have different reactions to drugs. You feel less apathetic on Zyprexa, but a lot of people feel very sedated and "dull" or "flat" on antipsychotics. Some people become apathetic on SSRIs. This effects is hypothesized to be due to indirect effects on the dopaminergic system, but nobody really knows for sure (my guess is that it's not that simple). Also, Zyprexa has some fairly selective effects -- it doesn't decrease the amount of dopamine, but rather, it blocks dopamine receptors. There are different types of dopamine receptors that serve different functions, and Zyprexa doesn't block all of them with equal affinities. The receptors designated "D2" are the ones that are relevant in the antipsychotic action of Zyprexa, but blockade of the other dopamine receptor subtypes may have clinically relevant effects too. Zyprexa also blocks a particular subtype of serotonin receptor, and this may contribute as well.
>
> I hope this answers your question.
>
> Best,
> -elizabethElizabeth,
Yes you did answer my question, thanks.
Denise
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.