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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 37. This is the beginning of the thread.
Posted by brynb on July 10, 2016, at 9:54:08
Hi All-
It's been quite a while since I've been back here. I have never been concretely DX'd with a depression "type" (meaning I exhibit many Bipolar 2 symptoms but not DX'd as such) and I'm on disability for MDD and GAD.
I recently went through a lot of changes, including changes to my meds which included dropping Tramadol (the only medicine that ever effectively treated my depression even though it was prescribed off-label). I did so because I have a substance abuse history (it's not active and is under control now), and had to stop the Tramadol as it kicked in too many triggers to want to use heavier opiates (it's an opioid) as well as other substances.
In it's place I'm using Subutex to help with the withdrawal. Its also used off-label as an AD, and I still take Lexapro and Klonopin.
Unfortunately, I've been suffering from great melancholia and loneliness and I'm sure dropping Tramadol has contributed to this. Going back on it is not an option. I've tried most every AD out there with the exception of MAOI's, which I'm very hesitant to take (and probably couldn't while on Subutex which I must take anyway). I've tried a lot of the Tricyclics with no success, every SSRI and Lexapro has been the "easiest" and at least addresses my anxiety, but I believe I need to try something in place of Lexapro again as I am in a minor depressive episode with melancholia being the biggest theme. (Note: I've been in many, many severe depressive episodes while on Lexapro and feel it most likely does nothing for my depression at this point, I'm just accustomed to it.)
I'm seeing my pdoc this week and we previously discussed switching to Pristiq, one of the few meds I haven't tried. To be clear, I've taken most AAPs and don't do well with them (but I'm willing to try Abilify with Lexapro again as I took it a while ago and don't remember anything positive or negative) and I can't take AEs/mood stabilizers (they make my depression worse).
So, ideas? Anything particularly good for melancholia?
Thanks in advance and I hope you're all faring well.
-b
Posted by jonhed on July 10, 2016, at 11:49:07
In reply to Best AD for Melancholia, posted by brynb on July 10, 2016, at 9:54:08
Since you have had abuse problems i think it's good to stop the tramadol, cause it's to light to be effective against the urge to take opiates.
I have sort of the same problems as you and i am very well now and have been for about three months.I take:
15mg of methadone, to target my ocd problems and to stop my urge for opiates.
I think that subutex is ineffective when it comes to that, because it stops working after 5 days.
When you're an addict, you need things that works every day, and always gives an effect.I've been on 15mg of methadone for 60 days now and i get effects every(!) morning from that small dose, and it has done wonders for my social anxiety and ocd. I do NOT think that you have to take 70-140mg of methadone for it to work, i very much don't.
And i take 2mg of clonazepam at the evening (20.00 8pm).
And 10mg of memantine right after i dosed clonazepam.Memantine reverse opiate tolerance and since i've been taking it, i feel my methadone every day as it was my firts day on it (okey, maybe 5th day but anyway not 60th day.)
I have just taken memantine for 10 days but for me it has been so so very good, i can't describe it.
I think people who has been addicted to drugs need pretty strong medications that you "feel" effects from.
You can read my memantine journal if you want to know more, it is on psychobabble.
So,
15mg methadone in the morning.
2mg clonazepam at the evening
10mg memantine at the evening (going up to 20 and then i will see if i want to raise it further).Memantine in my opinion is good for stopping drug seeking behaviour, or urge, what you want to call it.
Kind regards / J
Posted by jonhed on July 10, 2016, at 11:51:37
In reply to Re: Best AD for Melancholia, posted by jonhed on July 10, 2016, at 11:49:07
I want to add that every pdoc i see says that it is different to treat people with addiction and mental health problems, cause we may need bigger doses.
I've met 5-8 pdocs who have said the same thing.
that does NOT means that it must be applied on everyone, including you.
But this is my tip for you.
There are a lot of good people here who will give you equally good tips, i promise :-)
Posted by Christ_empowered on July 10, 2016, at 14:17:54
In reply to Best AD for Melancholia, posted by brynb on July 10, 2016, at 9:54:08
hi. maybe a more modern AD (the prisiq or the lexapro) with a non-neuroleptic, non-AED drug to augment it?
I dunno...maybe...lexapro+Provigil, or...Pristiq+gabapentin (or lyrica)...on and on it goes.
Or maybe lexapro+remeron, or Pristiq+Remeron, off the bat, from day 1. The combination is supposed to improve rates of response+remission, or at least it seems to in some small studies.
That's pretty much all I could come up with. Please keep us all posted.
Posted by linkadge on July 10, 2016, at 14:35:44
In reply to Re: Best AD for Melancholia, posted by Christ_empowered on July 10, 2016, at 14:17:54
I'm guessing you've tried regular Effexor?
SAMe + Effexor could be good for melancholia, but may trigger mania.
Linkadge
Posted by brynb on July 11, 2016, at 1:01:07
In reply to Re: Best AD for Melancholia, posted by jonhed on July 10, 2016, at 11:49:07
hi jonhed-
thanks for both of your responses. i am completely off the tramadol, which really is great. i used to sing its praises, as it helped with pain and hit practically every receptor making it GREAT for my depression/pain issues/etc., but as you mentioned, i needed large doses after 4 years to achieve what i needed and as i said, it led to too many substance issues again, so being off of it for 7-8 weeks is huge for me.
subutex has actually been great so far in its place and has eliminated cravings for me. i'm not looking to switch off, tho i realize some people like methadone. my pdoc is an addiction specialist and has been really spot on with his approach to my meds so far, so i'm ok with that.
i too am on 2mgs of klonopin, which is a low dose for me as far as benzos go, but definitely the sweet spot as anything more starts to backfire. i don't suffer from social anxiety; it's really GAD, but i'm beginning to wonder if a large part of my issue is OCD as it seems to play a much larger role in my depression than i initially thought (i.e.: the same intrusive and ruminating thoughts, etc.). i need to discuss this with my pdoc and think the big change i'm looking for here is swapping lexapro for something else more effective in treating OCD and/or melancholia.
i took the dna saliva test a few years ago that (i think) helps guide med choices, and all i really gained from it was the knowledge that i'm a fast metabolizer, and yes, typically need hire med doses than average.
thanks again for your help, i very much appreciate your responses. i'm so confused at this point and feel a bit defeated but hope i can get some ideas from my pdoc this week.
thanks so much!
Posted by brynb on July 11, 2016, at 1:11:26
In reply to Re: Best AD for Melancholia, posted by Christ_empowered on July 10, 2016, at 14:17:54
hi Christ_empowered,
thanks for your response. i think Pristiq is worth exploring, but i never had success with remeron or provigil. neurontin, oddly enough, makes me manic, so i can't take it.
i am willing to try abilify as an add on again. as i mentioned in my previous response, i'm beginning to feel defeated with my limited med options.
thanks so much for your response and i'll try to keep everyone updated on this thread.
Posted by brynb on July 11, 2016, at 1:15:40
In reply to Re: Best AD for Melancholia, posted by linkadge on July 10, 2016, at 14:35:44
hi linkadge,
i have tried effexor (a long time ago) and remember disliking it. my doc initially mentioned adding SAMe, but as you said, is afraid it will trigger mania.
i'm feeling a bit defeated right now but i very much appreciate everyone's responses and suggestions here. thanks so much for your response.
-b
Posted by SLS on July 11, 2016, at 8:02:03
In reply to Re: Best AD for Melancholia » linkadge, posted by brynb on July 11, 2016, at 1:15:40
> hi linkadge,
>
> i have tried effexor (a long time ago) and remember disliking it. my doc initially mentioned adding SAMe, but as you said, is afraid it will trigger mania.
>
> i'm feeling a bit defeated right now but i very much appreciate everyone's responses and suggestions here. thanks so much for your response.
>
> -bIf you get stuck for ideas, I would consider using a tricyclic antidepressant (TCA). I would try desipramine first. It is milder in terms of side effects than imipramine. My impression is that nortriptyline isn't quite as effective for melancholia, but desipramine will feel "harsher" in the beginning of treatment. A partial improvement using desipramine might be an indicator that its parent compound, imipramine, will work better. If falling asleep (sleep initiation) is a problem, you could use amitriptyine instead of imipramine, but weight gain is more of a problem. If you fall asleep initially, but wake up in the early morning, and your depression is at its worst, desipramine/imipramine will actually allow you to sleep the night though once the depression improves.
If desipramine works pretty well, but lacks a mood-brightening effect, you might then try nortriptyline before moving to imipramine. I find myself in this categegory.
- Scott
Posted by brynb on July 11, 2016, at 9:09:12
In reply to Re: Best AD for Melancholia » brynb, posted by SLS on July 11, 2016, at 8:02:03
Thanks, Scott. I had some of these in mind as I know they are effective with melancholia. I've tried a few of them before but only for very short periods. They were add-ons to the Lexapro.
Is that what you're suggesting?The other component here is I'm beginning to wonder if OCD plays a big role in my depression. I have the same recurring thoughts, fears, rumination all of the time but used to think that was a symptom of BI 2. From what I've been reading I'm thinking it's OCD (fears about things I can't control such as death, harm to family members, my dog, etc.) They're daily and intrusive and I can't get out of my head. That made me think about changing to Luvox, which I never tried. (I did try Prozac and it was terrible for me.)
I do fear weight gain so I'm weary of some Tricyclics and Abilify. With that in mind, I'm thinking about changing from Lexapro to Luvox or Pristiq, or staying on Lexapro and adding a Tricyclic or Abilify.
The other 2 constants are Subutex (which I'll eventually be weaned off of) and Klonopin, 2mg.
Feeling super confused :/. Thanks for the input.
Posted by SLS on July 11, 2016, at 15:07:24
In reply to Re: Best AD for Melancholia » SLS, posted by brynb on July 11, 2016, at 9:09:12
Ruminations and intrusive thoughts are known to be symptoms of melancholic depression. If true OCD is comorbid with melancholic depression, clomipramine (Anafranil) is a drug to explore.
I've had partial success with adding nortriptyline to a SNRI. I can't see why you couldn't add nortriptyline to Lexapro or Luvox. I don't think there are any interactions. Maybe someone else can comment on that.
- Scott
Posted by brynb on July 11, 2016, at 15:29:42
In reply to Re: Best AD for Melancholia » brynb, posted by SLS on July 11, 2016, at 15:07:24
> Ruminations and intrusive thoughts are known to be symptoms of melancholic depression. If true OCD is comorbid with melancholic depression, clomipramine (Anafranil) is a drug to explore.
Can Anafranil be added to my current 20mg of Lexarpro? And theoretically this would potentially address OCD & melancholic depression?
>
> I've had partial success with adding nortriptyline to a SNRI.For melancholic depression, OCD or both?
Thanks!!!
>>
> - Scott
Posted by SLS on July 11, 2016, at 16:16:30
In reply to Re: Best AD for Melancholia » SLS, posted by brynb on July 11, 2016, at 15:29:42
> > Ruminations and intrusive thoughts are known to be symptoms of melancholic depression. If true OCD is comorbid with melancholic depression, clomipramine (Anafranil) is a drug to explore.
>
> Can Anafranil be added to my current 20mg of Lexarpro?Theoretically, serotonin syndrome can be a complication of this combination. How much is the Lexapro helping?
> And theoretically this would potentially address OCD & melancholic depression?
I am thinking that clomipramine would address both. Clomipramine is a TCA with added SSRI-type actions. It is so good at doing the job, that doctors were writing prescriptions for it and having their patients fill them from Canadian pharmacies because it had not been approved in the USA yet.
> > I've had partial success with adding nortriptyline to a SNRI.
> For melancholic depression, OCD or both?I have bipolar depression without OCD.
Because clomipramine has anticholinergic side effects (dry mouth, blurred vision, constipation, difficulty urinating, etc.), you might want to first try adding nortriptyline or desipramine to Lexapro or Luvox.
You might think to add memantine for OCD if you get stuck.
From your description, I think I would act under the premise that you have melancholic depression without OCD. Work with your doctor to get a comprehensive screening for OCD if you are in doubt.
- Scott
Posted by jonhed on July 11, 2016, at 17:02:05
In reply to Re: Best AD for Melancholia » brynb, posted by SLS on July 11, 2016, at 16:16:30
I agree, and if the OCD is present i would highly recommend memantine.
I feel hell lot of difference with it, in case of my ocd.
Posted by brynb on July 11, 2016, at 17:23:25
In reply to Re: Best AD for Melancholia » brynb, posted by SLS on July 11, 2016, at 16:16:30
> Theoretically, serotonin syndrome can be a complication of this combination. How much is the Lexapro helping?
I can't say how much Lexapro is helping anymore. I've been on and off it for many years (trying other things for short periods in between) but eventually go back on it as I seemingly have few, if any, side effects from it. It's probably helping my anxiety a bit but i don't think it's working on my depression at all. When I was prescribed Tramadol, there was a big contraindication in taking it w/a SRI or NRI but I didn't have any issues with serotonin syndrome. I will ask my pdoc tomorrow about starting at the lowest dose of Anafranil and possibly lowering my Lexapro from the current dose of 20mg.
>
> > And theoretically this would potentially address OCD & melancholic depression?
>
> I am thinking that clomipramine would address both. Clomipramine is a TCA with added SSRI-type actions. It is so good at doing the job, that doctors were writing prescriptions for it and having their patients fill them from Canadian pharmacies because it had not been approved in the USA yet.That's very promising!
> Because clomipramine has anticholinergic side effects (dry mouth, blurred vision, constipation, difficulty urinating, etc.), you might want to first try adding nortriptyline or desipramine to Lexapro or Luvox.
I've tried nortriptyline in the past with lexapro and didn't like it, though I can't remember why.
>
> You might think to add memantine for OCD if you get stuck.This was recommended to me earlier in the thread. That's off-label, correct? Anything else about memantine that could be helpful?
> From your description, I think I would act under the premise that you have melancholic depression without OCD. Work with your doctor to get a comprehensive screening for OCD if you are in doubt.
I'll ask my doc about his thoughts on my Dx. I try not to get too caught up with it. I never thought I had clinical OCD but many of its symptoms resonate with me. I'm on disability for MDD and GAD but I also display Bipolar 2 symptoms. Sadness and intrusive thoughts/rumination have always been pronounced features of my depression. Regardless, I'm least concerned with a proper DX (though it could be helpful) and more interested in taking medication that addresses everything.
I obviously have a lot to think about and present to my doc. We just began working together, but I really like that he is an addiction specialist and very seasoned in psychiatry in general. He's been on the best pdoc list in Castle Connelly for years.
Thanks again!
>
>
> - Scott
Posted by brynb on July 11, 2016, at 17:50:11
In reply to Re: Best AD for Melancholia, posted by jonhed on July 11, 2016, at 17:02:05
> I agree, and if the OCD is present i would highly recommend memantine.
> I feel hell lot of difference with it, in case of my ocd.Does it help with your depression too?
Thanks!
Posted by jonhed on July 12, 2016, at 3:30:12
In reply to Re: Best AD for Melancholia » jonhed, posted by brynb on July 11, 2016, at 17:50:11
In fact i have no idea.
I have to be honest with you, and this is why the doctors always says "we take one change in a time", cause i don't know if it's just the methadone that act like an antidepressant or if memantine is too.I can describe my feeling of memantine, and that is that you are like in a "fuzz" and i feel very nurtured when i take it. You know, like being a little in your own bubble?
I can concentrate very easy and nothing feels like it is a pain in the *ss to do (like doing the dishes).
And this is in the evening when i take the memantine and the initial wakefulness of methadone has faded long ago, so yeah i think it is antidepressant.
especially when you take subutex to, i think that would be to a great combo as with methadone, since both is opioids, and memantine seem to synergize or potentiate opioids (i haven't decided which of them there is yet).
And some last words about what i think.
If my OCD is under control, it has to have AD properties to, but i can't be sure.It is off label but not for long (my pdoc is, for real, very famous here in sweden and says that in maybe 1-2 years there will be a lot more indications written in the, what you now call it).
Kind regards, i hope you find what you're looking for.
Posted by jonhed on July 12, 2016, at 5:09:25
In reply to Re: Best AD for Melancholia, posted by jonhed on July 12, 2016, at 3:30:12
are you french or swedish?
If i may ask.
Posted by brynb on July 12, 2016, at 5:20:26
In reply to Re: Best AD for Melancholia, posted by jonhed on July 12, 2016, at 5:09:25
> are you french or swedish?
> If i may ask.hi,
American, actually.
thanks again for your input; i'll post an update after seeing my doc today.
-b
Posted by jonhed on July 12, 2016, at 5:32:11
In reply to Re: Best AD for Melancholia » jonhed, posted by brynb on July 12, 2016, at 5:20:26
Thanks, do that :-)
Keep memantine in mind, cause it doesn't have nearly no side effects. It has like 18 side effects which all are not serious, so it can't hurt you so to speak :-)
Posted by jonhed on July 12, 2016, at 5:32:51
In reply to Re: Best AD for Melancholia, posted by jonhed on July 12, 2016, at 5:32:11
none* is serious.
Posted by jonhed on July 12, 2016, at 5:34:13
In reply to Re: Best AD for Melancholia » jonhed, posted by brynb on July 12, 2016, at 5:20:26
I was asking because you used the name "subutex", and that is common in sweden and france :-)
just so you don't think i thought you speak bad english hehe
Posted by brynb on July 12, 2016, at 8:36:52
In reply to Re: Best AD for Melancholia, posted by jonhed on July 12, 2016, at 5:34:13
> I was asking because you used the name "subutex", and that is common in sweden and france :-)
>
> just so you don't think i thought you speak bad english heheno worries =)! I take subutex because suboxone has naloxone in it (subutex is strictly buprenorphine) and naloxone makes me ill/gives me side effects.
i see my pdoc today and will be discussing a lot of options including suggestions in this thread.
thanks again for your help!
Posted by jonhed on July 12, 2016, at 11:45:45
In reply to Re: Best AD for Melancholia » jonhed, posted by brynb on July 12, 2016, at 8:36:52
Yeah, it makes you sick instead of making you sound. (suboxone)
Good luck today :-)
Posted by brynb on July 12, 2016, at 14:07:49
In reply to Re: Best AD for Melancholia » brynb, posted by SLS on July 11, 2016, at 16:16:30
Thanks everyone for your input.
I met w/my pdoc this morning and we decided to add a low dose of Desipramine to my existing cocktail (Lexapro 20mg, Subutex and Klonopin 2mg).
We decided it's the easiest tweak right now rather than dropping Lexapro and or adding Anafranil, which may carry too many SEs to start and apparently is quite expensive (I already pay out of pocket for Subutex which is $165/monthly). We'll see if it addresses the melancholia and that it would be the easiest/most gentle addition and the only new variable.I'm hoping that this addition will brighten my mood enough to treat/target the melancholia and in turn serve as a catalyst to my practicing some non-med options (meditating, exercising, etc.) to address my OCD-like thoughts and overall mental health.
I'd also like to keep my med cocktail simple.
SLS, you mentioned Anafranil has a huge success rate, and after an easy search, it's apparently miraculous for OCD and depression, rated very highly in reviews. Unfortunately, as you mentioned, it carries A LOT of side effects. As I'm currently functioning, I feel like I can hold off on a major med change like that for now.
Thanks again and I'll keep everyone posted. Hope you're all feeling well =).
-b
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