![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 7 of 7. This is the beginning of the thread.
Posted by Ant-Rock on March 16, 2000, at 18:08:23
My name is Anthony, and many of you (Adam,Scott,JohnL) have helped me with important questions and showed great empathy to my posts in the past. I've also tried to help others when I've felt that I could. Today I could use some help.
A few years back I had a severe adverse reaction to the drug Amoxapine, while being treated for low-grade chronic depression. This reaction was so strange and severe, no doctors I've met have ever heard of anything like it. I became overwhelmed with extremely intense feelings of grief,unstoppable crying for days; my body went weak, legs felt like rubber, and this lasted for over a week. Pure Hell. I never before had an abnormal reaction from AD's. Frankly, I was terrified. Understandably, no one around me knew what to do.
As this bad trip came to an end, emotional symptoms lessened but my body was never the same. The energy has been sapped out of me. I'm left with apathy,no sex drive, (Sorry this is so long). Docs were of no help since they never had dealt with this before, and I certainly haven't found any relavent info researching this drug.
Anyway, I knew some damage was done seeing that the weakness and fatigue have to this day not subsided and depression gradually worsened. After going to neurologist and endocrinologist I'm left with: Borderline low cortisol. It sure feels like my body has no adrenalyn or ability to call on reserves, but the endo doc said he wasn't certain he could contribute my fatigue to the cortisol outcome.(I find this strange).
So as not to ramble further, My psychiatrist agreed for me to try ritalin, which I started 3days ago(10mgs/day). I also received an order of amisulpride today and was wondering if these two drugs can be combined. I figure the amisulpride might do the opposite of amoxapine and maybe help. I've read all the posts favoring low-dose amisulpride.
Thanks again for any advise you can give me, because I have hit a lot of brick walls and after a while it takes a toll!
Anthony
(I apologize if this wasn't that coherent)
Posted by AndrewB on March 17, 2000, at 11:40:54
In reply to Amisulpride w/ Stimulant (anyone?), posted by Ant-Rock on March 16, 2000, at 18:08:23
Anthony,
What a strange story. It’s so weird Amoxapine would do that. After looking up some info. on Amoxapine I think I understand why you are trying amisulpride. Amoxapine is a tricyclic with dopamine receptor blocking activity and amisulpride acts sort of opposite to that. Best of luck with the amisulpride, I hope it works for you as well as it has for me.
There are no drug interactions listed for amisulpride. It can be combined safely with dopamine activating and NE activating meds. Therefore it is my guess that amisulpride can be combined with a stimulant. What I would do however is to take amisulpride for a 5 to 7 days alone so you can evaluate its effects. Then add a small amount of Ritalin to it and go up in dosage from there watching for any reactions.
As far as the borderline low cortisol goes, it brings a lot of questions to my mind. Low cortisol is associated with atypical depression, chronic fatigue syndrome (CFS), adrenal dysfunction and other conditions that have fatigue as a symptom. Possibly these various conditions have a common locality for the perception of fatigue. It seems that hypofunction of the D2-D3 receptors may be responsible for the perception of fatigue in at least some of those with CFS and atypical depression. I would be curious to know whether atypicals who are relieved of depression by an AD find their low cortisol levels have normalized, much as ‘normal’ depressives tend to have their high cortisol levels normalize with successful AD treatment. I’ve also wondered how effective the various purported treatments for adrenal dysfunction, such as hydrocortisone and licorice root, really are in treating fatigue and if they also might be able to make a dent in atypical depression.
I am very interested in how this goes for you. Please keep us informed.
AndrewB
Posted by Scott L. Schofield on March 17, 2000, at 23:40:37
In reply to Amisulpride w/ Stimulant (anyone?), posted by Ant-Rock on March 16, 2000, at 18:08:23
> My name is Anthony, and many of you (Adam,Scott,JohnL) have helped me with important questions and showed great empathy to my posts in the past. I've also tried to help others when I've felt that I could. Today I could use some help.
> A few years back I had a severe adverse reaction to the drug Amoxapine, while being treated for low-grade chronic depression. This reaction was so strange and severe, no doctors I've met have ever heard of anything like it. I became overwhelmed with extremely intense feelings of grief,unstoppable crying for days; my body went weak, legs felt like rubber, and this lasted for over a week. Pure Hell. I never before had an abnormal reaction from AD's. Frankly, I was terrified. Understandably, no one around me knew what to do.
> As this bad trip came to an end, emotional symptoms lessened but my body was never the same. The energy has been sapped out of me. I'm left with apathy,no sex drive, (Sorry this is so long). Docs were of no help since they never had dealt with this before, and I certainly haven't found any relavent info researching this drug.
> Anyway, I knew some damage was done seeing that the weakness and fatigue have to this day not subsided and depression gradually worsened. After going to neurologist and endocrinologist I'm left with: Borderline low cortisol. It sure feels like my body has no adrenalyn or ability to call on reserves, but the endo doc said he wasn't certain he could contribute my fatigue to the cortisol outcome.(I find this strange).
> So as not to ramble further, My psychiatrist agreed for me to try ritalin, which I started 3days ago(10mgs/day). I also received an order of amisulpride today and was wondering if these two drugs can be combined. I figure the amisulpride might do the opposite of amoxapine and maybe help. I've read all the posts favoring low-dose amisulpride.
> Thanks again for any advise you can give me, because I have hit a lot of brick walls and after a while it takes a toll!
>
> Anthony
-------------------------------------------
Dear Anthony,
I remember replying to your post of January 30, 2000, at 13:36:12.http://www.dr-bob.org/babble/20000128/msgs/20118.html
I would certainly like to reaffirm the sentiments I expressed then.
AndrewB has given you some very sound recommendations, and he has surely done his homework.
BTW - brilliant musings, Andrew.
As far as the cortisol thing is concerned, I can't make it past the chicken vs. the egg dilemma. I have little doubt that abnormalities of cortisol dynamics are involved in depressive disorders, but I have always thought of them as being more the result of rather than the cause of depression. It seems to me that the cascade of events would begin higher up and work its way down through the HPA (hypothalamo-pituitary-adrenal) axis. On the other hand, Cushing's Disease provides a paradigm for the reverse. Perhaps a self-reinforcing dysfunctional interaction is established between the two systems. We'll see. (hopefully)
The degree of fatigue that you describe can very easily be ascribed to the diagnosis of a severe retarded-type depression.
Just to chuck something else out there - I have recently run across some stuff that suggests there are biological overlaps between depression, chronic fatigue syndrome, and chronic pain disorders (fibromyalgia). Hypocortisolemia has been associated with fibromyalgia, chronic fatigue syndrome, and possibly atypical unipolar depression. Currently, there are investigations underway testing the efficacy of using low-dose hydrocortisone in the treatment of chronic fatigue syndrome.
PLEASE let me know how you do with the amisulpiride treatment. It looks as though there may be some important commonalities to both our cases. I have put amisulpiride near the top of my short-list. Are you bipolar?
Good luck!
- Scott
Posted by Barbara on March 18, 2000, at 14:18:18
In reply to Re: Amisulpride w/ Stimulant (anyone?), posted by Scott L. Schofield on March 17, 2000, at 23:40:37
Andrew and Scott:
I have been reading your posts to various threads this past week since I am laid up with two sheared off fingers. I am ADD with depression as co-morbidity. I am convinced that dopamine depletion is the cause of the depression. Whether it is a symptom of/or cause of ADD I dont know. I cannot articulate well what I am going to write here since it is more intuitive than scholarly. Right now I am on Wellbutrin, dex, cytomel, celexa with almost no results from any. Not enough dopamine. I also feel I have SAD which is a first cousin to atypical depression.
Add to this symptomatic mess the fact that in the two years since I started on SSRIs I have joint pain - sometimes excruciating - which hops all over my body. Starts in one place and leaves and moves to another joint. At one sight someone suggested that it was the ssris - and its effect on cortisol levels - does the increase of serotonin cause depletion of dopamine thereby disturbing cortisol levels which in turn causes the joint problem? My current pdoc is clueless and before my recent move, I was going to find some one at Johns Hopkins to help me. Oh also, I was in a car accident in '85 with closed head injury and loss os consciousness. The effects of this injury - esp as a causative agent for depression - has never been investigated.
As an aside, I had to use prednisone for a while several years ago for about a month -- I was never better - happy as a lark and energetic as a rabbitt. My doctor thought that should be investigated but we never did it. And FOCUSED!!! Is this somehow related to all of the above. Andrew, I would like to know how to obtain dopamine agonists - how do I do that - I recently moved to Cleveland and need to find a new pdoc. Any suggestions on how to find one who understands the dopamine connection?
Thank you for the gifts you two bring to this board.
Barbara
Posted by JohnL on March 18, 2000, at 16:41:47
In reply to Re: Amisulpride w/ Stimulant (anyone?), posted by Barbara on March 18, 2000, at 14:18:18
Barbara,I was reading in a psychopharmacology book that psychostimulants are often successful treatments for depression and related psychiatric symptoms when there is a history of head injury. The stimulants work in many ways. They increase brain blood flow, correct brain chemical imbalance in patchy parts of the brain, mimic dopamine/NE, stimulate neurotransmitters. In short, following a head injury stimulants can kick-start the patchy parts of the brain that suffered damage. And since they are dirt cheap and work in 24 to 72 hours--if they are to work--it might be worth considering as a first line treatment at this point.
Posted by Barbara on March 18, 2000, at 16:58:03
In reply to Re: Amisulpride w/ Stimulant (anyone?), posted by JohnL on March 18, 2000, at 16:41:47
>
> Barbara,
>
> I was reading in a psychopharmacology book that psychostimulants are often successful treatments for depression and related psychiatric symptoms when there is a history of head injury. The stimulants work in many ways. They increase brain blood flow, correct brain chemical imbalance in patchy parts of the brain, mimic dopamine/NE, stimulate neurotransmitters. In short, following a head injury stimulants can kick-start the patchy parts of the brain that suffered damage. And since they are dirt cheap and work in 24 to 72 hours--if they are to work--it might be worth considering as a first line treatment at this point.
John:I already take Dexedrine although only 40mgs per day. Many others with ADD tell me they take considerably more. Do you know anything about this. I have become tolerant to the dex after 2 years at this dose. Any suggestions?
Barbara
Posted by AndrewB on March 19, 2000, at 11:53:56
In reply to Re: Amisulpride w/ Stimulant (anyone?), posted by Barbara on March 18, 2000, at 14:18:18
Barbara,
I looked up some information on prednisone, a glucocortisoid. From what I read, there doesn’t seem to be any connection between prednisone and dopamine. It is fairly common for people taking prednisone to experience elevated mood (mania) or, conversely, depression.
I’m also not aware of any connection of SSRIs to joint pain via dopamine depletion or other mechanisms. On the contrary, SSRIs are often effective in mitigating fibromyalgic type joint pain.
I presume that you feel that dopamine may be involved with your depression because (1) you have fatigue and lack of motivation involved with your depression and (2) you have already tried a wide array of more traditional antidepressants. If this is so, you should talk to a psychiatrist about the possibility of using a dopaminergic AD. To find a psychiatrist that would consider this option I suggest in general you look for one that has had experience using a wide variety of medication strategies to deal with treatment resistant depression. Such a person may call himself a psychopharmacologist. Look for such people to be affiliated with large hospitals or universities. So what you might do for example is call your local university or hospital psych. departments and tell them you are looking for a psychopharmocologist or someone who specializes in treatment resistant depressions. Once you have some contacts, call up these psychiatrist’s offices ask for 5 minutes of the psychiatrist’s time over the phone. When talking with them, ask them if they think that the dopaminergic system may be involved in some types of depression and whether they would consider prescribing a dopaminergic AD such as amisulpride or pramipexole.
Pramipexole (Mirapex) is mostly used for Parkinson’s disease and it may be purchased at a local pharmacy. Amisulpride must be ordered from overseas with a prescription. For ordering information and abstracts of studies showing the safety and efficacy of amisulpride, email me at andrewb@seanet.com. Pramipexole for use in depression has been studied much less but for some information see the abstract below. (Note that one of the two patient treated was anergic and the other vegetative.)
Best wishes for your health,
AndrewB
-------------------------------------------------------------
Am J Psychiatry 156:798, May 1999
(c) 1999 American Psychiatric AssociationLetter to the Editor
Pramipexole in Refractory Bipolar DepressionJOSEPH F. GOLDBERG, M.D.
New York, N.Y., MARK A. FRYE, M.D. and
ROBERT T. DUNN, M.D., PH.D.To the Editor: Pramipexole, a direct dopamine agonist with D3 receptor selectivity, recently approved by the FDA for the treatment of Parkinson's disease (1), has been reported to be as effective as fluoxetine in the treatment of major depression (unpublished 1997 study by Corrigan and Evans) and an effective neuroleptic adjunct for the negative symptoms of schizophrenia (2). We report two cases of treatment-resistant bipolar depression where improvement followed augmentation with pramipexole.
Mr. A, a 50-year-old man with a 23-year history of bipolar I disorder and over 15 hospitalizations, had recurrent dysphoric manias and major depressions with reversed vegetative signs. There was a remote period of cocaine abuse and a dense family history of bipolar illness. Past manias had responded poorly to lithium, carbamazepine, and valproate monotherapies or combinations. Incidents of depression persisted despite regimens of bupropion; however, low doses of sertraline triggered mania. Depressions previously responded to ECT but resisted a course of 40 bilateral treatments. Mr. A's condition was stable for over 1 year on a high-dose regimen of lamotrigine and clonazepam, until he was rehospitalized for anergic depression that was unresponsive to lithium augmentation. Pramipexole was begun at a dose of 0.25 mg/day and increased over 10 days to 0.75 mg/day. Within 1 week, marked improvement was noted in mood and activity. Euthymia was achieved, and Mr. A remained without side effects at his 8-week follow-up.
Mr. B, a 33-year-old artist with a 15-year history of bipolar I illness and alcohol abuse (inremission), had 14 hospitalizations for both psychotic depressions and manias. His episodes improved minimally with lithium, carbamazepine, valproate, verapamil, and gabapentin alone and in combination with adjunctive typical neuroleptics and benzodiazepines. Sertraline, tricyclics, and one course of ECT were ineffective for his depressions. Nortriptyline and venlafaxine each induced dysphoric mania and cycling. Bupropion plus lithium and lamotrigine provided substantial improvement until he developed a tolerance after 2 months.
Olanzapine, topiramate, and lamotrigine controlled mania and cycling until severe depression recurred, with reversed vegetative signs, prompting a trial of pramipexole. Mr. B was given a 1-mg/day dose of pramipexole; after 6 weeks, a marked antidepressant response occurred, and the drug was well tolerated except for transient, dose-related nausea. Subsequently, a brief depressive exacerbation resolved itself without medication changes. Mr. B's functional improvement, with only low-grade depression and no cycling, continued through his 6-month follow-up.
The greater density of D3 receptors in the mesolimbic areas (3) involved in mood regulation may relate to pramipexole's efficacy in psychomotor-retarded conditions (i.e., negative symptoms, Parkinson's disease, depression). Controlled studies of pramipexole, in doses of 0.25–10.25 mg/day over 4–8 weeks (2, unpublished 1997 study by Corrigan and Evans), are encouraged to clarify dose-related acute and long-term efficacy in bipolar depression, possible side effects (e.g., insomnia, fatigue, dyskinesias, orthostatic hypotension, hallucinations), potential induction of mania/psychosis, and preferential response in atypical versus melancholic depression.
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.