![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 13 to 37 of 47. Go back in thread:
Posted by Elizabeth on January 23, 2002, at 14:11:50
In reply to Re: Are tricylics safer than ssris? » Mr. Scott, posted by spike4848 on January 20, 2002, at 16:13:29
> As far as long term side effects, we have use tricyclic for years with no known long term adverse effects. And there studies to show TCA are safe on the heart.
Depends what you mean. They can cause cardiac arrhythmias (this is well known), especially in overdose. For a person who's seriously suicidal, this can be an important issue. There are also plenty of people who don't metabolize TCAs normally. For these people, taking a normal therapeutic dose of a TCA will result in abnormally high serum levels. This can have serious consequences. (I had a seizure on desipramine, and my serum level turned out to be high, probably due to inadequate metabolism. Lowering of the seizure threshold is another serious side effect of the TCAs, BTW.)
> With SSRIs .... who knows? We do know that similar drugs that raise serotonin levels may cause primary pulmonary hypertension and cardiac valve defects.
You mean fenfluramine, I guess. I wouldn't call that a "similar drug" to the SSRIs. Fenfluramine enhances serotonin release rather than blocking reuptake. It has been pretty well established, that SSRIs don't cause the problems that fenfluramine can cause. (These problems occur rapidly enough that we would know by now if SSRIs caused them. Fenfluramine had been around since the '70s, but it wasn't until dexfenfluramine (Redux) was approved in the mid-1990s (1995 or 1997, I think) that the serious side effects were discovered. Prozac has been around since late 1987, much longer than Redux had been available before it got pulled from the market.)
Also, of course, Anafranil (the TCA that borderliner21 was considering) blocks serotonin reuptake to a clinically significant degree at prescribed doses, just as the SSRIs do. (Most of the tertiary-amine TCAs are mixed serotonin-norepinephrine reuptake inhibitors, while the secondary-amine TCAs mainly affect norepinephrine.)
> Unfornuately .... companies pushing SSRI downplay the fact that many people on ssri's are suffer from nausea, impotency, insomnia!
I think Remeron is a good addition for people who benefit from SSRIs but suffer from these side effects, FWIW.
> So my vote is for tertiary TCA!
I prefer the secondary-amine TCAs, myself (such as the ones you tried) -- they have milder side effects, in general.
-elizabeth
Posted by spike4848 on January 23, 2002, at 16:56:26
In reply to Re: Are tricylics safer than ssris? » spike4848, posted by Elizabeth on January 23, 2002, at 14:11:50
>They can cause cardiac arrhythmias (this is well known), especially in overdose. For a person who's seriously suicidal, this can be an important issue
Yes, I believe in normal doses though, the only cardiac contraindication to a TCA is Left Bundle Branch or 2 degree heart block. In overdose, I understand SSRIs can cause serontonin syndrome ... also potential lethal.
>There are also plenty of people who don't metabolize TCAs normally. For these people, taking a normal therapeutic dose of a TCA will result in abnormally high serum levels. This can have serious consequences. (I had a seizure on desipramine, and my serum level turned out to be high, probably due to inadequate metabolism. Lowering of the seizure threshold is another serious side effect of the TCAs, BTW.)
I am sorry you had to go through that horrible experience. I have heard of slow metabolizers and the risk of elevated serum TCAs .... more often elevated TCAs levels with combination with SSRIs. I think a blood level is always wise during a course of TCA therapy.
>It has been pretty well established, that SSRIs don't cause the problems that fenfluramine can cause. (These problems occur rapidly enough that we would know by now if SSRIs caused them. Fenfluramine had been around since the '70s, but it wasn't until dexfenfluramine (Redux) was approved in the mid-1990s (1995 or 1997, I think) that the serious side effects were discovered. Prozac has been around since late ?1987, much longer than Redux had been available before it got pulled from the market.)
I didn't mean to infer that SSRIs will have the same effects as fenfluramine/phentermine, just that we simply haven't had them as long as the TCAs, and really don't know the long term side effect profile. I wasn't aware that there were studies ongoing concerning the long term safety of SSRIs .... can you give me those citations. Thanks.
>I think Remeron is a good addition for people >who benefit from SSRIs but suffer from these >side effects, FWIW.I think I would prefer just to take one medication ... I need to take ambien with nardil currently for sleep. It is very inconvenant .... if I am invited to stay over a friends apartment and I don't have ambien .... no sleep. An also the extra cost as well. If one has a good response to an SSRI .... remeron at low dose is a great option for side effects.
> > So my vote is for tertiary TCA!
>
> I prefer the secondary-amine TCAs, myself (such as the ones you tried) -- they have milder side effects, in general.Oops ... I mean't secondary TCA .... sorry.
Thanks for the information Elizabeth!
Spike
Posted by Chloe on January 23, 2002, at 18:33:04
In reply to Re: Are tricylics safer than ssris? » borderliner21, posted by Elizabeth on January 23, 2002, at 13:53:44
"there's evidence that at least some of the TCAs can make BPD symptoms worse."
Elizabeth,
Could you explain in what way TCA's can make BPD worse? I had never heard of this.
Thanks in advance.
Chloe
Posted by finelinebob on January 24, 2002, at 21:18:52
In reply to Re: TCA's and BPD » Elizabeth, posted by Chloe on January 23, 2002, at 18:33:04
YMMV, as always...
SSRIs always gave me worse side effects than therapeutic effects (which, for a few, were nil anyway). Within a month of being on nortriptyline, I knew TCAs were for me. Over two years now, and no noticable side effects.
cheers,
flb
Posted by Elizabeth on January 25, 2002, at 0:57:13
In reply to Re: TCA's and BPD » Elizabeth, posted by Chloe on January 23, 2002, at 18:33:04
> Could you explain in what way TCA's can make BPD worse? I had never heard of this.
I should have been more specific. The TCAs are definitely not a treatment of choice for BPD, simply because it's been pretty well established that they don't work very well. There have also been some studies and case reports suggesting that TCAs (amitriptyline in particular) can have "paradoxical" effects in depression associated with BPD, making patients feel worse rather than better. I'm out of town and don't have my books around, but I believe that TCAs can worsen symptoms such as self-destructiveness, paranoia, and hostility. Again, I think this may not apply to clomipramine.
There may be a relationship between BPD symptoms and mixed mania or hypomania in bipolar disorder. Tricyclics are thought to be more likely to trigger or exacerbate dysphoric (mixed) manic states than other ADs, and this may be why they make some borderline patients worse: because dysphoric mania is part of the problem.
Of course, people with BPD are a heterogeneous group, so it's hard to make general statements about them.
-elizabeth
Posted by Chloe on January 25, 2002, at 17:15:47
In reply to Re: TCA's and BPD » Chloe, posted by Elizabeth on January 25, 2002, at 0:57:13
> >There have also been some studies and case reports suggesting that TCAs (amitriptyline in particular) can have "paradoxical" effects in depression associated with BPD, making patients feel worse rather than better. I believe that TCAs can worsen symptoms such as self-destructiveness, paranoia, and hostility.
>
> There may be a relationship between BPD symptoms and mixed mania or hypomania in bipolar disorder. Tricyclics are thought to be more likely to trigger or exacerbate dysphoric (mixed) manic states than other ADs, and this may be why they make some borderline patients worse: because dysphoric mania is part of the problem.
Elizabeth,I just added 20 mgs of Amitriptyline to my cocktail for neuropathic scalp pain. I also take less than 2 mgs of celexa, plus a low dose of neurontin and lithium.
After two weeks on amitriptyline, I am having increased cycling and horrific aggitated mixed states. I have not lost my temper in such abrupt and abusive ways in so long. I am sure it's the amitrip. and asked my pdoc to switch to doxepin. She refused. Saying that all TCA;s are alike. Changing won't make a difference. So she said to decrease the celexa more and see if the cycling stops. But I think it's the Ami...Celexa can make me irritable, but not explosive, hostile and rageful, like I feel on ami...
Anyway, I was hoping you had a link that I could give to her that says Ami is "particularly" bad for the rapid cycling bipolar (ex-BPD, since I have not been self destructive in over a decade..), like me. Any info would be greatly appreciated.
If I just didn't have this dumb scalp pain induced from the lithium, I could just go up on that and I think the cycling would decrease. But without a TCA, the burning is so painful, I can't tolerate the Li...
Many thanks for answering. I really enjoy reading your informative posts.
Chloe
Posted by Ritch on January 26, 2002, at 0:41:41
In reply to Re: TCA's and BPD-Link? » Elizabeth, posted by Chloe on January 25, 2002, at 17:15:47
> > >There have also been some studies and case reports suggesting that TCAs (amitriptyline in particular) can have "paradoxical" effects in depression associated with BPD, making patients feel worse rather than better. I believe that TCAs can worsen symptoms such as self-destructiveness, paranoia, and hostility.
> >
> > There may be a relationship between BPD symptoms and mixed mania or hypomania in bipolar disorder. Tricyclics are thought to be more likely to trigger or exacerbate dysphoric (mixed) manic states than other ADs, and this may be why they make some borderline patients worse: because dysphoric mania is part of the problem.
>
>
> Elizabeth,
>
> I just added 20 mgs of Amitriptyline to my cocktail for neuropathic scalp pain. I also take less than 2 mgs of celexa, plus a low dose of neurontin and lithium.
>
> After two weeks on amitriptyline, I am having increased cycling and horrific aggitated mixed states. I have not lost my temper in such abrupt and abusive ways in so long. I am sure it's the amitrip. and asked my pdoc to switch to doxepin. She refused. Saying that all TCA;s are alike. Changing won't make a difference. So she said to decrease the celexa more and see if the cycling stops. But I think it's the Ami...Celexa can make me irritable, but not explosive, hostile and rageful, like I feel on ami...
>
> Anyway, I was hoping you had a link that I could give to her that says Ami is "particularly" bad for the rapid cycling bipolar (ex-BPD, since I have not been self destructive in over a decade..), like me. Any info would be greatly appreciated.
>
> If I just didn't have this dumb scalp pain induced from the lithium, I could just go up on that and I think the cycling would decrease. But without a TCA, the burning is so painful, I can't tolerate the Li...
>
> Many thanks for answering. I really enjoy reading your informative posts.
> ChloeHi Chloe,
Just an FYI, I am taking Celexa and have taken Celexa and/or Nortripyline recently and have found that Celexa and other SSri's can and have caused just as much or worsened *cycling* than TCA's do (I am BPII as well-and have been on several TCA's in the past), the difference is that TCA's have more tendency to *not* help impulsiveness like SSri's seem to help. It is interesting that your pdoc wants you to wean off the Celexa, did she mention any reasons why she thinks that might be the culprit for your troubles?
Mitch
Posted by Chloe on January 26, 2002, at 9:32:21
In reply to Re: TCA's and BPD-Link? » Chloe, posted by Ritch on January 26, 2002, at 0:41:41
Hey Mitch,
Boy am i ever glad to see you! I was hoping I would hear from you.
I am really peeved with my pdoc (my current stage of hypo/rage doesn't help!). She is so clueless and just treating me by the seat of her pants in her spare moments. BTW, I went for a med consult, and my pdoc won't even consider his suggestions like verapamil, or clonidine.Anyway, I can't really go down on the Celexa. She had me do this once before and it was awful. I need the SSRI for my ruminating thoughts and probably some impulse control. Other AD's just don't help with the obsessons. The TCA is helping with the scalp burning, but I have had to go down on that because I keep getting into very abusive, nasty rages, hostility, mixed states. And I can't go up on the lithium (and I am only at 112 mgs right now, which is not helping the cycling at all!)if I can't take the TCA at 20 mgs or above...
So I was thinking of switching the Li(and pdoc also gave this option), for depakote which is supposed to be better for rapid cycling anyway.
My feeling is that this is probably the way to go. Then I can stay on the Celexa and low dose ami(until the scalp pain is totally gone) but not have the added AD push from the lithium. The down side of depakote for me though is hair loss! My scalp and hair just can't get a break...
Do you have any comments on my options, or other suggestions? I am still on the neurontin, 400 mgs. I think you had good result with dep and N together. Am I right?
Option 1
NO celexa
225-450 lithium(if tolerated)
400 neurontin
20 amitrip
10 valiumOption 2
1.75 Celexa
250? Depakote
400 Neurontin
10-20 ami(until pain is gone, or keep on to help with sleep?)
10 ValiumI really hope you are doing ok. It probably about time for a med adjustment for you too...The days are getting longer, have you noticed?
Thanks,
Chloe
> Just an FYI, I am taking Celexa and have taken Celexa and/or Nortripyline recently and have found that Celexa and other SSri's can and have caused just as much or worsened *cycling* than TCA's do (I am BPII as well-and have been on several TCA's in the past), the difference is that TCA's have more tendency to *not* help impulsiveness like SSri's seem to help. It is interesting that your pdoc wants you to wean off the Celexa, did she mention any reasons why she thinks that might be the culprit for your troubles?
>
> Mitch
Posted by Ritch on January 26, 2002, at 10:43:19
In reply to Re: TCA's and BPD-Link? » Ritch, posted by Chloe on January 26, 2002, at 9:32:21
> Anyway, I can't really go down on the Celexa. She had me do this once before and it was awful. I need the SSRI for my ruminating thoughts and probably some impulse control. Other AD's just don't help with the obsessons. The TCA is helping with the scalp burning, but I have had to go down on that because I keep getting into very abusive, nasty rages, hostility, mixed states. And I can't go up on the lithium (and I am only at 112 mgs right now, which is not helping the cycling at all!)if I can't take the TCA at 20 mgs or above...
>
> So I was thinking of switching the Li(and pdoc also gave this option), for depakote which is supposed to be better for rapid cycling anyway.
>
> My feeling is that this is probably the way to go. Then I can stay on the Celexa and low dose ami(until the scalp pain is totally gone) but not have the added AD push from the lithium. The down side of depakote for me though is hair loss! My scalp and hair just can't get a break...
>
> Do you have any comments on my options, or other suggestions? I am still on the neurontin, 400 mgs. I think you had good result with dep and N together. Am I right?
>
> Option 1
> NO celexa
> 225-450 lithium(if tolerated)
> 400 neurontin
> 20 amitrip
> 10 valium
>
> Option 2
> 1.75 Celexa
> 250? Depakote
> 400 Neurontin
> 10-20 ami(until pain is gone, or keep on to help with sleep?)
> 10 Valium
>
> I really hope you are doing ok. It probably about time for a med adjustment for you too...The days are getting longer, have you noticed?
> Thanks,
> Chloe
>
> > Just an FYI, I am taking Celexa and have taken Celexa and/or Nortripyline recently and have found that Celexa and other SSri's can and have caused just as much or worsened *cycling* than TCA's do (I am BPII as well-and have been on several TCA's in the past), the difference is that TCA's have more tendency to *not* help impulsiveness like SSri's seem to help. It is interesting that your pdoc wants you to wean off the Celexa, did she mention any reasons why she thinks that might be the culprit for your troubles?
> >
> > Mitch
Hi Chloe,I would definitely consider option#2 and stay on the Celexa. Obviously you know the Celexa helps. Your pdoc probably thinks it is aggravating your cycling and wants to pitch it-it *does* aggravate my cycling as well, but for the same reasons you list I need to take a minimal dose (not really for depression-but for anxiety probs.).
You've had trouble before with lithium at doses that are going to be helpful. I found I have to get my dose up to about 450mg/day to really notice a difference-but for me those doses make me *really* foggyheaded and cause severe cramping and diarrhea.
The Neurontin also seems to help you (I think you said it does?). So you could leave that one in-and you appear to tolerate it ok.
So, the tiny dose of amitrip. is definitely helping your neuropathic pain, right? It probably is working together with the Neurontin on that one. It does help you sleep better. I was taking nortrip. with my Celexa before (also nortrip. and Zoloft) and it worked fairly well. The NE boost *can* increase the likelihood for raging behavior. I popped off a little more often than otherwise-but I could focus a *lot* better at work and it didn't make me anxious.
So...the only thing left to try is the Depakote... I would suggest it. I have extra 125mg, 250mg, and 500mg tabs around just in case. I didn't notice any increased hairloss on it. I *did* gain some weight though. You could try adding just 125mg to your current mix (ditching the lithium) and see what happens. I have to take 125mg-250mg every so often when I get a mild mixed state and it really helps that.
Yes, I am starting to have an increased level of agitation and may need to start taking some Dep. a little bit here myself. That goes away by the end of March and then I just deal with plain-old bubbly hypomania during April, March, and part of June-which I don't mind :)
good luck,
Mitch
Posted by Chloe on January 26, 2002, at 18:30:46
In reply to Re: Depakote and Neurontin-yes » Chloe, posted by Ritch on January 26, 2002, at 10:43:19
> You've had trouble before with lithium at doses that are going to be helpful. I found I have to get my dose up to about 450mg/day to really notice a difference-but for me those doses make me *really* foggyheaded and cause severe cramping and diarrhea.Mitch,
You know what is funny, I really like the "foggyheaded" feeling. I feel really sensitive to noise and things around me. I prefer not being so *sharp*. I know that must sound strange. But I find the world very harsh, and I like how lithium tones things down, or reduces the volume for me...Is there any chance Depakote will do that at low doses? I don't remember feeling much cognitive "dulling" at all after adjusting to the stuff...But perhaps it has a different way of reducing the volume???
> The Neurontin also seems to help you (I think you said it does?). So you could leave that one in-and you appear to tolerate it ok.There is something about neurontin that makes it so I can't stop it! Everytime I try to reduce the dose, I go crashing into an unmodivated, teary depression. And oh, my body aches, and I get horrible charlie horses in my arches and calves...I really do like N. But I think it adds to my skin troubles. And feel mixed about leaving it out, but I just can't!
So, I would like to increase the dose a bit. I think it's useful for calming me, and not letting me get too enraged. But everytime I increase the dose, I get such dry skin and scalp pain. Go figure. So people take 3600 mgs of this stuff without a side effect! Not me!
> So, the tiny dose of amitrip. is definitely helping your neuropathic pain, right? It probably is working together with the Neurontin on that one. It does help you sleep better. I was taking nortrip. with my Celexa before (also nortrip. and Zoloft) and it worked fairly well. The NE boost *can* increase the likelihood for raging behavior. I popped off a little more often than otherwise-but I could focus a *lot* better at work and it didn't make me anxious.I know it's the ami that's making me "pop off." But I would describe it as I feel like my "blood is boiling." And the first person to look at me wrong is going to get hurt! Backing off to 10 mgs of ami has helped with the rages already...But my scalp is more "burny" with the lower dose. Also, I do wonder if it's causing my hair to fall out. I haven't even started the dep. and I seem to be shedding an awful lot. I thought I saw alot of scalp today, too...My hair is just not tolerating any of these meds well. My long thick hair is definitely no more. I just hope I can have moderate amount of hair, not desperately thin hair, where I am headed :(
> So...the only thing left to try is the Depakote... I would suggest it. I have extra 125mg, 250mg, and 500mg tabs around just in case. I didn't notice any increased hairloss on it. I *did* gain some weight though. You could try adding just 125mg to your current mix (ditching the lithium) and see what happens. I have to take 125mg-250mg every so often when I get a mild mixed state and it really helps that.I have never heard of depakote prn...And you gained weight on lower doses of 500 or less? Was it related to increased appetite? God, I dread that. I hate the idea that medication can change the way I desire and consume food. Just doesn't seem fair...I do remember gaining weight when I was on 750 a few years ago. It was amazing. The weight just appeared. I never really felt any shift in eating or exercise...
> Yes, I am starting to have an increased level of agitation and may need to start taking some Dep. a little bit here myself. That goes away by the end of March and then I just deal with plain-old bubbly hypomania during April, March, and part of June-which I don't mind :)Boy, I love how predictable your cycling is. At least you have some idea as to when all hell is going to break loose! But I am sure it doesn't make you suffering any less.
Many thanks, Mitch
Chloe
Posted by Ritch on January 26, 2002, at 21:45:47
In reply to Re: Depakote/Neurontin/Amitrip » Ritch, posted by Chloe on January 26, 2002, at 18:30:46
>
>
>
> > You've had trouble before with lithium at doses that are going to be helpful. I found I have to get my dose up to about 450mg/day to really notice a difference-but for me those doses make me *really* foggyheaded and cause severe cramping and diarrhea.
>
> Mitch,
> You know what is funny, I really like the "foggyheaded" feeling. I feel really sensitive to noise and things around me. I prefer not being so *sharp*. I know that must sound strange. But I find the world very harsh, and I like how lithium tones things down, or reduces the volume for me...Is there any chance Depakote will do that at low doses? I don't remember feeling much cognitive "dulling" at all after adjusting to the stuff...But perhaps it has a different way of reducing the volume???Well, Chloe, all I can say is that you are lucky in some ways not to be bothered with this stuff. My job is so horrendously demanding-so left-brained-so draining. *Anything* that reduces my cognitive abilities-it shows straight away.
>
> > The Neurontin also seems to help you (I think you said it does?). So you could leave that one in-and you appear to tolerate it ok.
>
> There is something about neurontin that makes it so I can't stop it! Everytime I try to reduce the dose, I go crashing into an unmodivated, teary depression. And oh, my body aches, and I get horrible charlie horses in my arches and calves...I really do like N. But I think it adds to my skin troubles. And feel mixed about leaving it out, but I just can't!
> So, I would like to increase the dose a bit. I think it's useful for calming me, and not letting me get too enraged. But everytime I increase the dose, I get such dry skin and scalp pain. Go figure. So people take 3600 mgs of this stuff without a side effect! Not me!Neurontin was the first *anticonvulsant* I have tried that had a clear antidepressant effect-but I can't take more than about 400mg/day. Otherwise-I get blunting from it as well-esp. at doses above 600mg/day.
>
> > So, the tiny dose of amitrip. is definitely helping your neuropathic pain, right? It probably is working together with the Neurontin on that one. It does help you sleep better. I was taking nortrip. with my Celexa before (also nortrip. and Zoloft) and it worked fairly well. The NE boost *can* increase the likelihood for raging behavior. I popped off a little more often than otherwise-but I could focus a *lot* better at work and it didn't make me anxious.
>
> I know it's the ami that's making me "pop off." But I would describe it as I feel like my "blood is boiling." And the first person to look at me wrong is going to get hurt! Backing off to 10 mgs of ami has helped with the rages already...But my scalp is more "burny" with the lower dose. Also, I do wonder if it's causing my hair to fall out. I haven't even started the dep. and I seem to be shedding an awful lot. I thought I saw alot of scalp today, too...My hair is just not tolerating any of these meds well. My long thick hair is definitely no more. I just hope I can have moderate amount of hair, not desperately thin hair, where I am headed :(
>
> > So...the only thing left to try is the Depakote... I would suggest it. I have extra 125mg, 250mg, and 500mg tabs around just in case. I didn't notice any increased hairloss on it. I *did* gain some weight though. You could try adding just 125mg to your current mix (ditching the lithium) and see what happens. I have to take 125mg-250mg every so often when I get a mild mixed state and it really helps that.
>
> I have never heard of depakote prn...And you gained weight on lower doses of 500 or less? Was it related to increased appetite? God, I dread that. I hate the idea that medication can change the way I desire and consume food. Just doesn't seem fair...I do remember gaining weight when I was on 750 a few years ago. It was amazing. The weight just appeared. I never really felt any shift in eating or exercise...Well, Depakote prn is what I *do*. I can take 250mg if I am feeling unusally agitated or panicky and it augments the Neurontin/Klonopin I am taking and makes things a lot easier.
>
> > Yes, I am starting to have an increased level of agitation and may need to start taking some Dep. a little bit here myself. That goes away by the end of March and then I just deal with plain-old bubbly hypomania during April, March, and part of June-which I don't mind :)
>
> Boy, I love how predictable your cycling is. At least you have some idea as to when all hell is going to break loose! But I am sure it doesn't make you suffering any less.
>
> Many thanks, Mitch
> Chloe
Predictability *is* nice-but you have to get your pdoc tuned in to the graph! They have this tendency to think that your "troubles" are the same all year round(static). I think I am going to have to do a Powerpoint presentation and bring in all the hardware, etc. I don't really think they *want* to be lazy, but for what I am paying.......Mitch
Posted by Chloe on January 27, 2002, at 17:50:28
In reply to Re: Depakote/Neurontin/Amitrip » Chloe, posted by Ritch on January 26, 2002, at 21:45:47
Mitch,
Do you think that amitrip in itself, being a "dirty" drug, could be contributing to my rages? Or do you think all the TCA's are pretty much the same?
I like the sedating effect of Ami (at last I sleep at night!!!), but I do think it causes my heart to race at time during the day...And I get so damn furious and hostile, I can't think straight.
Of course I haven't had time for the depokote to work yet...
But is there another "calming" or sedating TCA that might work better than Ami for neuropathic pain (and sleeping at night, too!)?
I have heard that Doxepin has some antihistimine in it. Is it the same kind like in Remeron or Zyprexa? I hate the appetite increase thing. I know I wouldn't like Doxe if it's similar to them..
Any thoughts?Best,
Chloe
Posted by Ritch on January 27, 2002, at 22:05:04
In reply to Re:TCA less likely to cause rage?, posted by Chloe on January 27, 2002, at 17:50:28
> Mitch,
> Do you think that amitrip in itself, being a "dirty" drug, could be contributing to my rages? Or do you think all the TCA's are pretty much the same?
> I like the sedating effect of Ami (at last I sleep at night!!!), but I do think it causes my heart to race at time during the day...And I get so damn furious and hostile, I can't think straight.
> Of course I haven't had time for the depokote to work yet...
> But is there another "calming" or sedating TCA that might work better than Ami for neuropathic pain (and sleeping at night, too!)?
> I have heard that Doxepin has some antihistimine in it. Is it the same kind like in Remeron or Zyprexa? I hate the appetite increase thing. I know I wouldn't like Doxe if it's similar to them..
> Any thoughts?
>
> Best,
> ChloeChloe, I have tried most of the TCA's for several weeks and some cases several years. Doxepin was the first antidepressant I took and I had the dose up to 150mg/day for a while (with lithium). All of the TCA's have antihistaminic effects more or less-one could say they are antihistamines that happen to have antidepressant properties. Doxepin even at 75mg/day gave me tachycardia. For some weird reason it was the worst when I first woke up in the morning. I would be dreaming and then I would startle and wake and my heart would race up to 150+bpm for a few minutes.
I had more *rages* while on high-dose doxepin (doxepin has an anti-serotonin effect) than low-dose amitriptyline (no remarkable rage incidents there). All TCA's are *dirty* to some extent-that is if you look at them as several drugs in one-they can be helpful for irritable bowel(anticholinergic action), insomnia(sedative-antihistaminegic action), neuropathic pain (NE-opioid potentiation?).
Notriptyline was the easiest one for me to tolerate (the active metabolite of amitripytline). I didn't get any dizziness and vertigo on it like the others, and dry mouth wasn't as bad. Also, FWIW, I didn't experience any noticeable appetite increase with it either( unlike Remeron or Seroquel). Desipramine did aggravate temper and caused some hypomania, though. Maybe if you could switch the amitriptyline to nortriptyline and still get the analgesic effect you need with fewer side effects??? Ask your doc. I found low-dose Celexa + low-dose Nortriptyline to work quite well.
BTW, Older antipsychotics like chlorpromazine are structurally quite similar to the first TCA's. Older AP's and even the newer ones like Zyprexa have a fairly powerful antihistaminic effect. Nortrip. has a much lowered antihistaminic effect, but it doesn't increase extracellular serotonin very much-although it *does* downregulate serotonin receptors (which is probably helpful for panic sufferers).
Mitch
Posted by Chloe on January 28, 2002, at 9:42:05
In reply to Re:TCA less likely to cause rage? » Chloe, posted by Ritch on January 27, 2002, at 22:05:04
Thanks Mitch,
This is useful. I tried to talk to my pdoc about this, and she hadn't heard of any TCA causing rages, per say, that I was just probably in a mixed state from too much AD. Hence she told me to lower the Celexa. NOT a good idea.So I am the one who has to choose the meds. She doesn't want to make a switch at all. So I really have to make a case and advocate for myself. I thought doxepin was a good one try next since it's used often in neuropathic pain. And from what I read at google, is supposes to have less cardiac issues than ami. But clearly, that is not your experience! And is sedating, so I will sleep through the night.
I did not think Nort. would be useful because it can be activating. And that just seems to make my temper worse...But I just don't know. I am so lost here, and feel so stranded, trying to pick out meds for myself. I wish I could hook up with a pdoc who had some experience with this. But my last pharm consult was expensive and not useful. So I guess for now I have to try to figure this out on my own. I wish I had heard from you before I called her about doxepin. But it's already done. It's all trial and error anyway. And I don't plan to take more than 20 mgs of any these TCA's. And it may turn out that I can't tolerate any of them. I just have to be so careful. I keep blowing up and saying really mean things and just feeling nasty and grumpy...
I am really scared. I have to try and be in better control of my anger today. This is NOT ususally something I have to work at...
BTW, did nortrip help you sleep better?
Thanks again
Chloe
Posted by Ritch on January 28, 2002, at 10:41:21
In reply to Re:TCA less likely to cause rage? » Ritch, posted by Chloe on January 28, 2002, at 9:42:05
> Thanks Mitch,
> This is useful. I tried to talk to my pdoc about this, and she hadn't heard of any TCA causing rages, per say, that I was just probably in a mixed state from too much AD. Hence she told me to lower the Celexa. NOT a good idea.
She might be correct about that-given that your levels of mood stabilizer(s) are quite low. I am starting to have a problem with "mixed" symptomology. I have backed off the Wellbutrin to just 1/4 of a 75mg tablet with my 2.5 mg of Celexa 4-5x a week (I skip days here and there because of the heartburn). I go to sleep, but it is very light and unrestful, and I just tend to lay around in bed half-awake for a long time. Then I am half-awake all day long it seems. The WB is starting to make my skin itch (pruritis) and for some odd reason the bottoms of my feet are *sweating*. (whatever!)
I am going to bug my pdoc about going back on a pstim (swap out the WB). With the other meds I think it will work out better. Christ, I started checking my BP the last few days (when I was taking nearly 75mg of WB every day) and it had consistently gone up from around 120/75 to nearly 150/95! I didn't have an increase like that with Adderall and it worked better.
>
> So I am the one who has to choose the meds. She doesn't want to make a switch at all. So I really have to make a case and advocate for myself. I thought doxepin was a good one try next since it's used often in neuropathic pain. And from what I read at google, is supposes to have less cardiac issues than ami. But clearly, that is not your experience! And is sedating, so I will sleep through the night.
>
> I did not think Nort. would be useful because it can be activating. And that just seems to make my temper worse...But I just don't know. I am so lost here, and feel so stranded, trying to pick out meds for myself. I wish I could hook up with a pdoc who had some experience with this. But my last pharm consult was expensive and not useful. So I guess for now I have to try to figure this out on my own. I wish I had heard from you before I called her about doxepin. But it's already done. It's all trial and error anyway. And I don't plan to take more than 20 mgs of any these TCA's. And it may turn out that I can't tolerate any of them. I just have to be so careful. I keep blowing up and saying really mean things and just feeling nasty and grumpy...
>
> I am really scared. I have to try and be in better control of my anger today. This is NOT ususally something I have to work at...
> BTW, did nortrip help you sleep better?
> Thanks again
> Chloe
Perhaps *I* shouldn't have knocked doxepin so much! YMMV. Nortrip. produces a "light" sedative effect at best-it was the only TCA I could stand to take during the day. You are correct-it might be too activating. What the heck-give the doxepin a shot (just 10mg at bedtime). You WILL really sleep good on that one. My brother is taking it now for arthritis with other meds. I just tend to get grouchy on sedative meds, that's all.Let me know how the doxepin goes, OK?
Mitch
Posted by Chloe on January 28, 2002, at 19:48:33
In reply to Re:TCA less likely to cause rage? » Chloe, posted by Ritch on January 28, 2002, at 10:41:21
Thanks for getting back to me so fast...
So far reply from the pdoc. My suspicion is that she just thinks I am in a mixed agitated state. And that with time and depakote, I will forget about how amitriptyline is making me more enraged! I am not sure she was buying that it was "the amitriptyline."
Or she is just really busy, that's a possiblity too, I suppose...I will let you know what happens. I really appreciate your thoughtful, informative posts, esp when I feel so edgy and stranded! I am sorry about your WB problems. Sounds like it maybe time to make a switch to a tad of adderall. Will your pdoc go for it? I hope you can get some relief soon. Maybe you could try 100%cotton (absorbent!) socks for your feet?
Chloe
Posted by Chloe on January 28, 2002, at 20:45:54
In reply to Re:TCA less likely to cause rage? » Chloe, posted by Ritch on January 28, 2002, at 10:41:21
I got some crazy ambiguous email from my pdoc saying that she doesn't know which TCA is better than another for neuropathic pain (completely missing the part about how I think ami, in particular, is causing my increased cycling and rages). And that she is sorry that things "aren't much better."
She never even mentioned the doxepin 10 mgs capsules I specifically asked for. Did she even read the damn detailed email I sent her, with excerpt? I am living in bazarro world...I have a mind to torpedo a scathing email back. But I think I better wait until the morning and see if I should actually send it. Damn, I am so tired of this crap. I spent all this time researching doxepin, TCAs, Ami and increase cycling. And she just ignored it. What the hell?
Sorry for the rant.
Chloe
Posted by Ritch on January 28, 2002, at 23:12:07
In reply to Re:TCA less likely to cause rage? » Ritch, posted by Chloe on January 28, 2002, at 19:48:33
> Thanks for getting back to me so fast...
>
> So far reply from the pdoc. My suspicion is that she just thinks I am in a mixed agitated state. And that with time and depakote, I will forget about how amitriptyline is making me more enraged! I am not sure she was buying that it was "the amitriptyline."
> Or she is just really busy, that's a possiblity too, I suppose...
>
> I will let you know what happens. I really appreciate your thoughtful, informative posts, esp when I feel so edgy and stranded! I am sorry about your WB problems. Sounds like it maybe time to make a switch to a tad of adderall. Will your pdoc go for it? I hope you can get some relief soon. Maybe you could try 100%cotton (absorbent!) socks for your feet?
>
> Chloe
Well..I already wear absorbent 100% cotton socks. Our company president is "casual Friday" all week long. I already noticed less itching and sweating today by reducing the WB. I don't really need it that much right now anyhow. The thing that dissapoints me about it is that it doesn't seem to help my attentiveness as much as pstims or even nortripytline helped. It seems to just eliminate melancholia and keeps me awake-that's about it. I would like to get rid of it and try a different low-dose pstim (than Adderall). I am interested in trying either Provigil or Focalin. The Focalin sounds interesting because we never tried methylphenidate before, just amphetamines. Also, the Focalin appears to be easier on your liver, etc. than the Provigil.Oh, as far as your thoughts/questions about the difference between doxepin and amitripytline.... Don't get too worried about it..really. Just take 10mg of the amitrip. at bedtime for sleep (if that's what your pdoc wants you to do anyhow). If it is helping you sleep and reducing pain-hey-maybe just waiting for the right mood stabilizer(s) to work could be the right plan.
Mitch
Posted by Chloe on January 30, 2002, at 9:09:25
In reply to Re:TCA less likely to cause rage? » Chloe, posted by Ritch on January 28, 2002, at 23:12:07
> Well..I already wear absorbent 100% cotton socks. Our company president is "casual Friday" all week long. I already noticed less itching and sweating today by reducing the WB. I don't really need it that much right now anyhow. The thing that dissapoints me about it is that it doesn't seem to help my attentiveness as much as pstims or even nortripytline helped. It seems to just eliminate melancholia and keeps me awake-that's about it. I would like to get rid of it and try a different low-dose pstim (than Adderall). I am interested in trying either Provigil or Focalin. The Focalin sounds interesting because we never tried methylphenidate before, just amphetamines. Also, the Focalin appears to be easier on your liver, etc. than the Provigil.I thought methylphenidate was an amphetimine. I took Ritalin in my "golden days" when I was on Mellaril. Ritalin is very effective for improving mood and concentration. But the crashes, even with the ER formula were almost unbearable. I have read a little about focalin. It's supposed to be gentler...Too bad your pdoc is not a fan of Provigil. But, in all fairness to him, it is still quite new. I hope you find something better than what you have now. Sounds like less WB is helping a little.
> Oh, as far as your thoughts/questions about the difference between doxepin and amitripytline.... Don't get too worried about it..really. Just take 10mg of the amitrip. at bedtime for sleep (if that's what your pdoc wants you to do anyhow). If it is helping you sleep and reducing pain-hey-maybe just waiting for the right mood stabilizer(s) to work could be the right plan.Thanks for your levelheadedness! I got so enraged at my pdoc for not even answering the question I put out to her. I have since learned that she just doesn't know anything about TCA's causing rages in particalar...Whatever. Pdoc's are so behind the times. So frustrating...
I think the depakote is helping, though. I have had a day without a unrelenting rage outburst. But I since starting dep, 125mg at bedtime, my sleep is totally disrupted. It's like I went back to per-amitriptyline sleep. I though Dep. was supposed to help sleep! Do you have any thoughts on this? Should I take it in the am? I think I will try to start a thread about Dep and sleep disturbance...Got to rush off now though.Take care
Chloe
>
> Mitch
Posted by Ritch on January 30, 2002, at 9:37:37
In reply to Re:TCA/focalin/depakote/sleep? » Ritch, posted by Chloe on January 30, 2002, at 9:09:25
>
> > Well..I already wear absorbent 100% cotton socks. Our company president is "casual Friday" all week long. I already noticed less itching and sweating today by reducing the WB. I don't really need it that much right now anyhow. The thing that dissapoints me about it is that it doesn't seem to help my attentiveness as much as pstims or even nortripytline helped. It seems to just eliminate melancholia and keeps me awake-that's about it. I would like to get rid of it and try a different low-dose pstim (than Adderall). I am interested in trying either Provigil or Focalin. The Focalin sounds interesting because we never tried methylphenidate before, just amphetamines. Also, the Focalin appears to be easier on your liver, etc. than the Provigil.
>
> I thought methylphenidate was an amphetimine. I took Ritalin in my "golden days" when I was on Mellaril. Ritalin is very effective for improving mood and concentration. But the crashes, even with the ER formula were almost unbearable. I have read a little about focalin. It's supposed to be gentler...Too bad your pdoc is not a fan of Provigil. But, in all fairness to him, it is still quite new. I hope you find something better than what you have now. Sounds like less WB is helping a little.Actually, I have *transitioned* out of the melancholic winter SAD episode entirely this week and probably will taper what little WB I am taking away by next week. The attentional probs I have obviously get quite bad during the major depressions. When those clear my focus is adequate enough probably without a pstim. That would leave me on Neurontin, Klonopin, and Celexa. That's cool.
As far as pstim "crashes" go I didn't have any problem on Adderall. I took one 5mg tab in the morning as soon as I got up and felt fine all day. I noticed a little fatigue about an hour or two before I went to sleep. I remember when I took just 2.5mg in the am, I *did* crash in the evenings at work and got kind of grouchy. I don't have any probs with taking small doses up to 3x daily (I already take Neurontin 3x daily).
>
> > Oh, as far as your thoughts/questions about the difference between doxepin and amitripytline.... Don't get too worried about it..really. Just take 10mg of the amitrip. at bedtime for sleep (if that's what your pdoc wants you to do anyhow). If it is helping you sleep and reducing pain-hey-maybe just waiting for the right mood stabilizer(s) to work could be the right plan.
>
> Thanks for your levelheadedness! I got so enraged at my pdoc for not even answering the question I put out to her. I have since learned that she just doesn't know anything about TCA's causing rages in particalar...Whatever. Pdoc's are so behind the times. So frustrating...
> I think the depakote is helping, though. I have had a day without a unrelenting rage outburst. But I since starting dep, 125mg at bedtime, my sleep is totally disrupted. It's like I went back to per-amitriptyline sleep. I though Dep. was supposed to help sleep! Do you have any thoughts on this? Should I take it in the am? I think I will try to start a thread about Dep and sleep disturbance...Got to rush off now though.
>
> Take care
> Chloe
> >
> > Mitch
Yes, I doubt if you are going to find many agents as capable of producing sleep as amitriypline. You might chop one of those 10mg tabs in half and just take 5mg at bedtime-use it as your sleeper. Depakote *helps* with sleep, but it won't guarantee it.Mitch
Posted by Chloe on January 30, 2002, at 9:55:31
In reply to Re:TCA/focalin/depakote/sleep?, posted by Ritch on January 30, 2002, at 9:37:37
> Yes, I doubt if you are going to find many agents as capable of producing sleep as amitriypline. You might chop one of those 10mg tabs in half and just take 5mg at bedtime-use it as your sleeper. Depakote *helps* with sleep, but it won't guarantee it.
Mitch,
I am still taking the 10 mgs of Ami+125 depakote at bedtime. But since adding the dep, my sleep is very light, and I have several wakings in the night/early am. Like it was before I started ami. BUT I am still on the ami. Do you know if I will adjust to the dep and start sleeping through the night again? That was heaven...Chloe
Posted by Elizabeth on January 30, 2002, at 13:21:41
In reply to Re: TCA's and BPD-Link? » Elizabeth, posted by Chloe on January 25, 2002, at 17:15:47
Hi Chloe. No, I don't know of a web site where you could read about BPD (or rapid cycling) and tricyclics. It's something I've read in several places, though.
> After two weeks on amitriptyline, I am having increased cycling and horrific aggitated mixed states.
20 mg is a small amount in normal metabolizers, so the worsening might have nothing to do with the amitriptyline. You might want to see a neurologist about the pain, though.
> I have not lost my temper in such abrupt and abusive ways in so long. I am sure it's the amitrip. and asked my pdoc to switch to doxepin. She refused. Saying that all TCA;s are alike. Changing won't make a difference.
That's not really true, although I'm not sure that doxepin would be better than amitriptyline. (Doxepin is generally more sedating, but otherwise there isn't really much predictable difference.)
> Anyway, I was hoping you had a link that I could give to her that says Ami is "particularly" bad for the rapid cycling bipolar (ex-BPD, since I have not been self destructive in over a decade..), like me.
Self-destructiveness is just one symptom of BPD, and rapid-cycling bipolar disorder like you describe is pretty much indistinguishable from BPD. But anyway, no, I don't know of any web sites. Have you tried doing searches? Searching Medline would definitely turn up some results (although bear in mind that this hasn't been studied extensively so you're not going to get any rigorous clinical trials).
> If I just didn't have this dumb scalp pain induced from the lithium, I could just go up on that and I think the cycling would decrease. But without a TCA, the burning is so painful, I can't tolerate the Li...
Do you think the lithium is helping? It sounds like that may be more of a problem than a help!
-elizabeth
Posted by Elizabeth on January 30, 2002, at 13:28:00
In reply to Re:TCA less likely to cause rage?, posted by Chloe on January 27, 2002, at 17:50:28
Chloe,
Most of the TCAs are antihistamines; doxepin is the strongest, and amitriptyline is the second-strongest. I don't think that an antihistamine will help with your rages, though.
-e
Posted by Ritch on January 30, 2002, at 13:30:40
In reply to Re:TCA/depakote/sleep? » Ritch, posted by Chloe on January 30, 2002, at 9:55:31
> > Yes, I doubt if you are going to find many agents as capable of producing sleep as amitriypline. You might chop one of those 10mg tabs in half and just take 5mg at bedtime-use it as your sleeper. Depakote *helps* with sleep, but it won't guarantee it.
>
> Mitch,
> I am still taking the 10 mgs of Ami+125 depakote at bedtime. But since adding the dep, my sleep is very light, and I have several wakings in the night/early am. Like it was before I started ami. BUT I am still on the ami. Do you know if I will adjust to the dep and start sleeping through the night again? That was heaven...
>
> Chloe
Chloe,It is possible that the AD effect of the amitrip. is starting to "kick in" and/or you are starting to become tolerant to the antihistamine-induced drowsiness. How long have you been taking the amitrip.? TCA's are weird-they have this 2-3week waiting period before they kick-in. SSRi's can "kick-in" right away up to less than 10 days with me.
Oh yeah! I just remembered, when I started taking Depakote my pdoc wanted me to take it about four hours before bedtime in the evening. It takes a little while to peak. That way the "peak" hits right about bedtime. Also, it will accumulate for a while and it may take a week or so before you see the sleep benefit-I definitely did have sleep benefits from it.
Mitch
Posted by Chloe on January 31, 2002, at 18:12:31
In reply to Re:TCA less likely to cause rage?, posted by Elizabeth on January 30, 2002, at 13:28:00
Elizabeth,
My pdoc didn't think a switch would make any difference either. She just thought I was having a mixed, agitated state from too much AD (1.5 mgs Celexa and 10 mgs of amitriptyline!). I was so enraged and so sure she was wrong !
Turns out she was right. Adding Depakote to my neurontin has smoothed things out pretty well. I am humble again :)Thanks for your reply
Chloe
>
> Most of the TCAs are antihistamines; doxepin is the strongest, and amitriptyline is the second-strongest. I don't think that an antihistamine will help with your rages, though.
>
> -e
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