![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 5 to 29 of 60. Go back in thread:
Posted by bleauberry on November 23, 2009, at 18:37:08
In reply to Add anything to help with the EMSAM wait...., posted by Monica L on November 22, 2009, at 16:16:39
I don't know. It's really hard. Damn, holiday time and feeling so bad. Man oh man can I relate. My heart hurts reading your post.
If you can manage another 10 days, maybe go for that? If you feel the same then, I personally would ditch it. If anyone gave me a lecture on how the drug needs more time, I would tell them to go to...well, keep it nice...go jump in a lake.
If you aren't feeling any improvement at two weeks, the odds for success...clinically and scientifically proven in several pubmed studies...are already plummeting.
Did you feel this bad before you started? I mean, most people don't talk about it enough, but there is such a thing as deterioration after starting a new med. It could be ensam is making you feel worse? In clinical studies when people withdraw prematurely due to side effects...well, some of those withdrawals were because they got worse. It was called side effects. But the facts were, they were direct effects. The drug made the person worse. That's no side effect.
Just a possibility to consider.
In the years since Deprenyl has been tried as an antidepresant, I have seen ZERO people find it effective for any length of time. When it was reformulated into the Ensam skin patch version, I have seen I think 3 strong success stories, maybe 4 ho-hum not satisfactory stories, and maybe 12 miserable failures.
I have no idea why doctors would go for Ensam when the kings Parnate and Nardil cannot be beat. Even after 5 decades, nothing can top their track record. That's just the way it is. Screw the diet thing. Take a drug with a very long and very strong track record.
Since you have felt jumpy and irritable thus far with ensam, that alone tells me it is doing the wrong stuff for you.
My two cents.
I do wish you a smooth day and wish to heck there was something any of us could do to improve things right now. The best I can do is say I'm with you, don't let it get worse, stop if you have to. You would not be the first person to say you felt better after stopping ensam. All I know is I felt irritable and crappy on it, a lot better beginning the third day after stoppin it. Would it have ever worked if I had stuck with it? Do I really care? I'm alive and doing better with other things. I wouldn't have been if I didn't stop. I can name several drugs that would have killed me if I didn't abort them.
So you've been on a lot of drugs? And in the hospital? And never been on parnate or nardil? I don't get that. You were a highly qualified candidate for those a long time ago.
Posted by Monica L on November 23, 2009, at 19:23:35
In reply to Re: Add anything to help with the EMSAM wait...., posted by bleauberry on November 23, 2009, at 18:37:08
> I don't know. It's really hard. Damn, holiday time and feeling so bad. Man oh man can I relate. My heart hurts reading your post.
>
> If you can manage another 10 days, maybe go for that? If you feel the same then, I personally would ditch it. If anyone gave me a lecture on how the drug needs more time, I would tell them to go to...well, keep it nice...go jump in a lake.
>
> If you aren't feeling any improvement at two weeks, the odds for success...clinically and scientifically proven in several pubmed studies...are already plummeting.
>
> Did you feel this bad before you started? I mean, most people don't talk about it enough, but there is such a thing as deterioration after starting a new med. It could be ensam is making you feel worse? In clinical studies when people withdraw prematurely due to side effects...well, some of those withdrawals were because they got worse. It was called side effects. But the facts were, they were direct effects. The drug made the person worse. That's no side effect.
>
> Just a possibility to consider.
>
> In the years since Deprenyl has been tried as an antidepresant, I have seen ZERO people find it effective for any length of time. When it was reformulated into the Ensam skin patch version, I have seen I think 3 strong success stories, maybe 4 ho-hum not satisfactory stories, and maybe 12 miserable failures.
>
> I have no idea why doctors would go for Ensam when the kings Parnate and Nardil cannot be beat. Even after 5 decades, nothing can top their track record. That's just the way it is. Screw the diet thing. Take a drug with a very long and very strong track record.
>
> Since you have felt jumpy and irritable thus far with ensam, that alone tells me it is doing the wrong stuff for you.
>
> My two cents.
>
> I do wish you a smooth day and wish to heck there was something any of us could do to improve things right now. The best I can do is say I'm with you, don't let it get worse, stop if you have to. You would not be the first person to say you felt better after stopping ensam. All I know is I felt irritable and crappy on it, a lot better beginning the third day after stoppin it. Would it have ever worked if I had stuck with it? Do I really care? I'm alive and doing better with other things. I wouldn't have been if I didn't stop. I can name several drugs that would have killed me if I didn't abort them.
>
> So you've been on a lot of drugs? And in the hospital? And never been on parnate or nardil? I don't get that. You were a highly qualified candidate for those a long time ago.
Thanks for taking the time to respond to my post. I dont' know if I feel worse because I expected so much from Emsam or what. I expected for it to work fairly quickly for me, everything I have tried in the past has kicked in that way. And as far as what I have tried, I have tried it ALL, over a period of almost 5 years. I have been hosp. once and all they did was put me on about 5 different meds. I wouldn't say I was depressed, more of just lacking interested in anything, no motivation or drive and little energy. I know all those things sound like depression, but I'm not really SAD. I'm actually more talkative and outgoing and laugh more since I've been off all meds., but still no motivation, drive or energy, no dopamine. Then I start thinking about how the Emsam is not working and get very discouraged, things shouldnt be this hard to do, I used to do things without thinking whenever meds were working for me. I looked forward to things and felt like I had a purpose.So I called the doc today and of course he didnt get back with me, I'm sure they were busy though being monday and all. The guy that takes the msg will I'm sure get back with me tomorrow. I'm thinking of just telling him to tell my doc that I'm going to stop the Emsam so I can start Parnate. Do you know how long the washout would be? I hate when they bring up the diet as if they think you wouldnt try the drug because of it. If they understood what this feels like, they would know I'd be willing to sacrifice not eating certain foods, anything to not feel this way and feel normal again. I'm tired of waiting, I'm trying to hang in there, nothing matters more to me than my mental health, I wish the docs could understand that.
Sorry I wrote so much..
Monica
Posted by bleauberry on November 24, 2009, at 5:05:07
In reply to Re: Add anything to help with the EMSAM wait...., posted by Monica L on November 23, 2009, at 19:23:35
Monica,
If you are going to do a washout, I believe one week would be sufficient. I am not a doctor or rocket scientist, just common sense. I think it would also be important to start Parnate, if you do, at a very low dose for the first week...5mg, half of a 10mg pill, as an introduction. Then week two begin ramping up. I was suprised even a mere 5mg once every other day helped me quite a bit, contrary to the posts of so many people who say they felt nothing at much larger doses. Sometimes I wonder if less is more, as I've seen so often in various topics of life. In any case, as ensam washes out, introduce parnate lowly.
Your symptoms sound more like anhedonia, which is a syndrome that is usually a component of depression, but which can also be a stand-alone syndrome without depression, usually be confused as depression. That might be possible with you?
My primary symptom has always been the same as yours. When ADs worked, I was still lifeless and joyless. No depression when the meds worked, but no life and no joy either.
Some things I found helpful:
Either Adrafinil, Provigil, or Ritalin added to a very low dose of your favorite SSRI.
Low dose Milnacipran, with possible Ritalin addition.
10mg prozac (enough to ease depression but not enough to worsen the AD emotional numbness thing), 300mg Adrafinil, and 25mg Amisulpride, was a decent combo.
The best single agent I've ever tried, Amisulpride 25mg once every other day. Begins working on day 2 or 3.
Amisulpride and Adrafinil are both international meds available mailorder. Adrafinil is a quasi-stimulant, Amisulpride is an antipsychotic at doses higher than 50mg, but an anti-anhedonia antidepressant at lower doses.
And my very short trial of Parnate at tiny doses was positive. I have Lyme complications of low blood pressure, cold body temperature, and easily provoked numbness/tingling of extremeties, all of which got much worse on Parnate. Too bad.
In the natural arena, people who have stuck with it and experimented to find their exact dosing have had great success with combinations of 5htp (usually lower doses than suggested on the bottle) combined with Tyrosine.
You have lots of options, so if there is no other reason to smile today, hold on to hope! :-)
Anhedonia requires a different approach than the generic term depression. While we assume anhedonia is dopamine, it really involves at complex interaction of all the neurotransmitters, but dopamine and/or norepinephrine are the biggest players.
On paper it is often suggested to take dopamine agonists for anhedonia. I don't like that option. Very troublesome side effects, and longterm outcomes are poor or worse than baseline.
If I were meeting with a friend who was trying to make a list of things for his/her anhedonia, the list of ingredients for mono agents or combos would be:
Low dose prozac. (not more than 10mg)
Low dose Milnacipran (Savella) (12.5mg bid)
Ritalin. As needed.
Adrafinil. 300mg - 600mg per day.
Amisulpride. 25 mg once every two days.
Parnate 5mg - 80mg.
Tyrosine.
5htp.Anything not on that list, waste of time. Of course I realize we are all different. The list is not just my own, but a gathering from various people at various forums of various diseases where anhedonia happened to be the issue.
>
> Thanks for taking the time to respond to my post. I dont' know if I feel worse because I expected so much from Emsam or what. I expected for it to work fairly quickly for me, everything I have tried in the past has kicked in that way. And as far as what I have tried, I have tried it ALL, over a period of almost 5 years. I have been hosp. once and all they did was put me on about 5 different meds. I wouldn't say I was depressed, more of just lacking interested in anything, no motivation or drive and little energy. I know all those things sound like depression, but I'm not really SAD. I'm actually more talkative and outgoing and laugh more since I've been off all meds., but still no motivation, drive or energy, no dopamine. Then I start thinking about how the Emsam is not working and get very discouraged, things shouldnt be this hard to do, I used to do things without thinking whenever meds were working for me. I looked forward to things and felt like I had a purpose.
>
> So I called the doc today and of course he didnt get back with me, I'm sure they were busy though being monday and all. The guy that takes the msg will I'm sure get back with me tomorrow. I'm thinking of just telling him to tell my doc that I'm going to stop the Emsam so I can start Parnate. Do you know how long the washout would be? I hate when they bring up the diet as if they think you wouldnt try the drug because of it. If they understood what this feels like, they would know I'd be willing to sacrifice not eating certain foods, anything to not feel this way and feel normal again. I'm tired of waiting, I'm trying to hang in there, nothing matters more to me than my mental health, I wish the docs could understand that.
>
> Sorry I wrote so much..
>
> Monica
Posted by maxime on November 24, 2009, at 15:39:53
In reply to Re: Add anything to help with the EMSAM wait...., posted by Monica L on November 23, 2009, at 19:23:35
If I remember correctly, it's a one week washout period. I think you should try Parnate. :) It has worked wonder on me and it didn't take too long to kick in once I got to 40 mg. I am now on 80 mg and feeling really good.
Posted by floatingbridge on November 26, 2009, at 15:44:29
In reply to Add anything to help with the EMSAM wait...., posted by Monica L on November 22, 2009, at 16:16:39
Hi Monica,
I'm sorry to hear that you're in distress and that your hoped for relief has not arrived yet.
Hugs your way,
fb
Posted by inanimate peanut on November 28, 2009, at 18:53:11
In reply to Add anything to help with the EMSAM wait...., posted by Monica L on November 22, 2009, at 16:16:39
I'm on day 8 of Emsam and in total hell. I don't know whether I can survive just keeping waiting to see whether it works or whether I should try to switch to Nardil or ECT. This is torture.
Posted by inanimate peanut on November 28, 2009, at 18:55:23
In reply to Re: Add anything to help with the EMSAM wait...., posted by emmanuel98 on November 22, 2009, at 17:04:56
Do you have to have a wash out between Emsam and other MAOIs like Parnate and Nardil?
Posted by floatingbridge on November 28, 2009, at 18:56:52
In reply to Re: Add anything to help with the EMSAM wait...., posted by Monica L on November 23, 2009, at 19:23:35
Monica,
I'm sorry the emsam seems to be a bust. How are you doing? Will you withdraw? I thought the washout was two weeks, but what do I know? I hope it is only one.
best wishes,
fb
Posted by floatingbridge on November 28, 2009, at 18:59:05
In reply to Re: Add anything to help with the EMSAM wait...., posted by inanimate peanut on November 28, 2009, at 18:53:11
> I'm on day 8 of Emsam and in total hell. I don't know whether I can survive just keeping waiting to see whether it works or whether I should try to switch to Nardil or ECT. This is torture.
Is it just not working, or are you having side effects? Someone on the thread said one week washout--I heard two. Good luck to you!
fb
Posted by inanimate peanut on November 28, 2009, at 19:02:49
In reply to Re: Add anything to help with the EMSAM wait.... » inanimate peanut, posted by floatingbridge on November 28, 2009, at 18:59:05
It's just not working and I'm on the verge of going to the hospital. I don't know whether to keep giving it a chance or to go back on Wellbutrin and Pristiq (which I was horribly depressed on but not this bad), but that requires a wash out, or to try Nardil, or to try ECT. I just know I need to feel better soon before I go completely crazy.
Posted by Monica L on November 28, 2009, at 19:18:47
In reply to Re: Add anything to help with the EMSAM wait.... » floatingbridge, posted by inanimate peanut on November 28, 2009, at 19:02:49
> It's just not working and I'm on the verge of going to the hospital. I don't know whether to keep giving it a chance or to go back on Wellbutrin and Pristiq (which I was horribly depressed on but not this bad), but that requires a wash out, or to try Nardil, or to try ECT. I just know I need to feel better soon before I go completely crazy.
That's so weird that you just posted to my thread. I'm looking up hospitals on the internet right now. I don't know what's making me feel this way, is it the holidays or what? I've been off EMSAM for almost a week now, cause I dont' have what it takes to give it time unless I'm in the hospital. I'm tired of having my kids see me like this and having my husband take over everything. I'm so thankful that he's so supportive of me and has been for the past 5 yrs that Ive been through this. I've tried ECT and felt that it did help, but I still struggle with low dopamine. It's too the point that because of the low dopamine and inability to function is making me depressed. I dont' know where to turn anymore, I took some ritalin earlier and I felt better for about 4 hrs and then of course it wears off. I'm sorry you are struggling too, I know how you feel.
Posted by Monica L on November 28, 2009, at 19:27:03
In reply to Re: Add anything to help with the EMSAM wait.... » Monica L, posted by floatingbridge on November 28, 2009, at 18:56:52
> Monica,
>
> I'm sorry the emsam seems to be a bust. How are you doing? Will you withdraw? I thought the washout was two weeks, but what do I know? I hope it is only one.
>
> best wishes,
>
> fbI'm not doing to good, I spent all week trying to get in touch with my pdoc, he never returned my call. I left messages with the patient coordinator that I wanted off the emsam and wanted to try something else. I don't understand how he puts me on 6 mg emsam and suggests he sees me in a month to see how I'm doing. One month is a long time when to follow up when you start a new med, with no increase in the dosage and during that month just hope it works. So I stopped the emsam on my own and so far no withdrawls except maybe just feeling worse. I'm think I',m going to see my reg dr on monday, explain whats been going on and see if she will prescribe the parnate. At this point though I'm afraid to try anything because I feel nothing will work. I'm willing to give it two weeks in PILL form, the patch drove me crazy, it never stuck completely.
Anyways, sorry I wrote so much....
Posted by Monica L on November 28, 2009, at 19:29:02
In reply to Re: Add anything to help with the EMSAM wait...., posted by emmanuel98 on November 22, 2009, at 17:04:56
> I tried Emsam last summer, first 6mg then up to 12. It didn't do a thing for me. However parnate worked wonders. Have you tried parnate? Unfortunately, once you're on Ensam, you need a 10-day washout to try anything else.
How long did it take for the parnate to kick in?
Thanks
Posted by floatingbridge on November 28, 2009, at 20:50:52
In reply to Re: Add anything to help with the EMSAM wait...., posted by Monica L on November 28, 2009, at 19:27:03
> I'm not doing to good, I spent all week trying to get in touch with my pdoc, he never returned my call. I left messages with the patient coordinator that I wanted off the emsam and wanted to try something else. I don't understand how he puts me on 6 mg emsam and suggests he sees me in a month to see how I'm doing. One month is a long time when to follow up when you start a new med, with no increase in the dosage and during that month just hope it works. So I stopped the emsam on my own and so far no withdrawls except maybe just feeling worse. I'm think I',m going to see my reg dr on monday, explain whats been going on and see if she will prescribe the parnate. At this point though I'm afraid to try anything because I feel nothing will work. I'm willing to give it two weeks in PILL form, the patch drove me crazy, it never stuck completely.
>
> Anyways, sorry I wrote so much....Monica, I'm glad you posted. Frankly, that your pdoc just left you on your own, esp. given your history, is irresponsible and bad medicine--I'm really sorry. Will you try segeline in pill, or just go for the parnate? Whichever, I hope you achieve some success. And I hope your gp will give you the parnate if that's what you decide. Sound very rough, Monica. Keep us posted. Many experienced people here w/ parnate to draw advice from.
my best wishes for you,fb
>
>
Posted by emmanuel98 on November 29, 2009, at 0:33:26
In reply to Re: Add anything to help with the EMSAM wait.... » emmanuel98, posted by Monica L on November 28, 2009, at 19:29:02
Parnate worked within a couple of days. I mean I literally went from severe, in the hospital, suidical depression to fine within 48 hours of starting parnate. Emsam did nothing for me.
But this is my experience and everyone responds differently.
> > I tried Emsam last summer, first 6mg then up to 12. It didn't do a thing for me. However parnate worked wonders. Have you tried parnate? Unfortunately, once you're on Ensam, you need a 10-day washout to try anything else.
>
> How long did it take for the parnate to kick in?
>
> Thanks
Posted by Monica L on November 29, 2009, at 8:46:26
In reply to Re: Add anything to help with the EMSAM wait.... » Monica L, posted by emmanuel98 on November 29, 2009, at 0:33:26
> Parnate worked within a couple of days. I mean I literally went from severe, in the hospital, suidical depression to fine within 48 hours of starting parnate. Emsam did nothing for me.
>
> But this is my experience and everyone responds differently.
>
>
> > > I tried Emsam last summer, first 6mg then up to 12. It didn't do a thing for me. However parnate worked wonders. Have you tried parnate? Unfortunately, once you're on Ensam, you need a 10-day washout to try anything else.
> >
> > How long did it take for the parnate to kick in?
> >
> > Thanks
>
>Thanks for the response, one more question if you don't mind, do you know if you take the generic parnate or the brand name?
Thanks Again
Posted by inanimate peanut on November 29, 2009, at 12:46:57
In reply to Re: Add anything to help with the EMSAM wait...., posted by Monica L on November 28, 2009, at 19:18:47
It's horrible to feel like this. I'm glad your husband is supportive. I had a supportive boyfriend but he left last time I was like this so now I'm all alone trying to deal with this. I have family but they live 2 hours away. I feel so alone and don't know what to do. I'm sorry you're feeling so bad too. I just wish there was something to help us. Do you know what you're going to try next?
Posted by Monica L on November 29, 2009, at 14:29:26
In reply to Re: Add anything to help with the EMSAM wait.... » Monica L, posted by inanimate peanut on November 29, 2009, at 12:46:57
> It's horrible to feel like this. I'm glad your husband is supportive. I had a supportive boyfriend but he left last time I was like this so now I'm all alone trying to deal with this. I have family but they live 2 hours away. I feel so alone and don't know what to do. I'm sorry you're feeling so bad too. I just wish there was something to help us. Do you know what you're going to try next?
Well first thing tomorrow morning I'm going to try and get an appointment with my regular Dr. My next appointment with the Pdoc isn't until the 14 of Dec., which I think is ridiculous, I cannot wait that long. I'm going to tell her that the emsam isn't working out for me and that I want to try parnate. I've been taking 40 mg of ritalin though, I don't know if that would prevent me from trying the parnate right away. If she does prescribe it, I'm going to start it regardless. I dont' know what else to do. My husband and I were talking about whether or not I should admit myself to the hospital and wait everything out there, for the medication to work basically. I'm sorry that you have to go through this alone and away from family. Do you work during the day, or have something to keep your mind busy during the day? It's hard for me because I stay home, and I really need something to keep me busy during the day. Being like this and being a homemaker do not mix well. Are you still on the emsam? The washout to start another maoi is 10 days or a week, I'm not sure but I'm going with the 10 days. Well, let me know how you're doing and hang in there..
Posted by inanimate peanut on November 29, 2009, at 14:53:46
In reply to Re: Add anything to help with the EMSAM wait...., posted by Monica L on November 29, 2009, at 14:29:26
I hope it works out for you to switch to Parnate. I too am wondering whether I should go in the hospital. I'm just not sure. I have a job but am too sick to work right now so I'm home alone all day. This is really too horrible for words. I'm just trying to get through each minute...
Posted by emmanuel98 on November 29, 2009, at 16:04:08
In reply to Re: Add anything to help with the EMSAM wait.... » emmanuel98, posted by Monica L on November 29, 2009, at 8:46:26
I take generic tranylcypromine.
> Thanks for the response, one more question if you don't mind, do you know if you take the generic parnate or the brand name?
>
> Thanks Again
Posted by ColoradoSnowflake on November 30, 2009, at 21:40:43
In reply to Re: Add anything to help with the EMSAM wait...., posted by emmanuel98 on November 29, 2009, at 16:04:08
I take generic Parnate, also. Gayle
Posted by floatingbridge on November 30, 2009, at 22:56:41
In reply to Add anything to help with the EMSAM wait...., posted by Monica L on November 22, 2009, at 16:16:39
Monica, my thoughts are with you.
fb
Posted by Kingston on December 2, 2009, at 4:24:05
In reply to Re: Add anything to help with the EMSAM wait...., posted by inanimate peanut on November 28, 2009, at 18:55:23
To be honest, EMSAM is pretty good stuff but it does have the nasty habit of lowering my already low Blood Pressure (98/33) and I'm a 180 lb male. Thus it requires stimulant augmentation; I just can't afford EMSAM--plain and simple so I'm looking to alternatives--Parnate being my final alternative b/f up and moving to Bolivia where I can legally chew coca leaves on a perpetual basis. Apparently you can buy coca leaves on Amazon.com now though so maybe I'll stay.
As for EMSAM, you can safely add a stimulant to MAOIs(see discussion below). A low dose of Desoxyn or Dexedrine to the patch should suffice if it is Dopamine or and increase in BP that you are after. I would go with Desoxyn if you can get a script of it. It can be filled at any local Target pharmacy with a 1-2 day response time. It is the best medication on the market, 70 year efficacy record and quite possibly responsible for World War I. It does tend to make you feel like GOD but it blows all MAOIs out of the pharmaceutical abyss in regards to depression. Side effects are benign: increased narcissism, delusions of grandeur, increased strength, stamina and perceived intellect, propensity towards God Complex: all good things if you are someone suffering from Major Depression/Social Phobia.
Problem is, it's pure methamphetamine HCL(as are all the metabolites of the MAOIs: little known secret but the driving force behind these puppies) but Desoxyn has no guise to hide behind. It's very difficult to get and when you do get it, getting a script for the necessary 30+mg/day to knock out depression with an Ike Turner on Tina-uppercut is virtually impossible. It's not like Adderall or Dex in terms of the 'anxious space cadet effect' that comes with. It doesn't make you shaky or socially awkward. This is largely b/c it brushes your serotonin and opiate receptors. Feels sort of like happiness in a pill and you become supremely confident by defacto. Social Phobia, agoraphobia, depression quickly dissipate into thin smog after minutes of ingestion. Withdrawal?...i've never experienced it from Stims. You want to discuss withdrawal, try weaning off Klonopin; it's a nightmare on Elm street; wish i had never been introduced to this demotivating med that works all to well for just about everything but intellectual function/productivity/motivation. I feel like i'm permanently stoned inside a comfortably numb womb of Novicaine for the brain. They say it's more difficult to kick Klonopin than heroine.
I personally can't take Desoxyn anymore b/c like EMSAM, I can longer afford the exorbitant 500 dollar monthly fee(lost all my money in the stock market last year). I currently take the 6mg EMSAM patch with a 15mg Dexedrine Spansule, 30mg of Lamictal & 1mg of Klonopin(couldn't kick it). The cocktail works decently but I actually came on this site to hear people's thoughts about Parnate.
Rather than increasing my EMSAM dose to 12mg, I'm considering a batch of Parnate. I've been toggling Parnate for about five years now but haven't had the courage to succumb to this beast of a drug which is supposed to be the best when tolerated. Is it really that bad in terms of side effects? I've taken almost every drug known to man and have never once had any 'real' side effects. I think this is b/c I exercise daily and eat healthy by default of having Celiac's disease and having to be on a gluten, casein, lactose free diet. The MAOi diet is nothing compared to what i'm forced to eat. Broccoli and Chicken and that's about it. So yeah, not worried about weight gain. Can't see how an amphetamine based drug like Parnate would cause weight gain anyhow, and if it did, I would welcome it. EMSAM has turned me into a toothpick, albeit a ripped tooth pic. Sexual side effects, ACNE and cognition are my major concerns. One positive effect from EMSAM has been that my libido has skyrocketed and I no longer need Viagra to get it up. I know that Nardil is notorious for phallic Down Syndrome but what about Parnate?
Concerning EMSAM, you have to give this drug time. At least 1 month before passing final judgment. At 6mg, it is pretty much just targeting dopamine(it's major metabolite being methamphetamine). If you have severely low dopamine levels already, than you will need to up the dose. And at higher doses, you get some serotonergic and norepinephrinergic effects that are the hallmarks of Parnate and Nardil.
And as for Parnate, it is KING b/c it is essentially a high dose of amphetamine which is why it helps with depression. Parnate is about as close as you'll will get to street methamphetamine/cocaine which is another reason I think doctors tend to stay away from it; highly addictive and tolerance builds rapidly. Parnate does however, have the added benefits of serotonin and some GABA release(not sure about GABA? although I know Nardil releases GABA in megaton quantities) to quell excessive dopaminergic stimulation. This is what EMSAM lacks and why so many people can't tolerate it. If you get anxious on ESAM, contrary to what seems logical, increasing the dose will actually decrease anxiety due to the onset of both MAO-b and MAO-a effect. At 6mg, you are only getting MAO-b. Why they didn't make a Nardil or Parnate patch boggles the mind?? Probably b/c it would work too well and put the SSRI machine that is raking in billions, out of business.
I can imagine that tolerance with Parnate is the same as it would be with any stimulant: you get used to it after a while which makes augmenting with Namenda to abate amphetamine tolerance a possibility. Augmentation with Aricept would also boost the effects of any amphetamine based drug in my experience.
Not sure if Parnate will be any cheaper since my insurance isn't covering anything brand name(tapped out at 2000 max) till January and I refuse to take anything but brand; especially with a drug such as Parnate. For ex: I switched from GSK Lamictal that i was getting from overseas for a ridiculously cheap price to generic Lamictal. It felt like i'd been roofied with sugar pills so I was forced to switch back. Generics are just plain garbage and full of fillers that cause more problems than the intended med cures. I try to avoid anything in pill form and instead ask for either liquid, sub-lingual or transdermal. Pills are primitive and for ex: if you have a bowl of fiber, the pill will get absorbed with the fiber and you will defecate it out a-la-stool without it ever getting absorbed. This is the problem with pills and the major reason why I try to stay away from them. Here's another example of why generics are a waste of money: I take a 15mg GSK Dexedrine Spansule and watch my BP go from 110 to 130 in a matter of minutes. I feel it kick after about 15 minutes. If I take 30 mg of Barr (generic) Dex, there is no BP elevation and the cerebral effect is mild. It all has to do with asorbtion which is why I was hoping that my insurance would cover a new form of liquid Dexedrine called Procentra but nope. Without insurance, that has a 1000 dollar price tag. Ridiculous and I certainly can't afford it.
In long winded conclusion, I can imagine that if you're used to a much more potent drug like Parnate or have low dopamine levels, ESMAM would seem like the difference between caffeine and crystal meth; nothing basically; your dopamine threshold levels have habituated to a very high level so you are going to need a more potent drug or combo. Ask your doc about augmenting the patch with a stimulant. Read below. It was once common practice, even with Parnate.
FOUND THIS THREAD ON THE WEB AND THOUGHT IT MIGHT BE APPLICABLE TO EMSAM AS WELL.The commonest reason people do not respond to tranylcypromine (Parnate) is an inadequate dose. When using an MAOI I follow platelet MAO levels and keep increasing the dose is sufficient to reduce those levels almost to zero. This often takes > 60 mg/day of tranylcypromine.
If a month or so on 80 mg/day or so does not lead to a significant improvement, the next thing I usually do is to add a psychostimulant such as methylphenidate or dextroamphetamine to the cocktail. Starting with small doses, the dose is gradually increased until the patient is taking about 30 mg/day of dextroamphetamine, or twice as much methylphenidate.
Date: Fri, 14 Apr 1995 15:06:15 -0700 (PDT)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: MAOIs in high doses and with stimulantsThere are recently been a number of warnings posted there that MAOIs should not be prescribed together with psychostimulants. While that is the conventional wisdom, if universally implemented, it would deprive many severely and intractably depressed people from relief.
In the olden days, the early 1960s, we used to treat some patients with resistant depressions with up to 200 mg/day of tranylcypromine and if that was not effective potentiate it with dextroamphetamine, starting with 2.5 mg once a day and gradually increasing to 15 or 20 mg/day.
Until it was recently withdrawn, a 60ish year old patient of mine was only able to continue in his professional work by taking 170 mg/day of isocarboxazid + 5 mg of dextroamphetamine t.i.d. Since the isocarboxazid became unavailable, he has been doing almost as well on phenelzine 135 mg/day + the dextroamphetamine.
When treating patients with unusually hard to treat syndromes it is often necessary to use combinations [and doses] of medication that are conventionally considered to be contraindicated.
From: "Steven L. Dubovsky" <Steven.Dubovsky@UCHSC.edu>
Date: 15 Apr 95 08:47:17 MST-0700
Subject: MAOIs in high doses and with stimulantsIt is common practice where I come from to combine MAOIs and stimulants for MAOI-induced hypotension and treatment resistance. This is also mentioned in Jan Fawcett's book of a number of years ago. Also, remember Feighner's report of MAOI + TCA + stimulant in ECT-resistant depression. I have tried this a number of times and found it helpful. Since half the caucasian population are (is?) rapid acetylators, higher doses of Parnate are frequently necessary. Other patients are rapid metabolizers of hydrazide MAOIs and need high doses of those. The PDR is a legal, not a medical, document, so I don't think their doses are always reliable.
From: Donald Franklin Klein <dfk2@columbia.edu>
Date: Sun, 16 Apr 1995 23:44:11 -0400
Subject: MAOIs with stimulantsMAOIs plus methylphenidate (Ritalin) has not been a problem in my hands although theoretical risk requires discussion with patient, consent, and available nifedipine. Very useful for orthostatic hypotension.
Date: 06 Sep 95 11:38:03 EDT
From: Troy Caldwell <75112.1676@compuserve.com>
Subject: MAOIs with stimulantsNone other than my teacher, John Rush, some years ago referred just such a refractory person to me specifically to try adding a stimulant to her MAOI. This was in the days when doctors could still hospitalize and had authority to do things. Apparently, we private practitioners had a bit more autonomy than the university MDs at that time, so I got the referral.
Social commentary aside, I put the pt in the ICU and added very slowly Dexedrine or Desoxyn to the patient's regimen. It was wonderful -- a grand remission occurred -- and complications were zero. I've tried it since a few times, starting a low doses and titrating gradually upward, and each time no complications arose. Like all treatment efforts, it has been variably effective, but definitely worth trying. Of course, give them nifedipine as an antidote to carry.
Date: Fri, 09 Feb 1996 10:57:43 -0600
From: Kevin Miller <MillerKB@wpogate.slu.edu>
Subject: MAOIs with stimulantsHypotension is a frequent side-effect of MAOIs. If hypotension limits appropriate dosage increases, either based on clinical response, or on not reaching the target dose of about 1 mg/kg in the case of phenelzine (Robinson and Nies), the slow and careful addition of stimulants while monitoring BP makes wonderful sense. The hypotension is treated, the antidepressant effect is augmented, and, if methylphenidate is used, there may be pharmacokinetic effects as well. This is riskier with tranylcypromine given that spontaneous elevations of BP have been noted with this MAOI despite strict dietary adherence. It's also easier to do safely on an inpatient basis.
From: JoelSHoffm@aol.com (Joel S Hoffman)
Date: Sun, 18 Feb 1996 21:43:52 -0500
Subject: MAOIs with stimulantsThere is fortunately a small literature on combining MAOI and stimulant medication: Fawcett, J Clin Psychopharm 1991, 127-132; Feighner, J Clin Psych 1985, 206-209. Also, Clary, J Clin Psych 1990, 226-231, reported in a survey of prescribing habits of Pennsylvania psychiatrists that among those who prescribed MAOIs, use of high doses and combined use of MAOIs with stimulant meds were not unusual.
I have used this combination for the treatment of refractory depression and have at times have found it a great help and at other times useless. I do not remember it being helpful when a patient was not at least partially responsive to either the stimulant or the MAOI alone. However if there is a partial response to one of those meds, then when the two are combined, there can be either an additive or synergistic effect.
I have never had a problem with elevated BP, however I most often add the MAOI to the stimulant rather than the reverse... If I do add a stimulant to an MAOI, I start with 1.25 mg d-amphetamine or equivalent, the idea being that it probably takes at least 5 mg tyramine to precipitate a hypertensive crisis, and since the molecular weights are about the same 1.25 mg amphetamine would be sub-threshold. Starting at that level has not caused any reactions, but I still prefer to start with the stimulant and add the MAOI later.
I find that with time, as more treatment options are available, I use this combination less but there are still some patients for whom nothing else seems to work. The side effects that do cause problems include activation sometimes resembling or identical to dysphoric mania. Stereotypy and choreiform movements including bucco-facial dyskinesia can also occur. These side effects have to watched for closely. If it is essential to continue the regimen, pimozide can usually alleviate the movement disorder.
From: "David A. Kahn" <kahndav@cpmc3.cpmc.columbia.edu>
Date: Wed, 21 Feb 1996 10:31:11 EDT
Subject: MAOIs with stimulantsI'm always in the position of trying to augment an existing MAOI regimen, so it's never seemed feasible to stop the MAOI, start the stimulant, and then restart the MAOI. I just add the stimulant. The only adverse reaction I've encountered is an odd lability of blood pressure on two occasions, where supine blood pressure was somewhat elevated on a tonic basis, together with a worsening of orthostatic hypotension. The supine elevation made it impossible to think of Florinef, etc., so we had to stop the combination. Interestingly, both of these individuals had prior histories of intermittent bordereline essential hypertension which had resolved on the MAOI alone.
From: JoelSHoffm@aol.com (Joel S Hoffman)
Date: Wed, 21 Feb 1996 08:29:48 -0500
Subject: MAOIs with stimulantsBy the way, I do not get signed consent. I do not think that that holds up very well anyway. Well documented clear chart notes indicating the clinical rationale and including what is told to the patient should always be standard practice and especially with atypical treatment modalities such as this.
Posted by Kingston on December 2, 2009, at 4:33:56
In reply to Re: Add anything to help with the EMSAM wait...., posted by inanimate peanut on November 28, 2009, at 18:55:23
To be honest, EMSAM is pretty good stuff but it does have the nasty habit of lowering my already low Blood Pressure (98/33) and I'm a 180 lb male. Thus it requires stimulant augmentation; I just can't afford EMSAM--plain and simple so I'm looking to alternatives--Parnate being my final alternative b/f up and moving to Bolivia where I can legally chew coca leaves on a perpetual basis. Apparently you can buy coca leaves on Amazon.com now though so maybe I'll stay.
As for EMSAM, you can safely add a stimulant to MAOIs(see discussion below). A low dose of Desoxyn or Dexedrine to the patch should suffice if it is Dopamine or an increase in BP that you are after. I would go with Desoxyn if you can get a script of it. It can be filled at any local Target pharmacy with a 1-2 day response time. It is the best medication on the market, 70 year efficacy record and quite possibly responsible for World War I. It does tend to make you feel like GOD but it blows all MAOIs out of the pharmaceutical abyss in regards to depression. Side effects are benign: increased narcissism, delusions of grandeur, increased strength, stamina and perceived intellect, propensity towards God Complex: all good things if you are someone suffering from Major Depression/Social Phobia.
Problem is, it's pure methamphetamine HCL(as are all the metabolites of the MAOIs: little known secret but the driving force behind these puppies) but Desoxyn has no guise to hide behind. It's very difficult to get and when you do get it, getting a script for the necessary 30+mg/day to knock out depression with an Ike Turner on Tina-uppercut is virtually impossible. It's not like Adderall or Dex in terms of the 'anxious space cadet effect' that comes with. It doesn't make you shaky or socially awkward. This is largely b/c it brushes your serotonin and opiate receptors. Feels sort of like happiness in a pill and you become supremely confident by defacto. Social Phobia, agoraphobia, depression quickly dissipate into thin smog after minutes of ingestion. Withdrawal?...i've never experienced it from Stims. You want to discuss withdrawal, try weaning off Klonopin; it's a nightmare on Elm street; wish i had never been introduced to this demotivating med that works all to well for just about everything but intellectual function/productivity/motivation. I feel like i'm permanently stoned inside a comfortably numb womb of Novicaine for the brain. They say it's more difficult to kick Klonopin than heroine.
I personally can't take Desoxyn anymore b/c like EMSAM, I can longer afford the exorbitant 500 dollar monthly fee(lost all my money in the stock market last year). I currently take the 6mg EMSAM patch with a 15mg Dexedrine Spansule, 30mg of Lamictal & 1mg of Klonopin(couldn't kick it). The cocktail works decently but I actually came on this site to hear people's thoughts about Parnate.
Rather than increasing my EMSAM dose to 12mg, I'm considering a batch of Parnate. I've been toggling Parnate for about five years now but haven't had the courage to succumb to this beast of a drug which is supposed to be the best when tolerated. Is it really that bad in terms of side effects? I've taken almost every drug known to man and have never once had any 'real' side effects. I think this is b/c I exercise daily and eat healthy by default of having Celiac's disease and having to be on a gluten, casein, lactose free diet. The MAOi diet is nothing compared to what i'm forced to eat. Broccoli and Chicken and that's about it. So yeah, not worried about weight gain. Can't see how an amphetamine based drug like Parnate would cause weight gain anyhow, and if it did, I would welcome it. EMSAM has turned me into a toothpick, albeit a ripped tooth pic. Sexual side effects, ACNE and cognition are my major concerns. One positive effect from EMSAM has been that my libido has skyrocketed and I no longer need Viagra to get it up. I know that Nardil is notorious for phallic Down Syndrome but what about Parnate?
Concerning EMSAM, you have to give this drug time. At least 1 month before passing final judgment. At 6mg, it is pretty much just targeting dopamine(it's major metabolite being methamphetamine). If you have severely low dopamine levels already, than you will need to up the dose. And at higher doses, you get some serotonergic and norepinephrinergic effects that are the hallmarks of Parnate and Nardil.
And as for Parnate, it is KING b/c it is essentially a high dose of amphetamine which is why it helps with depression. Parnate is about as close as you'll will get to street methamphetamine/cocaine which is another reason I think doctors tend to stay away from it; highly addictive and tolerance builds rapidly. Parnate does however, have the added benefits of serotonin and some GABA release(not sure about GABA? although I know Nardil releases GABA in megaton quantities) to quell excessive dopaminergic stimulation. This is what EMSAM lacks and why so many people can't tolerate it. If you get anxious on ESAM, contrary to what seems logical, increasing the dose will actually decrease anxiety due to the onset of both MAO-b and MAO-a effect. At 6mg, you are only getting MAO-b. Why they didn't make a Nardil or Parnate patch boggles the mind?? Probably b/c it would work too well and put the SSRI machine that is raking in billions, out of business.
I can imagine that tolerance with Parnate is the same as it would be with any stimulant: you get used to it after a while which makes augmenting with Namenda to abate amphetamine tolerance a possibility. Augmentation with Aricept would also boost the effects of any amphetamine based drug in my experience.
Not sure if Parnate will be any cheaper since my insurance isn't covering anything brand name(tapped out at 2000 max) till January and I refuse to take anything but brand; especially with a drug such as Parnate. For ex: I switched from GSK Lamictal that i was getting from overseas for a ridiculously cheap price to generic Lamictal. It felt like i'd been roofied with sugar pills so I was forced to switch back. Generics are just plain garbage and full of fillers that cause more problems than the intended med cures. I try to avoid anything in pill form and instead ask for either liquid, sub-lingual or transdermal. Pills are primitive and for ex: if you have a bowl of fiber, the pill will get absorbed with the fiber and you will defecate it out a-la-stool without it ever getting absorbed. This is the problem with pills and the major reason why I try to stay away from them. Here's another example of why generics are a waste of money: I take a 15mg GSK Dexedrine Spansule and watch my BP go from 110 to 130 in a matter of minutes. I feel it kick after about 15 minutes. If I take 30 mg of Barr (generic) Dex, there is no BP elevation and the cerebral effect is mild. It all has to do with absorption which is why I was hoping that my insurance would cover a new form of liquid Dexedrine called Procentra but nope. Without insurance, that has a 1000 dollar price tag. Ridiculous and I certainly can't afford it.
In long winded conclusion, I can imagine that if you're used to a much more potent drug like Parnate or have low dopamine levels, EMSAM would seem like the difference between caffeine and crystal meth; nothing basically; your dopamine threshold levels have habituated to a very high level so you are going to need a more potent drug or combo. Ask your doc about augmenting the patch with a stimulant. Read below. It was once common practice, even with Parnate.
FOUND THIS THREAD ON THE WEB AND THOUGHT IT MIGHT BE APPLICABLE TO EMSAM AS WELL.The commonest reason people do not respond to tranylcypromine (Parnate) is an inadequate dose. When using an MAOI I follow platelet MAO levels and keep increasing the dose is sufficient to reduce those levels almost to zero. This often takes > 60 mg/day of tranylcypromine.
If a month or so on 80 mg/day or so does not lead to a significant improvement, the next thing I usually do is to add a psychostimulant such as methylphenidate or dextroamphetamine to the cocktail. Starting with small doses, the dose is gradually increased until the patient is taking about 30 mg/day of dextroamphetamine, or twice as much methylphenidate.
Date: Fri, 14 Apr 1995 15:06:15 -0700 (PDT)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: MAOIs in high doses and with stimulantsThere are recently been a number of warnings posted there that MAOIs should not be prescribed together with psychostimulants. While that is the conventional wisdom, if universally implemented, it would deprive many severely and intractably depressed people from relief.
In the olden days, the early 1960s, we used to treat some patients with resistant depressions with up to 200 mg/day of tranylcypromine and if that was not effective potentiate it with dextroamphetamine, starting with 2.5 mg once a day and gradually increasing to 15 or 20 mg/day.
Until it was recently withdrawn, a 60ish year old patient of mine was only able to continue in his professional work by taking 170 mg/day of isocarboxazid + 5 mg of dextroamphetamine t.i.d. Since the isocarboxazid became unavailable, he has been doing almost as well on phenelzine 135 mg/day + the dextroamphetamine.
When treating patients with unusually hard to treat syndromes it is often necessary to use combinations [and doses] of medication that are conventionally considered to be contraindicated.
From: "Steven L. Dubovsky" <Steven.Dubovsky@UCHSC.edu>
Date: 15 Apr 95 08:47:17 MST-0700
Subject: MAOIs in high doses and with stimulantsIt is common practice where I come from to combine MAOIs and stimulants for MAOI-induced hypotension and treatment resistance. This is also mentioned in Jan Fawcett's book of a number of years ago. Also, remember Feighner's report of MAOI + TCA + stimulant in ECT-resistant depression. I have tried this a number of times and found it helpful. Since half the caucasian population are (is?) rapid acetylators, higher doses of Parnate are frequently necessary. Other patients are rapid metabolizers of hydrazide MAOIs and need high doses of those. The PDR is a legal, not a medical, document, so I don't think their doses are always reliable.
From: Donald Franklin Klein <dfk2@columbia.edu>
Date: Sun, 16 Apr 1995 23:44:11 -0400
Subject: MAOIs with stimulantsMAOIs plus methylphenidate (Ritalin) has not been a problem in my hands although theoretical risk requires discussion with patient, consent, and available nifedipine. Very useful for orthostatic hypotension.
Date: 06 Sep 95 11:38:03 EDT
From: Troy Caldwell <75112.1676@compuserve.com>
Subject: MAOIs with stimulantsNone other than my teacher, John Rush, some years ago referred just such a refractory person to me specifically to try adding a stimulant to her MAOI. This was in the days when doctors could still hospitalize and had authority to do things. Apparently, we private practitioners had a bit more autonomy than the university MDs at that time, so I got the referral.
Social commentary aside, I put the pt in the ICU and added very slowly Dexedrine or Desoxyn to the patient's regimen. It was wonderful -- a grand remission occurred -- and complications were zero. I've tried it since a few times, starting a low doses and titrating gradually upward, and each time no complications arose. Like all treatment efforts, it has been variably effective, but definitely worth trying. Of course, give them nifedipine as an antidote to carry.
Date: Fri, 09 Feb 1996 10:57:43 -0600
From: Kevin Miller <MillerKB@wpogate.slu.edu>
Subject: MAOIs with stimulantsHypotension is a frequent side-effect of MAOIs. If hypotension limits appropriate dosage increases, either based on clinical response, or on not reaching the target dose of about 1 mg/kg in the case of phenelzine (Robinson and Nies), the slow and careful addition of stimulants while monitoring BP makes wonderful sense. The hypotension is treated, the antidepressant effect is augmented, and, if methylphenidate is used, there may be pharmacokinetic effects as well. This is riskier with tranylcypromine given that spontaneous elevations of BP have been noted with this MAOI despite strict dietary adherence. It's also easier to do safely on an inpatient basis.
From: JoelSHoffm@aol.com (Joel S Hoffman)
Date: Sun, 18 Feb 1996 21:43:52 -0500
Subject: MAOIs with stimulantsThere is fortunately a small literature on combining MAOI and stimulant medication: Fawcett, J Clin Psychopharm 1991, 127-132; Feighner, J Clin Psych 1985, 206-209. Also, Clary, J Clin Psych 1990, 226-231, reported in a survey of prescribing habits of Pennsylvania psychiatrists that among those who prescribed MAOIs, use of high doses and combined use of MAOIs with stimulant meds were not unusual.
I have used this combination for the treatment of refractory depression and have at times have found it a great help and at other times useless. I do not remember it being helpful when a patient was not at least partially responsive to either the stimulant or the MAOI alone. However if there is a partial response to one of those meds, then when the two are combined, there can be either an additive or synergistic effect.
I have never had a problem with elevated BP, however I most often add the MAOI to the stimulant rather than the reverse... If I do add a stimulant to an MAOI, I start with 1.25 mg d-amphetamine or equivalent, the idea being that it probably takes at least 5 mg tyramine to precipitate a hypertensive crisis, and since the molecular weights are about the same 1.25 mg amphetamine would be sub-threshold. Starting at that level has not caused any reactions, but I still prefer to start with the stimulant and add the MAOI later.
I find that with time, as more treatment options are available, I use this combination less but there are still some patients for whom nothing else seems to work. The side effects that do cause problems include activation sometimes resembling or identical to dysphoric mania. Stereotypy and choreiform movements including bucco-facial dyskinesia can also occur. These side effects have to watched for closely. If it is essential to continue the regimen, pimozide can usually alleviate the movement disorder.
From: "David A. Kahn" <kahndav@cpmc3.cpmc.columbia.edu>
Date: Wed, 21 Feb 1996 10:31:11 EDT
Subject: MAOIs with stimulantsI'm always in the position of trying to augment an existing MAOI regimen, so it's never seemed feasible to stop the MAOI, start the stimulant, and then restart the MAOI. I just add the stimulant. The only adverse reaction I've encountered is an odd lability of blood pressure on two occasions, where supine blood pressure was somewhat elevated on a tonic basis, together with a worsening of orthostatic hypotension. The supine elevation made it impossible to think of Florinef, etc., so we had to stop the combination. Interestingly, both of these individuals had prior histories of intermittent bordereline essential hypertension which had resolved on the MAOI alone.
From: JoelSHoffm@aol.com (Joel S Hoffman)
Date: Wed, 21 Feb 1996 08:29:48 -0500
Subject: MAOIs with stimulantsBy the way, I do not get signed consent. I do not think that that holds up very well anyway. Well documented clear chart notes indicating the clinical rationale and including what is told to the patient should always be standard practice and especially with atypical treatment modalities such as this.
Posted by meltingpot on December 2, 2009, at 12:45:10
In reply to Re: Add anything to help with the EMSAM wait...., posted by inanimate peanut on November 28, 2009, at 18:53:11
Hi,
I feel like you do right now and the only thing that has worked for me in the past when I feel so bad is 10mg of Zyprexa once every 7 days.
I'm taking one tomorrow because the way I feel now feels unbearable. I can't even concentrate on the television in the evening. I promise you that if you react to Zyprexa like I do you will feel a lot better and it will make sticking the Emsam trial out a hell of a lot easier.
Denise
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