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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 9 of 9. This is the beginning of the thread.
Posted by pedr on November 30, 2011, at 9:05:40
Hi PB,
I'm on the process of switching to Parnate after 2+ years on Nardil. I have been dreading the transition since my mental health is bad even when on the Nardil. I've now reached 15mg a day of Nardil by decreasing 15mg a week from 45mg (note that I was on 90mg for the majority of the 2 years).However, I am finding that my mood has stabilised and overall improved over the last 2 weeks. Does anyone have a good feel for why this might be? In theory, there's not enough active metabolite in my system to effect sufficient MAO inhibition and so I should be feeling rotten. Don't get me wrong, I plan to enjoy it while it lasts but I know things can change radically and rapidly for the worse.
Thanks
Pedr
Posted by SLS on November 30, 2011, at 10:39:12
In reply to Feeling better during Nardil taper-off?, posted by pedr on November 30, 2011, at 9:05:40
> Hi PB,
> I'm on the process of switching to Parnate after 2+ years on Nardil. I have been dreading the transition since my mental health is bad even when on the Nardil. I've now reached 15mg a day of Nardil by decreasing 15mg a week from 45mg (note that I was on 90mg for the majority of the 2 years).
>
> However, I am finding that my mood has stabilised and overall improved over the last 2 weeks. Does anyone have a good feel for why this might be? In theory, there's not enough active metabolite in my system to effect sufficient MAO inhibition and so I should be feeling rotten. Don't get me wrong, I plan to enjoy it while it lasts but I know things can change radically and rapidly for the worse.
What you are experiencing is called a withdrawal-rebound-improvement. I believe it occurs more often with TCA and MAOI than it does with other classes of antidepressants. In my experience with Nardil, this improvement can last for 2-3 weeks. Mania can sometimes be triggered as a result of this phenomenon.
- Scott-------------------------------------------
http://www.ncbi.nlm.nih.gov/pubmed/20156925J Psychopharmacol. 2011 Mar;25(3):306-13. Epub 2010 Feb 15.
Antidepressant discontinuation manic states: a critical review of the literature and suggested diagnostic criteria.
Narayan V, Haddad PM.
SourceCromwell House Community Mental Health Centre, Manchester, UK.
AbstractWe critically appraised all published reports of hypomania and mania following antidepressant termination. To increase reliability and validity we devised diagnostic criteria for an antidepressant discontinuation or withdrawal 'manic state' based primarily on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition substance withdrawal criteria. A systematic literature review identified 24 reports meeting our criteria. Mean age was 39 years (range 18-74), men and women were approximately equally represented, and more cases involved people with unipolar (n = 19) than bipolar disorder (n = 4). The median duration of preceding antidepressant treatment was 12 weeks (range 4 weeks-12 years). All major antidepressant classes were involved (tricyclic antidepressants = 13; selective serotonin reuptake inhibitors = 5; monoamine oxidase inhibitors = 3; selective serotonin-norepinephrine reuptake inhibitors = 2; miscellaneous = 1). More cases followed abrupt antidepressant withdrawal (n = 11) than a tapered withdrawal (n = 6). Six cases appeared to meet the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition for a manic episode, with two cases requiring inpatient admission. Of the 24 cases, nine resolved spontaneously without treatment (median duration = 25.5 days), six responded to antimanic drugs, four resolved following antidepressant reinstatement, and treatment was unclear in five cases. We conclude that antidepressant discontinuation hypomania/mania is a valid syndrome. It should be added to the differential diagnosis of hypomania/mania. The clinical implications and possible mechanisms are discussed.
PMID:
20156925
[PubMed - indexed for MEDLINE]--------------------------------------------
http://www.ncbi.nlm.nih.gov/pubmed/15291689
J Clin Psychiatry. 2004 Jul;65(7):987-93.
Antidepressant-withdrawal mania:a critical review and synthesis of the literature.
Andrade C.
SourceDepartment of Psychopharmacology, National Institute of Mental Health and Neurosciences, Bangalore, India. andrade@nimhans.kar.nic.in
Abstract
BACKGROUND:Hypomania or mania have rarely been reported to develop shortly after the discontinuation of an antidepressant drug. The true incidence of this discontinuation syndrome is unknown because it may be underreported as a consequence of underrecognition or misattribution. This article examines the possible etiology, nosology, mechanisms, and other aspects of the syndrome.
DATA SOURCES AND STUDY SELECTION:A PubMed search was conducted in May 2003 and repeated in January 2004 using the search terms antidepressant and mania. Relevant articles containing adequate descriptions for presentation were retrieved, and their reference lists were hand-searched for further pertinent material. Hand-searches of the indexes of leading psychiatry journals were also performed for the years 1998-2003. Twenty-three articles were identified for review.
CONCLUSIONS:Antidepressant-withdrawal hypomania or mania may occur rarely with almost any antidepressant drug after sudden withdrawal, tapered discontinuation, or even merely a decrease in dose. The syndrome may be self-limiting, may abate with the reinstitution of the antidepressant drug, or may require specific anti-manic treatments; mood stabilizers do not necessarily protect against the syndrome. The true incidence of the syndrome is unknown. Narrow and broad diagnostic criteria are proposed for the syndrome, and a synthesis of literature is provided.
PMID:
15291689
[PubMed - indexed for MEDLINE]
------------------------------------------http://www.ncbi.nlm.nih.gov/pubmed/3435883
Can J Psychiatry. 1987 Dec;32(9):764-7.
Transient mood elevation associated with antidepressant drug decrease.
Corral M, Sivertz K, Jones BD.
SourceDepartment of Psychiatry, UBC Health Sciences Centre Hospital, Vancouver.
AbstractThe development of hypomania, mania and transient mood elevation within 2-3 days of antidepressant discontinuation, and lasting days to several weeks has been reported in unipolar depressed patients. Imipramine and desipramine are the antidepressants most frequently associated with the above phenomena. A reported case of transient mood elevation following abrupt reduction but not discontinuation of desipramine therapy in a woman with unipolar depression is described. The phenomenon was observed and documented on two separate occasions. Mood elevation occurred despite decreased plasma levels of the drug. Relapse followed despite maintenance of dose and similar drug plasma levels. Factors which could account for the transitory improvement of mood are examined. It is suggested that the patient's improvement in mood may have occurred due to a rebound paradoxical therapeutic effect. The features of the presented case history which appear to support this hypothesis are discussed. Also the clinical implications of this phenomenon are reviewed.
PMID:
3435883
[PubMed - indexed for MEDLINE]
Posted by Phillipa on November 30, 2011, at 11:16:29
In reply to Re: Feeling better during Nardil taper-off?, posted by SLS on November 30, 2011, at 10:39:12
Is this also why some with unipolar depression also feel better when then discontinue the meds? Thanks Phillipa
Posted by pedr on November 30, 2011, at 12:53:21
In reply to Re: Feeling better during Nardil taper-off?, posted by SLS on November 30, 2011, at 10:39:12
Hi Scott,
thanks for the response. I experienced hypomania/elation when ramping up on Nardil and this is very different. I feel composed, level-headed, healthy and content whereas during the hypomania I felt ***great***, very happy, excited and a little out-of-control.In some ways I regret posting since I now feel less optimistic. It's such an unexpected occurrence though that I had to find out if others had had the same experience.
Is there any mileage in staying at this dose do you think? Prolly not but I suppose it's only natural to want to cling to this glimpse of health.
Pedr
Posted by sigismund on December 1, 2011, at 1:39:59
In reply to Re: Feeling better during Nardil taper-off? » SLS, posted by pedr on November 30, 2011, at 12:53:21
>Is there any mileage in staying at this dose do you think? Prolly not but I suppose it's only natural to want to cling to this glimpse of health.
Go by your instincts and feelings, rather than any theory.
Posted by SLS on December 1, 2011, at 6:48:04
In reply to Re: Feeling better during Nardil taper-off? » SLS, posted by pedr on November 30, 2011, at 12:53:21
> Is there any mileage in staying at this dose do you think? Prolly not but I suppose it's only natural to want to cling to this glimpse of health.
If it were me, I would hang out at 15 mg for awhile just to see. Otherwise, you might always regret not trying it. It won't hurt.
- Scott
Posted by pedr on December 1, 2011, at 12:41:53
In reply to Re: Feeling better during Nardil taper-off? » pedr, posted by SLS on December 1, 2011, at 6:48:04
thanks guys. I will see what the PDoc thinks. He's pretty open-minded and I think he'll agree to try 15mg out for a bit longer.
Posted by bleauberry on December 1, 2011, at 14:30:07
In reply to Feeling better during Nardil taper-off?, posted by pedr on November 30, 2011, at 9:05:40
I've experienced that rebound improvement on various meds, zoloft being the most notable for me. Saw it happen to a friend also. Various posters have commented on experiencing this phenomenon.
I believe there is a unique custom dose for each person, where either too much or too little is not nearly as good as just right. Of course we can only find out what just right is with time and experimentation. Maybe you accidentally discovered your new just right dose window is around 15mg? Maybe some stuff has been fixed or reset during your time on nardil and now not as much is needed for maintenance? Dunno, just thinking out loud.
My gut instinct though is it is a temporary rebound but I would love to be wrong.
I think what happens is this: (thinking out loud) There is a flood of neurotransmitters at the synapse and everything is adapted to that...the firing mechanisms have slowed down because the feedback mechanisms are telling them there is already more than enough....but then when the med is reduced or stopped the flood of neuros gets quite thin....the feedback mechanisms pick up on that and send signals to speed up firing....that is when we all of a sudden feel great, with all the new firing going on....but then the feedback mechanisms sense things are back in balance now and so the firing is slowed down....and we feel worse again. Just a crazy theory. In other words, the time of feeling good was a particular stage of the body as it begins searching for a new homeostasis. to match its new environment.
If it were me I would definitely stay at 15mg for a while and see what happens. Then I would decide whether to stay, go back up higher again, or wean off more.
Posted by pedr on December 10, 2011, at 13:14:32
In reply to Re: Feeling better during Nardil taper-off?, posted by bleauberry on December 1, 2011, at 14:30:07
hi bleuberry, thanks for the post. Your theory sounds perfectly plausible to me - "up-regulation" and "down-regulation", right? That makes me wonder if there's any legs in continually adjusting the dose up and down - keeping the transmitter levels in flux as it were. In fact I think I read elsewhere on this site that some people have tried this.
As it turned out, this last week on 15mg has been rotten due to IBS pain, which makes me feel pretty depressed too. That's the problem when you have interacting illnesses - it's very hard to isolate and measure how any one of them is being treated. The upshot being that I've decided to try Parnate and thus stopped the 15mg on Thursday. If anything interesting/unusual happens, I'll post it up.
Cheers, Pedr
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