Posted by bleauberry on June 18, 2009, at 20:04:38
In reply to Question about med combinations, posted by tonyz on June 18, 2009, at 12:23:16
> I am currently taking Nortriptyline 150mg, 14mg valium, and 150 mg seroquel. My depression seems like it gets worse each day.
Hello? Do you see what you just said? It does not speak well of the meds you are taking, and could easily be, likely be, that one of them is making you WORSE.
>Sleep seems to alternate between maybe 4-5 hours to 2 hours the next night. This has been going on for a while now.
Serotonin is important for sleep. The current combo is pretty much anti-serotonin. Nortirptyline is mostly norepinephrine. Seroquel is increasing norepinephrine and dopamine in the brain, and leaving serotonin either untouched or lowering it. Valium is causing the body to make even less serotonin since it already perceives the GABA department as taking the lead role in calming things. That's my way of viewing it. Could be wrong.
>
> Discussed a number of options with my pdoc today. I think lithium will be a good long term maintenance choice for me but for now we kind of settled on these 2 options. I am wondering if anyone out there has taken this combination or something similar and has any thoughts on the subject. I am getting pretty desperate at this point.
>
> Option 1: 200mg Seroqeul, 20mg Valium, 150mg Nortriptyline
>
> Option 2: 200mg Seroquel, 15mg valium, 150mg Nortriptyline, 50mg trazodone.
>I am sorry to say, I do not like any of the above options. You know, in clinical trials when patients deteriorate on the meds, one of two things happens. They either drop out, or the people in charge remove them. They don't continue. Why is that a lot of us deteriorate on certain meds and we continue with them? Why do we not see that it is highly possible it is the meds themselves causing the deterioration, and not just a normal course of the disease worsening. Well, ok, even if it is naturally worsening, that also speaks badly for those meds, because they are obviously impotent at stopping it, much less reversing it. I do not feel your worsening depression is a natural course. It is the meds. They are the wrong ones for you.
I am not very suspect of Nortriptyline. But I am very suspect of Seroquel and Valium. I mean, you take ten people off the street and put them on Valium for a few weeks or months, 8 of them are going to get depressed.
The APs can and do work magic when combined with SSRIs or SNRIs. But with the strong antihistamine effect of Nortriptyline in combination with the super strong antihistamine effect of Seroquel, I am not surprised you are getting more depressed.
This is all armchair quaterbacking. That said, what would I do in your shoes? Well, the thought of getting off Seroquel is not fun, and Valium, not fun, but that's what I would be planning.
If I absolutely had to have a benzo for the switch, it would be Xanax. At least it has some antidepressant potential.
To keep an AP in the mix, it would have to be a real good one. And it would have to have more of a serotonin partner to work with. To me, that would mean replacing Seroquel straight across for Zyprexa. Maybe risperdal very low dose. For the serotonin, I would add in low-moderate doses of either Zoloft, Lexapro, Prozac, or Celexa. Brand only. No generics. Too much at stake at this point to worry about the extra cost.
Forget the trazodone. That won't do you any good at all. Will probably make you feel worse. I hear you when you say sleep is an issue. It is. Take 10mg-25mg Amitriptyline instead. Its metabolite turns into Nortriptyline, so in a way you are getting a little more serotonin help, and a bit higher dose of Nortriptyline, and sleep, from just adding a little bit of Amitriptyline.
Nortriptyline, SSRI, Zyprexa, maybe Xanax, maybe Amitriptyline. I think you'll sleep a lot better and feel a lot better when you get some serotonin in the mix, get some of the antihistamine out of the mix, and get some of the GABA out of the mix.
You mentioned Lithium. Well, there have been a few cases here over the years where Lithium was THE thing that calmed everything down even when high doses of Klonopin would not. So that is possible. I personally feel lithium is not very useful when combined with serotonin meds, because it is sort of acting on the same pathways, but that it can be much more worthwhile as an enhancer for norepinephrine meds, since it gives a serotonin angle that is otherwise missing.
It is all more complicated than the way I am saying it of course. My basic message is, you are getting worse on your meds, it aint the depression getting worse by itself, and you gotta change the meds. I am trying to offer some rational ideas of what meds to change to, for maximum potential and for minimal trauma when ditching the ones you are on.
No one has ever done it, but I bet if we went back in time to collect all the posts on Seroquel and Zyprexa to get some kind of judgement as to which is better for depression, I think Zyprexa wins easy. That is my experience and observation. And you gotta get some serotonin in the mix. Nortriptyline works a ton better with an SSRI partner.
poster:bleauberry
thread:901793
URL: http://www.dr-bob.org/babble/20090611/msgs/901896.html