Posted by bleauberry on December 24, 2009, at 15:38:25
In reply to Help w/ atypical depression? (my first post here), posted by Walfredo on December 24, 2009, at 4:03:22
It looks to me like you've already gotten some excellent pointers from everyone else here. If you don't mind, I would chime in with a lot of agreements with them and maybe a couple more tidbits.
The feeling good for a day or two after coming off an SSRI, I totally know that. Why it happens, I'm not sure. I think it may be a sign that the circuitry that needs tweeking is the norepinephrine/dopamine circuit more than the serotonin circuit, though they are all probably involved.
Before I say this, keep in mind I am in no way suggesting anything. I just want to point out that the symptoms of "atypical" depression are almost picture perfect for what psychiatrists should look for when suspecting Lyme disease or candida overgrowth. A Lyme depression looks different than garden variety depression, it looks almost identical to atypical depression. You need not recall being bit by a tick to have Lyme.
Paxil may have continued to work good, and even worked better than ever, if a TCA like Nortriptyline had been added to it. I have no proof whatsoever, but my feeling is that when SSRIs poopout it is because serotonin has finally squashed out NE/DA so much that now there is a new chemical imbalance...too much serotonin, not enough of everything else. It could also be that the body just stop producing serotonin, so an SSRI is kind of like damming up a river that has no water in it. Who knows.
In any case, rounded strategies that hit all the neurotransmitters I believe have better longterm potential. That includes Nardil, Parnate, SSRI+TCA, but NOT Effexor or Cymbalta, since they are mostly serotonin with very little of anything else.
There is also the opioid connection to consider. Some depressions are not serotonin, NE, or DA. These respond profoundly well to things like Codeine and Hydrocodone...the patient feels "normal" rather than high. Someone else without this kind of depression would instead feel either dysphoric, nauseated, or euphoric, but not normal. There are so many stories of people who have tried all the ADs who discovered the best on the planet by a longshot is Tramadol when they were prescribed it for post-op pain or something.
I disagree with the Abilify strategy. Abilify in depression is best known as an augmentor of ongoing SSRIs. By itself, you have to hunt far and wide to find anyone that has found it useful all by itself.
Others like Remeron. I don't. The primary reason is because in my view it seems to have a poopout rate faster than SSRIS. I can't recall anyone who did well with it for long, or anyone that did real well with it period. It is an excellent theoretical discussion drug and clinical trial drug, but in the real world I just don't see it. Much more than anything else, it is one of the planet's most potent antihistamines. Lab tests have shown that it does not increase serotonin and it does not increase norepinephrine. It might be purely the receptor blockade that provides any temporary benefits, similar to what antipsychotics do. I don't know.
California Rocketful. Effexor + Remeron. Years ago this was a fad touted as being a potent combo. The problem is, in the real world we just don't actually see that. If it was such a good combo, it would be very commonly seen and talked about. But it isn't. I did know one person here many years ago that had a multi-year run on complete remission with the combo, but other than that, nada. I just don't feel Remeron lives up to the armchair hype or the clinical trials when it is tried on real patients.
A hospital in Boston added high doses of SAMe to stable doses of Lexapro and had significant results in the majority of their trial patients. SAMe is kind of hit-and-miss, like anything else. It can work fantastic or not at all. When it works, it usually does so within days. Worth a try with that in mind...but not by itself...with an AD. Nature's Way is top quality. I know a couple people at other forums that do not want pharmaceuticals for their Lyme depression and have pretty much resigned to dealing with rather than treating it, but they use SAMe on an as-needed basis on unusually bad days or strings of days. I've done the same. It can lift me out of a hole fast. I get other problems with it longterm, related to prior antipsychotic usage or Lyme, but for a quick fix stepping stone, it is reliable.
Sleep deprivation improvement, in my unsupported opinion, points again to the NE/DA circuits.
Parnate.
Paxil with Nortriptyline or Desipramine.
Zoloft or Lexapro with Nortriptyline.
Zoloft or Lexapro with Desipramine.
Tramadol.
Savella with any of the above.
If you could manage it, get a sample dose of hydrocodone just to test your response. It could tell you a lot.Those are the approaches I would favor for you.
Savella is a new drug for fibromyalgia. In the rest of the world it is a longstanding antidepressant called Milnacipran. Not new. Just in USA. It is one of the top 3 meds in Japan, commonly combined with Paxil or Luvox. It is a true SNRI...1 part serotonin to 2 parts norepinephrine. But that is too simplistic. It is unique in its method reuptake inhibition. Hey, nearly all psych meds made me feel worse, ECT did not work, but Savella pulled me out a slump fast. That has to say something. I believe it is an unsung hero waiting to be discovered. I think the biggest mistake people make with it is taking it as monotherapy, ramping up doses too fast, and not giving it enough time because they increased the dose too fast. I believe its true strength is as part of a combination.
I could get into a whole new topic explaining how to easily test various biological causes of your symptoms, but that is another story. For now the focus is on symptom control. More work can be done after that to figure out why all this happened in the first place.
The mention of Lyme was just a casual mention, but it has to mentioned and considered as a potential player anytime these things are present:
1. Resistant to treatment.
2. The cluster of symptoms you described.
poster:bleauberry
thread:930645
URL: http://www.dr-bob.org/babble/20091217/msgs/930742.html