![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
[email protected]Shown: posts 51 to 75 of 83. Go back in thread:
Posted by Michele on May 14, 2001, at 2:15:15
In reply to Re: and me.Shelli--Michele, posted by MorganW on May 14, 2001, at 1:16:19
Thanks morgan. Much appreciated... I'm really feeling beaten up over this whole thing.
Posted by JahL on May 14, 2001, at 13:38:22
In reply to Re: please be civil » Nichole, posted by SLS on May 14, 2001, at 7:33:30
>Personally, I would consider drinking horse piss if I thought it would relieve me of the illness that I find so oppressive, and that is responsible for the catastrophic dissolution of my life.
I would *inject* the stuff.
Nice post (I 'lurked' 4 6mths b4 posting & am glad I did).
j
Posted by Nichole on May 14, 2001, at 13:54:12
In reply to Re: Shelli, posted by gen on May 13, 2001, at 21:01:27
Gen
Are you sucking up or what? I at least respect Shelli for asking you not to compliment her.
Give me a break. You hold an opiate pusher as your idol?
Posted by shelliR on May 14, 2001, at 17:23:37
In reply to Shelli, posted by gen on May 13, 2001, at 16:52:04
:-)
shelli
Posted by Dr. Bob on May 14, 2001, at 17:52:26
In reply to Re: Shelli, posted by Nichole on May 14, 2001, at 13:54:12
> Are you sucking up or what?
Please be civil, or I'll need to try to block you from posting. Thanks,
Bob
Posted by SLS on May 14, 2001, at 18:07:55
In reply to Re: please be civil » Nichole, posted by Dr. Bob on May 14, 2001, at 17:52:26
Hi All.
I don't know why my post sort of disappeared along this thread. Anyway, I hope this one stays put for a while. I won't address it to any one person. At this point, I would rather address it to the issue. I posted this in another thread, so I apologize for redundancy.
"
...skepticism is healthy. As I suggested in my other post, it is sometimes difficult to keep an open mind, especially when a contention deviates so much from the currently accepted or traditional treatment modalities. Much can come from the type of dialogue we have here. For instance, I took your opinion seriously and decided to investigate the matter further. In doing so, I found something that I believe will be informative for both you and I, and hopefully for anyone else following this thread. It is not a short piece, and at times does not make for easy reading, but the introduction and discussion at the end are worth a reading. The article appeared in one of the most respected medical journals, the Journal of Clinical Psychopharmacology. At the end of the article is the bibliography that contains a wealth of equally respected and well-known authors. This is truly a serious investigation into the utility of opiates, particularly buprenorphine, in the treatment of treatment-resistant depression. It is worth noting that this article was published in 1995, so we are not talking about a novel or radical idea.It is worth keeping an open mind.
Article: Buprenorphine Treatment of Refractory Depression
http://balder.prohosting.com/~adhpage/bupe.html
Sincerely,
Scott"
- Scott
Posted by Dr. Bob on May 14, 2001, at 18:37:24
In reply to Re: please be civil - O.K., if I must. :-), posted by SLS on May 14, 2001, at 18:07:55
> I don't know why my post sort of disappeared along this thread.
I'm deleting posts that should have been redirected to Psycho-Babble Administration, like I said I might.
Bob
Posted by gen on May 14, 2001, at 19:56:44
In reply to Re: Shelli » gen, posted by shelliR on May 14, 2001, at 17:23:37
> :-)
>
> gen
Posted by kazoo on May 15, 2001, at 2:25:40
In reply to Drug Seeking Behavior » kazoo, posted by Elizabeth on May 12, 2001, at 20:36:43
Transferred to "Psycho-Social-Babble."
Posted by Elizabeth on May 16, 2001, at 12:59:48
In reply to Re: Elizabeth..................... Me too., posted by SLS on May 13, 2001, at 15:13:55
> Actually, Elizabeth, I find your behavior in the midst of this nuisance enviable. When I grow up, I want to be just like you.
*blush* Compliment accepted gladly.
My dad likes to say he won't consider himself grown up until he's...uhh, I think it's somewhere in the late 200's. < g >
I think Shelli is right, we should ignore the trolls and other extremists. It's hard to watch this board become a place for people to unleash their hatred and prejudice, though. I'm sure you know what I mean.
-elizabeth
Posted by Elizabeth on May 16, 2001, at 13:05:00
In reply to Re: Whats the best opiate for depression ?, posted by jimmygold70 on May 7, 2001, at 15:48:13
> Pacha,
>
> Did you try ECT ? (Electroconvulsive Therapy). That's more effective than most drugs.This is a common belief. It was viewed as more effective when "depression" was defined more narrowly to include only very extreme, classic presentations (they used to call this "endogenous" as opposed to "neurotic" depression).
ECT works extremely well in severe melancholic, psychotic, and catatonic depressions (as well as certain forms of mania and schizophrenia). For more atypical or ambiguous presentations, it's less clear whether ECT works very well at all. Also, IMO, the risks are too great. I consider ECT to be the ace up my sleeve, something I would do only out of true desperation.
-elizabeth
Posted by Elizabeth on May 16, 2001, at 13:29:28
In reply to Re: Drug Seeking Behavior » Elizabeth, posted by judy1 on May 12, 2001, at 21:08:52
> Just read your well written response, I'm glad you have had access to such knowledgeable pdocs. Another effective use for opiates is for treatment resistant panic disorder; my pdoc has also prescribed them for depression. And he also is part of a well-respected reasearch program. Take care, judy
I'm happy for anyone who has access to good psychiatric care. It's disgracefully rare.
An interesting note about opioids for PD: they do seem to block panic attacks, but the effects of buprenorphine on respiration seemed to be a *contributing* factor in a PA I had. (This was when I had just started taking it after a long hiatus and wasn't used to the side effects.) This might be something that is specific to buprenorphine, though.
I use Xanax for breakthrough PAs because buprenorphine doesn't work fast enough (through the route I use) that a booster dose would work in that event.
best,
-elizabeth
Posted by Elizabeth on May 16, 2001, at 14:01:54
In reply to Re: Whats the best opiate for depression ? » Elizabeth, posted by shelliR on May 12, 2001, at 21:27:54
> > Codeine isn't the best choice for an AD anyway, IMO -- if you need a full agonist, a longer-acting one with fewer adverse effects relative to desired effects would be preferable.
>
> Like Ultram?That wasn't what I was thinking (the fentanyl patch (Duragesic) would best meet the specifications I listed), but Ultram does seem like a good choice in some ways. It has a (*very* mild) monoamine reuptake action in addition to being an opioid agonist. I believe that it is relatively lacking in potential for abuse or physiological dependence compared with morphine, etc., and it has milder side effects. It is not a controlled substance and so it is easier to get a prescription for Ultram than typical opioids (I'd guess it would be even easier to get than, say, Tylenol #3).
The down sides of Ultram include its short duration of action, lowering of the seizure threshold (which limits the safe dose range), and potential for icky interactions with monoamine reuptake and metabolism inhibitors (in particular, SSRIs, MAOIs, and mixed reuptake inhibitors like Effexor and Meridia). It's probably not as big a risk for interactions as, say, Demerol, but there have been enough reports to warrant serious caution (an appropriate Medline search should elicit a number of published reports).
Apparently a slow-release preparation of tramadol is in the works, which is excellent news. Also, I'm not sure how long it's been around, but it might be going generic soon.
> > I've heard many stories of people suing their doctors over some pretty absurd things. Dr. Bodkin takes particular risks in that he is willing to work with patients who may be personality-disordered (which often is associated with a tendency to blame other people for one's problems -- e.g., a patient misuses or overdoses on medication, then blames the doctor). I take Dr. B's willingness to work with these "difficult" patients as a sign of exceptional compassion.
>
> Elizabeth, yes, I believe the scenario with the law suit is very close to what you described above, and I didn't take it that Dr. Bodkin had done anything wrong. If I don't find someone around here that I highly respect to consult with, I may fly up to Boston.I think that Dr. Bodkin has been willing to consult with psychiatrists in other parts of the country on this subject. (Considering how busy he always is, this is really sweet of him if it's correct.) Your best chance is to find a pdoc in your area who has ties to McLean (e.g., who worked there or did a residency there). Those guys all seem to know each other, and someone who knows Bodkin personally would be more receptive to his research, I think. Failing that, the next best option is to find someone in your area who has a research background or orientation, or who is interested specifically in creative approaches to TRD.
> I also have an old friend living in Somerset.
Somerset...? (Where's that?)
> Still, in the long run it would be best to find someone in my immediate area. He did make the suggestion of going up very high on selegiline, but I'm not really anxious to go off the nardil and start again with a new MAOI, unless perhaps it was the patch.
Going off MAOIs is hard, yup -- on top of the worst withdrawal syndrome of all the classic ADs, there's that damned "washout period." Although I generally prefer to follow the middle path (an expression I picked up from Buddhism to describe a belief system that I've carried all my life), my experience suggests that the extreme approaches may be the best way to deal with MAOI-nonMAOI switches. One way is to taper off the phenelzine extremely slowly, especially once you're down to 15mg/day (like, go to 15mg every other day and stay at that dose for a week or more). The alternative is to drop the dose very rapidly, use a lot of benzos to get yourself through the withdrawal, and go with a minimal washout period rather than the more conservative ones suggested in the PDR. It kind of depends how badly off you'll be without the MAOI. I once switched between a nonhydrazine MAOI (Parnate) and a hydrazine (Marplan) with only **3 days** between them. (Kids, don't try this at home. The risk is probably less than, say, switching between MAOI and SSRI, but there still can be problems, and MAOIs shouldn't be combined with other MAOIs.)
I think the idea of selegiline in very high doses is an excellent one, and I often wonder if it wouldn't be worth it for me to give it another shot. (I didn't use benzos or anything to deal with the panic symptoms that I got when I was on it, so I never got past 40mg.) Selegiline seems to cause very little orthostatic hypotension and does not cause weight gain.
Good luck, whatever you end up deciding to do.
-elizabeth
Posted by Elizabeth on May 16, 2001, at 16:54:46
In reply to For Elizabeth » Elizabeth, posted by SalArmy4me on May 12, 2001, at 21:53:43
> I am hopeful that you will still be able to find an effective pharmacological treatment, despite having tried so many of them. I got some nice ideas for you:
>
> 1) Mirapex - proven as effective as imipramine in depression:
>
> Corrigan MH, Denahan AQ, Wright CE, Ragual RJ, Evans DL. Comparison of pramipexole, fluoxetine, and placebo in patients with major depression. Depress Anxiety. 2000;11(2):58-65.
>
> DeBattista C, Solvason HB, Breen JA, Schatzberg AF. Pramipexole augmentation of a selective serotonin reuptake inhibitor in the treatment of depression. J Clin Psychopharmacol. 2000 Apr;20(2):274-5.That's an interesting idea (although I don't see anything about imipramine in either of your citations, and Medline seems to be down so I can't check right now). I'd forgotten about that one. I'll look into it and mention it to my pdoc. It sounds like there is very little research, but what there is has been consistently positive.
> 2) Pindolol - it once was a wonder drug for me that I took without an antidepressant, (but most people will need one).
Tried that one, at a variety of doses, and with a couple different serotonergic ADs. (Wrote a paper on it while I was using it myself. That was fun. Unfortunately my instructor -- a PhD behavioural pharmacologist who was, at the time, a post-doc at the primate lab doing animal experiments -- didn't share my orientation toward molecular pharmacology, so, while I got a decent grade, I don't think he appreciated my excitement about the subject.)
BTW, the evidence is stronger for pindolol as an AD accelerator than as an augmentor. (Well, it was when I was immersed in the topic, anyhow.) I actually ended up being more impressed with buspirone by the time I finished that paper, believe it or not! I believe the apparent failure of BuSpar as an antidepressant-anxiolytic is due to the use of inadequate doses.)
> 3) Definitely try Tegretol XR if you get a chance.
> Its very tolerable.I know a young woman who takes it for temporal lobe epilepsy and (probably secondary) rapid-cycling/dysphoric bipolar II disorder. It has a very minor place in the treatment of TRD. If I were to try another anticonvulsant, I'd prefer carbamazepine's analog oxcarbazepine, which is safer, more tolerable, and less likely to interact with other drugs.
Incidentally, my neuro consult confirmed what I already expected: that there's no evidence that what I experienced was the result of any type of seizure. (I *still* haven't gotten the report on the SPECT scan, though!)
> 4) Ludiomil (MAPROTILINE) - that's a good one that few have heard about since it came out around the time Prozac came out and was overshadowed by Prozac.
Maprotiline, despite a novel variation in the middle ring, turned out to be basically just another tricyclic -- it has similar biochemical properties and works for roughly the same patient population as the rest of the TCAs. Its side chain -- the part of TCAs that is most associated with structure-activity relationships -- has a secondary amine structure which results in NE-selectivity comparable to protriptyline's (but not increased potency). The term "tetracyclic" is really kind of misleading, IMO; it's basically a tricyclic with a novel center ring (this is also what distinguishes imipramine, amitriptyline, and doxepin (and the secondary amine forms of IMI and AMI -- DMI and NOR). The middle ring has an ethylene-type bridge connecting opposite carbons. Such a bridge increases the rigidity of a molecule's structure and may contribute to maprotiline's relatively long elimination half-life (which is not even close to protriptyline's but is on the high end for TCAs).
My pdoc actually considers it *less* effective than his preferred TCAs (nortriptyline, clomipramine, desipramine, imipramine, amoxapine) in TCA-responsive patients. It has the same type of side effects that I find so hard to tolerate in TCAs, as well as a greater propensity than other TCAs for lowering the seizure threshold.
If I want to give another shot at that class of drugs, it would be desipramine, Like maprotiline, DMI is extremely NE-selective and lacks those pesky sexual side effects. Unlike maprotiline, DMI has little affinity for muscarinic or H1 receptors, and was considered one of the preferred TCAs for epileptics before the much safer SSRIs showed up on the scene.
My family history of "V-type" atypical depression (as described in the Columbia Atypical Depression Study) makes tricyclics a dubious choice for me, anyway, despite my dx of melancholia. (I'm sure you know how tricky such diagnostic subtleties can be!)
> 5) Geodon (ziprasidone) - works on serotonin and norepinephrine with little weight gain or sedation.
Side effects weren't the main issue for me with the atypical antipsychotics. It was lack of efficacy. I'm aware of some of the novel effects of ziprasidone at 5-HT and NE transporters, but I'd prefer something that isn't a dopamine antagonist (*clearly* not an appropriate choice for me) if I want to go that route again!
> 6) BuSpar - only effective in depression at higher doses according to the last study done on it and depression.
Yes, I mentioned this one. I found it innocuous when I took it (up to I think 45mg, with several different ADs), although it had no beneficial effects. (My above-mentioned paper focused on buspirone and pindolol as prototypes of antidepressants acting specifically at the 5-HT1a receptor, so I'm reasonably well-versed.)
> 7) Serzone - I was on it for a month with no side-effects.
Tried it. Twice, in fact (both were adequate trials).
> Thyroid Hormones T3 + T4 - pioneered by Dr. Whybrow at UCLA.
I've considered this. I'm not sure that they are such a great choice for someone with panic disorder, though.
> Foreign drugs:
Before going any further, I'd like to point out that I already said I'm not willing to do this. Doing it the legit way takes too much red tape and time, and I'm not going to go shopping on internet "pharmacies" (i.e., drug dealers!). Among other things, I can't afford these (mostly quite expensive) drugs, which would not be covered by my insurance because they are not FDA-approved.
> *Reboxetine,
Not worth the hassle. I'm not concerned about SSRI/SNRI sexual side effects. I'd just as soon try Meridia, which I can get here and which my prescription plan will cover. (Effexor is something I need to avoid due to a very bad toxic reaction I had in 1998. I think that there were probably other, unknowable contributing factors, but all the doctors I've consulted with consider it too risky to repeat the experiment, particularly since I had milder toxic syndromes the two times I tried immediate-release Effexor.)
> *Moclobemide (I can prove that it is effective, albeit not more than irreversible MAOI's)
I think I've mentioned why I don't consider this a worthwhile pursuit. In countries where it is marketed, moclobemide is a good first-line drug (rather than a drug for people who've already tried everything else) due to its safety profile. It's not a good choice when irreversible MAOIs are tolerated but are not sufficient to do away with the depression.
> *Mianserin,
I believe its metabolite, mirtazapine (you know -- Remeron???) is responsible for most of its antidepressant activity. Thus, I don't consider it worthwhile trying the very similar (and less safe, and more expensive) mianserin after having tried Remeron.
Something that does interest me is a combination approach utilising Meridia and Remeron (with the option of adding Buspar, Provigil, high-dose alprazolam, and others).
> *Tianeptine,
This one does interest me, one of the few foreign drugs that do.
> *Modafanil,
That's Provigil -- not a foreign drug.
> Brofaromine,
More promising than moclobemide, probably due to a dual RIMA/reuptake inhibitor action. But still not worth the hassle.
> *Amisulpride,
Again, of interest.
> *Adrafanil.
Might be worthwhile for augmentation, but I'm not clear that it's better than Provigil.
> Others: Bromocriptine, Ropinirole (another dopamine agonist),Direct dopamine agonists are overrated, I think. Anyone want to weigh in (who's gotten this far < g >)?
> Norvasc(?),
Ca++ blocker. Good for refractory bipolar disorder but might actually exacerbate depression.
> Pemoline(?) (a stimulant),
Cylert. I used it for a few months in college. It helped somewhat.
> *Seroquel,
Tried it. (I mentioned low-dose atypical neuroleptics (and moderate-dose Zyprexa), didn't I? The only exception is Clozaril (too risky).
> Tamoxifen(?),
Cancer drugs? Jeez. You know that depression is a known side effect of this drug, right???
(Don't suggest estrogens either...I have a history of depressive relapse and exacerbation on hormonal contraceptives. This is why I now use only "natural birth control" -- condoms, that is. < g >)
> Doxepin,
Just Another Tricyclic, with a side effect profile comparable to imipramine or amitriptyline. (In particular, doxepin is *very* sedating, probably because it's such a strong antihistamine -- there's even a topical version marketed for pruritis.)
> Yohimbine,
Anxiogenic.
> the new Depakote _ER_,
Depakote had no beneficial effect for me. I'm not interested in other preparations of valproate.
> Nomifensine.
Now that's an interesting one. But I thought it had been removed from the market worldwide. Do you happen to know where it might be available?
Thanks for your ideas. Always interested in new thoughts.
-elizabeth
Posted by Elizabeth on May 16, 2001, at 17:00:37
In reply to Re: To Eric » Cecilia, posted by Michele on May 13, 2001, at 0:19:20
> There is pysical pain, and there is mental pain. They are different. I believe that's why they probably make different drugs for each. :-)
Do you think that the mind is not the result of activity originating in the body? Or that the body above the neck is fundamentally different than that below? Or that there isn't any overlap between centrally and peripherally acting drugs?
The type of pain you're referring to as "physical pain" is more properly called "nocioceptive pain" to distinguish it from the pain of, say, depression. And there are many possible causes of nocioceptive pain, some of which originate centrally, not peripherally. Conversely, the peripheral actions of such "mental" drugs as Tegretol have resulted in their widespread use for "physical pain" that is of neuropathic origin.
-elizabeth
Posted by Elizabeth on May 16, 2001, at 17:14:09
In reply to Re: To Eric-Michele » Cecilia, posted by Michele on May 13, 2001, at 1:01:12
> So if your reading this elizabeth..... he'll be gone soon. Take it with a grain of salt.
Believe me, I take *everything* that Eric says with a huge barrel of salt. :-) He's been well known for similar behaviour on unmoderated Usenet groups for several years. He is an intensely emotionally reactive person, and these emotional reactions often manifest as rage or hostility. Based on my observations of him over the years, the intensity of Eric's visceral reactivity makes it impossible to engage him in a rational debate.
What underlies his hostility -- who knows? Perhaps it is partially temperamental. He has consistently professed a disdain for insight-oriented therapies, so it's unlikely that anyone ever will know (unless perhaps he does know, at some level). I personally don't believe that insight-oriented therapies are cures for any type of illness, but I do believe that they can improve one's understanding of oneself, which sometimes can change the direction of one's search for a cure.
-elizabeth
Posted by Elizabeth on May 16, 2001, at 17:19:33
In reply to SLS, posted by JahL on May 14, 2001, at 13:38:22
> >Personally, I would consider drinking horse piss if I thought it would relieve me of the illness that I find so oppressive, and that is responsible for the catastrophic dissolution of my life.
>
> I would *inject* the stuff.That doesn't sound very hygeinic. (Hmm... "horse piss, USP." < g >)
I suppose you know what Premarin is, right?
> Nice post (I 'lurked' 4 6mths b4 posting & am glad I did).
Welcome. I hope that you decide to stay...the negativity expressed lately isn't the norm here.
-elizabeth
Posted by JahL on May 16, 2001, at 18:01:28
In reply to Re: SLS, posted by Elizabeth on May 16, 2001, at 17:19:33
> > >Personally, I would consider drinking horse piss
> > I would *inject* the stuff.
> That doesn't sound very hygeinic. (Hmm... "horse piss, USP." < g >):-) Hi Elizabeth.
> I suppose you know what Premarin is, right?Didn't, but just looked it up. Don't geddit. I'm a fella.
> > Nice post (I 'lurked' 4 6mths b4 posting & am glad I did).
> Welcome. I hope that you decide to stay...the negativity expressed lately isn't the norm here.
Thank you. Actually I've been posting for about 7 months now! I know you've been absent for a while which might explain why you haven't seen me before. Also I don't have many med Qs @ the moment & so many of my posts are on the Admin board. Rants mostly, against censorship, dogma, people who seek to condemn self-medicating drug-(ab)users. You get the pic. I like yr take on things.
While I've got yr attn, I would really appreciate a response to my post to you (now buried under another 9 posts) on the Methadone thread. I realise you may be a little gun-shy @ the mo but not all of us think you're some brain-addled junkie ;-) ! Yr description of 'Reward Deficit Syndrome' really struck a chord with me. Scarily accurate. I'm not so much depressed as overwhelmingly anhedonic.
Thanks (& welcome back!),
J
Posted by Elizabeth on May 16, 2001, at 19:14:45
In reply to Re: Horse p*** and RDS. » Elizabeth, posted by JahL on May 16, 2001, at 18:01:28
> > I suppose you know what Premarin is, right?
>
> Didn't, but just looked it up. Don't geddit. I'm a fella.It's a form of estrogen replacement therapy for postmenopausal women. It's an acronym for (brace yourself) "pregnant mare urine."
I swear that I'm not making that up. < g >
> Thank you. Actually I've been posting for about 7 months now! I know you've been absent for a while which might explain why you haven't seen me before. Also I don't have many med Qs @ the moment & so many of my posts are on the Admin board. Rants mostly, against censorship, dogma, people who seek to condemn self-medicating drug-(ab)users. You get the pic.
Capisce, and my sympathies.
> I like yr take on things.
Thank you. I appreciate it.
> While I've got yr attn, I would really appreciate a response to my post to you (now buried under another 9 posts) on the Methadone thread.
Jeez, I'm afraid I missed a lot of posts in that thread (rhymes with dread)!
> I realise you may be a little gun-shy @ the mo but not all of us think you're some brain-addled junkie ;-) ! Yr description of 'Reward Deficit Syndrome' really struck a chord with me. Scarily accurate. I'm not so much depressed as overwhelmingly anhedonic.
Ahh -- OK, I just posted something regarding that (although I think it was a direct response to someone else). Maybe a web search on "reward deficiency syndrome" (exact phrase) would turn something up?
-elizabeth
Posted by Michele on May 16, 2001, at 19:20:17
In reply to mind-body problem » Michele, posted by Elizabeth on May 16, 2001, at 17:00:37
I don't know... but I do know that any AD's I've tried, haven't helped the pain of cancer.... and any pain killer to help the pain of cancer, hasn't helped my depression.
> > There is pysical pain, and there is mental pain. They are different. I believe that's why they probably make different drugs for each. :-)
>
> Do you think that the mind is not the result of activity originating in the body? Or that the body above the neck is fundamentally different than that below? Or that there isn't any overlap between centrally and peripherally acting drugs?
>
> The type of pain you're referring to as "physical pain" is more properly called "nocioceptive pain" to distinguish it from the pain of, say, depression. And there are many possible causes of nocioceptive pain, some of which originate centrally, not peripherally. Conversely, the peripheral actions of such "mental" drugs as Tegretol have resulted in their widespread use for "physical pain" that is of neuropathic origin.
>
> -elizabeth
Posted by shelliR on May 16, 2001, at 22:28:02
In reply to Ultram, selegiline » shelliR, posted by Elizabeth on May 16, 2001, at 14:01:54
Hi Elizabeth.
>
> I think that Dr. Bodkin has been willing to consult with psychiatrists in other parts of the country on this subject. (Considering how busy he always is, this is really sweet of him if it's correct.) Your best chance is to find a pdoc in your area who has ties to McLean (e.g., who worked there or did a residency there). Those guys all seem to know each other, and someone who knows Bodkin personally would be more receptive to his research, I think. Failing that, the next best option is to find someone in your area who has a research background or orientation, or who is interested specifically in creative approaches to TRD.That is really difficult. Creative approaches to TRD here means adding stimulents with MAOIs and combining lots of meds, but nothing like Dr. Bodkin. He didn't really have a good referral down here either. My last trials were all with nardil with atypical antipsychotics--all of which made me feel strange. To tell you the truth, I don't believe that they have been out long enough for anyone to say that they are truely safe for long term use. My pdoc has had one case of TD with an atypical and one case with an SSRI, both resolved within four months. My doctor in the hospital has also had one case with an atypical and he doesn't have a very large patient population. So I'm sort of relieved that they did nothing for me. I actually feel safer taking hydrocodone. Really!
I picked my present pdoc because he's been around for years and years and I had the feeling he wouldn't be freaked out by my low dose of hydrocodone. I was right, but he's not of much help either. My last pdoc is best known for trd, but she was really critical about any opiate use (threatened to terminate with me) and also didn't understand my refusal to take lamictal because of a quick large weight gain. I was tired of defending myself. We worked together off and on (mostly on) for about ten years. Also I had to pay out of pocket and I pay too much for insurance to do that unless I felt I was getting something I couldn't get anywhere else.
>
> > I also have an old friend living in Somerset.
>
> Somerset...? (Where's that?)Woops--Somerville. (although there is a town called somerset in MA)
>>
> Going off MAOIs is hard, yup -- on top of the worst withdrawal syndrome of all the classic ADs, there's that damned "washout period."I had no withdrawal symptoms going of of Nardil. (I've done it twice, in less than a week). Maybe it's because my dose has never been higher than 45 mg a day.
>
> I think the idea of selegiline in very high doses is an excellent one, and I often wonder if it wouldn't be worth it for me to give it another shot. (I didn't use benzos or anything to deal with the panic symptoms that I got when I was on it, so I never got past 40mg.) Selegiline seems to cause very little orthostatic hypotension and does not cause weight gain.
I am crazy busy (too busy) with my business now to do any drug trials. Drug trials have always been really hard for me and sometimes have landed me in the hospital. So far I'm still so low on the hydrocodone that I'm not worried. (After three years I really haven't increased). But because it is so short term I am able to observe how really really depressed I am without it (unlike when the nardil was working well). So I go through these brief periods of real fear about my depression.If I do try selegiline, I will have to plan a few weeks off from responsibility. I hate responsibility, but I also know that meeting deadlines and having people come over a lot (I work from home) gets me out of bed during hard times. I don't want to disappoint anyone and I don't want to fail at something I'm really good at.
I just ordered codeiene with paracetamol--(Is that the same thing as tylenal?). I'm not particularly worried about combinations, since I still have never taken more than 7.5 mg a day, and usually less.
If you try selegiline again, I'd be really interested in hearing how it goes. I might be willing to take a few weeks off in August to try it. It's actually easier to go into the hospital for me to do drug trials because when you run a home business, your phone rings day and night and even though I turn the ringer off on my business line, some customers will call on my personal line, and I won't know and I'll answer. And it's is hard to say I'm out of town and then answer the phone!later, shelli
Posted by judy1 on May 17, 2001, at 11:10:43
In reply to panic disorder » judy1, posted by Elizabeth on May 16, 2001, at 13:29:28
Hi,
I bet it is a side-effect of the buprenorphine, since hydrocodone has been effective in this context for me (w/o breathing difficulties). Although the interesting thing about panic attacks is that although symptoms are shared, one seems to dominate. For me it's chest pain and if I get to it before a full blown attack subling xanax or nitroglycerin work equally well. I should ask my cardiologist about that... judy
Posted by Elizabeth on May 17, 2001, at 13:32:06
In reply to Re: Ultram, selegiline » Elizabeth, posted by shelliR on May 16, 2001, at 22:28:02
> Hi Elizabeth.
'Ay.
> Creative approaches to TRD here means adding stimulents with MAOIs and combining lots of meds, but nothing like Dr. Bodkin.
IOW, it doesn't really mean "creative," just "not entirely orthodox." Creativity should involve some originality, don't you think? Anyway, that's probably the situation in most parts of the U.S.
> He didn't really have a good referral down here either. My last trials were all with nardil with atypical antipsychotics--all of which made me feel strange. To tell you the truth, I don't believe that they have been out long enough for anyone to say that they are truely safe for long term use.
Me neither, but they're definitely *safer* than the old APs. (It's been 10 yrs since Clozaril was approved in the U.S.)
How do you mean when you say they make you feel "strange?" I just got zonked on all the neuroleptics I tried (in teeny doses, too). Except for Moban; that was peculiar and difficult to describe.
> My pdoc has had one case of TD with an atypical and one case with an SSRI, both resolved within four months.
TD? Or acute dystonia? (How long had the pts been on the meds, if you know?) TD actually does resolve a lot of the time -- because it *can* be permanent, a myth has evolved that it *must* be.
> My doctor in the hospital has also had one case with an atypical and he doesn't have a very large patient population. So I'm sort of relieved that they did nothing for me. I actually feel safer taking hydrocodone. Really!
I agree that hydrocodone/APAP is safer, as long as you don't get into dose ranges where Tylenol toxicity becomes an issue.
Respiratory depression is the main risk of opioids (aside from addiction!), and that is one of the first things you become tolerant to. It's possible to continue increasing the dose indefinitely without ever reaching toxic levels because tolerance to respiratory
(Street heroin isn't reliable enough for addicts to do this, however. I think they tend to "overshoot" (ha ha) when the purity is unpredictable.) However, it is possible to get to a sort of "saturation" dose where you are completely tolerant and taking more does not produce any additional effect. (Kind of like the ceiling effect of buprenorphine, but at a much higher (ha ha, another pun) level.) I've never met anybody who made it that far, but that was the original idea behind MMT -- to get people on such a high dose of methadone that they were chained to the clinic and that no conceivable amount of heroin would have any effect. Most people on MMT today are nowhere near saturation levels -- they are typically able to stabilise themselves on much lower doses. Methadone, taken as maintenance treatment, basically has no effect on mood as long as you're on a stable dose (although those guys must be *so* constipated -- *that's* a side effect that you never grow tolerant to).> I picked my present pdoc because he's been around for years and years and I had the feeling he wouldn't be freaked out by my low dose of hydrocodone. I was right, but he's not of much help either.
Yeah. That he knows you and is able to trust you is a big advantage. Building up trust is really important in a pdoc-pt relationship in any situation, but especially in one like yours.
> My last pdoc is best known for trd, but she was really critical about any opiate use (threatened to terminate with me) and also didn't understand my refusal to take lamictal because of a quick large weight gain.
That's one advantage of female pdocs -- they seem (IME) to be more sympathetic to the serious difficulties associated with weight gain (socially as well as medically).
You shouldn't have to be on the defensive all the time with your doctor. If you felt that way, and if he made threats to terminate (which I think is just as manipulative and obnoxious as a patient making suicide threats solely to get attention), I think you were right to find somebody else. I'm only sorry you spent so much of your time and money on a pdoc who wasn't a good match for you. I hope you feel you at least got some benefit out of the time you were seeing him.
> > Somerset...? (Where's that?)
>
> Woops--Somerville. (although there is a town called somerset in MA)Ahh! I lived there for a while. Crappy place. :-} My friends and I called it the "grad student ghetto."
> > Going off MAOIs is hard, yup -- on top of the worst withdrawal syndrome of all the classic ADs, there's that damned "washout period."
>
> I had no withdrawal symptoms going of of Nardil. (I've done it twice, in less than a week). Maybe it's because my dose has never been higher than 45 mg a day.Lucky you, for whatever reason! I never had problems with SSRIs or Effexor, myself, but getting off of Nardil and Parnate sucked. I've never had so much trouble d/c-ing anything, even controlled drugs like benzos, stimulants, and Ambien.
> I am crazy busy (too busy) with my business now to do any drug trials. Drug trials have always been really hard for me and sometimes have landed me in the hospital.
Yes, that's a particular risk when a MAOI is involved, because of the washout (even if you don't get w/d symptoms). It sounds like you'll just need to wait for a window of opportunity if you want to switch.
> So far I'm still so low on the hydrocodone that I'm not worried. (After three years I really haven't increased). But because it is so short term I am able to observe how really really depressed I am without it (unlike when the nardil was working well).
Yes, that's how buprenorphine is for me: when it wears off, it's painfully obvious. Not like ADs that work indirectly through compensatory mechanisms (like the monoamine reuptake and metabolism inhibitors).
> So I go through these brief periods of real fear about my depression.
Me too. :-(
> If I do try selegiline, I will have to plan a few weeks off from responsibility. I hate responsibility, but I also know that meeting deadlines and having people come over a lot (I work from home) gets me out of bed during hard times. I don't want to disappoint anyone and I don't want to fail at something I'm really good at.
I know just how you feel. Depression is bad enough without adding demoralisation ("behavioural despair" to rat doctors) on top of it.
> I just ordered codeiene with paracetamol--(Is that the same thing as tylenal?). I'm not particularly worried about combinations, since I still have never taken more than 7.5 mg a day, and usually less.
"Ordered?" I don't want to know what you mean by that. Paracetamol is the European name for APAP (Tylenol), yup. How much codeine is in the pills?
> If you try selegiline again, I'd be really interested in hearing how it goes.
It's not too likely, but I'll be sure to let you know.
> I might be willing to take a few weeks off in August to try it. It's actually easier to go into the hospital for me to do drug trials because when you run a home business, your phone rings day and night and even though I turn the ringer off on my business line, some customers will call on my personal line, and I won't know and I'll answer.
I've heard too many stories from people who have that problem! When I need a business phone number, I'm going to be sure to keep my personal number private and unlisted.
> And it's is hard to say I'm out of town and then answer the phone!
Doh!
best,
-elizabeth
Posted by Elizabeth on May 17, 2001, at 16:42:47
In reply to Re: panic disorder » Elizabeth, posted by judy1 on May 17, 2001, at 11:10:43
> I bet it is a side-effect of the buprenorphine, since hydrocodone has been effective in this context for me (w/o breathing difficulties). Although the interesting thing about panic attacks is that although symptoms are shared, one seems to dominate. For me it's chest pain and if I get to it before a full blown attack subling xanax or nitroglycerin work equally well. I should ask my cardiologist about that... judy
You've taken nitro for PD? Jeez...you're braver than I am! (Hyperventilation and palpitations are the biggies for me.)
-elizabeth
Posted by SLS on May 17, 2001, at 19:18:10
In reply to Re: Ultram, selegiline » shelliR, posted by Elizabeth on May 17, 2001, at 13:32:06
Hi Elizabeth.
I hope you are in a good place.
> How do you mean when you say they make you feel "strange?" I just got zonked on all the neuroleptics I tried (in teeny doses, too). Except for Moban; that was peculiar and difficult to describe.
My doctor mentioned using Moban (molindone) as an augmenter of antidepressants. I experienced a mild improvement with the additions of both Risperdal and Zyprexa. Unfortunately, I experienced unacceptable cognitive side effects when I tried to increase the dosages to 1.5mg and 5.0mg respectively. I was a bit surprised that he would consider an older, typical neuroleptic.
How would describe your experience with Moban?
Did you find it at all stimulating?
What was the rationale for trying it?I have been taking:
Parnate 80mg
nortriptyline 100mg (123mcg/ml)
Lamictal 300mgI am supposed to discontinue Parnate, but I am waiting until I get settled into my new apartment. I tried tapering, but I began to deteriorate at 40mg. I'm going to see if 60mg keeps my head above water in the interim. I don't know what comes next, but the top two candidates are Nardil and Effexor. I'm still waiting to see what lies within my doctor's repertoire of considerations. Since I began seeing him in September, I have tried to remain a fairly passive patient. I had decided to give over control to the doctor and trust his expertise. I didn't want to be my own worst enemy. I would like to interrogate him to determine what he knows and what treatments he is considering or willing to use, but I'm not real good at being an assertive consumer when it comes to physicians. To make things worse, my depression makes me feel passive (helpless) and socially inhibited, and I can't help but to avoid challenge and confrontation.
Sorry. Just thinking out loud.
< sigh >
Thanks.
- Scott
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