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Dr. Bob is Robert Hsiung, MD,
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Posted by Phillipa on September 24, 2006, at 20:10:59
In reply to Re: Time for Maoi -- Other stuff too. Phillipa, posted by Jost on September 24, 2006, at 18:55:23
Jost I totally agree. I've tried a lot of therapists that will accept medicaire my only insurance and none want to relive the past. But I feel that to move forward the past has to be left behind and I can think all I want about it but need help in going through each stage. A lot of years. I clicked with one young girl in the ER. Unfortunately she was new to the area too and knew no one and she only works for the hospital. I've had some that only want to talk about religion or their meds. And one believe it or not a man who said Lucky Ducky. Two sessions out of there. And when people say interview a few first where do they get the money? And I've even asked about self=pay and they won't take it. Stupid. Love Jan
Posted by Phillipa on September 24, 2006, at 20:13:23
In reply to Re: Time for Maoi -- Other stuff too., posted by bassman on September 24, 2006, at 20:06:21
So where is this big taboo that pdocs have against drinking? Love Jan
Posted by Phillipa on September 24, 2006, at 20:36:25
In reply to Re: Can't Take it AnyMore !!!!!!!!!!!!!!!!!!!!!!Help!! » Phillipa, posted by blueberry on September 24, 2006, at 18:59:37
Blueberry good luck. Wish I had your e-mail to talk to you. Love Jan
Posted by Jost on September 24, 2006, at 20:51:20
In reply to Re: Can't Take it AnyMore !!!!!!!!!!!!!!!!!!!!!!Help!! » blueberry, posted by SLS on September 24, 2006, at 20:04:21
The following site has a summary of the most recent papers from STAR*D.
In one study, particpants who'd failed in trials of three prior ADs were given Parnate or a combination of venlafaxine and mirtazapine. The results weren't encouraging-- the responses (I assume remission rates) were 7% for Parnate, 14% for the combination, the differences not considered statistically significant. However, improvement on the scale they use was greater for the combination (about 25%) than Parnate (quite low, can't remember, could have been 4%).
They published several papers, but overall, apparently, non-responders don't do well after earlier rounds of the study.
http://69.41.173.145/ww/www.nlm.nih.gov/medlineplus/antidepressants.htmlJost
Posted by SLS on September 24, 2006, at 22:07:42
In reply to Re: Can't Take it AnyMore !!!!!!!!!!!!!!!!!!!!!!He, posted by Jost on September 24, 2006, at 20:51:20
> They published several papers, but overall, apparently, non-responders don't do well after earlier rounds of the study.
I guess we are just going to have to do better, then.
TRD is TRD. That's the bad news.
We have the advantage of using many more drugs in different combinations. I wonder how many more people would get well if they were to add low-dose lithium to their treatment (300-600mg). It is the forgotton miracle drug. Lamictal might be an alternative as an augmenting agent. We have a couple of people who found their miracle pill in Lyrica.
Do you see why it becomes such a good idea to bring as many drugs to market as possible, regardless of their similarity? Creating treatments for people with TRD is sometimes evidence-based and sometimes closer to alchemy. Clinical experience has demonstrated that an individual can respond quite disparately to different drugs within a class. The more SSRIs, the better, as long as it doesn't prevent or delay the development of novel drugs. Let the market weed out the duds. I'm amazed that Ludiomil (maprotiline) is still on the market. That's one drug I haven't tried yet. It's supposed to be a piece of crap, but obviously it works great for some people. I hope it stays on the market. It will give me one more ray of hope to keep me going if I near rock-bottom. That's the great thing about this whole thing - uncertainty. You can't be certain how you are going to respond to anything. There is always the chance that you will respond therapeutically to just about anything. That's the good news.
Where did you find the Parnate study?
- Scott
Posted by Phillipa on September 24, 2006, at 22:24:01
In reply to Re: Can't Take it AnyMore ! Bad news - Good news, posted by SLS on September 24, 2006, at 22:07:42
Scott that's the one TCA I took. One time only. For me it made me feel like I was in a dream during sleep. Next day I had to work I was a new nurse and the spaciness was there all day. I didn't need an ad then. I flushed them down the toilet. Love Jan ps so that means it will probably work for you
Posted by SLS on September 24, 2006, at 23:03:12
In reply to Re: Can't Take it AnyMore ! Bad news - Good news » SLS, posted by Phillipa on September 24, 2006, at 22:24:01
> Scott that's the one TCA I took. One time only. For me it made me feel like I was in a dream during sleep. Next day I had to work I was a new nurse and the spaciness was there all day. I didn't need an ad then. I flushed them down the toilet.
So, then, you haven't taken a TCA or a MAOI?
Gosh, you're practically a virgin!
Remember, sometimes the drugs that work best are the ones that make you feel weird when you first start taking them.
You have at least two worlds to explore: TCA and MAOI, and all of the combinations that can be crafted around them.
Since you have demonstrated responsivity to both Paxil and Luvox, I would remain hopeful that you will find another treatment that you will find effective. Somehow, I get the feeling that you have never had much of a coherent treatment plan in place. I don't doubt that you could revisit Paxil and recapture a response from it at therapeutic dosages that are higher than the 10mg that you took. I see your options increasing in number as we speak. So, now we know that there are a bunch of drugs that you have yet to try at therapeutic dosages for 4-6 weeks. This isn't meant to confuse you any more than you already are as it is to give you real reasons to have hope. Even if Emsam isn't the right drug for you, there are many options available to you, including adding drugs to the Emsam before giving up on it.
To me, it looks like we are dealing with MDD and GAD. Is this correct?
If it is, I would move to Nardil after Emsam.
By the way, why do you find Emsam more attractive than Nardil?
- Scott
Posted by notfred on September 24, 2006, at 23:26:27
In reply to Re: Can't Take it AnyMore ! Bad news - Good news » Phillipa, posted by SLS on September 24, 2006, at 23:03:12
> So, then, you haven't taken a TCA or a MAOI?
>Both are often considered more successful at treating more significant depressions and TRD.
> Gosh, you're practically a virgin!
Indeed there are lots of options; it does not seem many big guns have been tried yet.
Posted by Jost on September 24, 2006, at 23:44:49
In reply to Re: Can't Take it AnyMore ! Bad news - Good news, posted by SLS on September 24, 2006, at 22:07:42
The Parnate study and another study are in the Sept. 2006 issue of the American Journal of Psychiatry (AJP).
The Parnate study, authored by Philip J. Mcgrath, of New York State Psychiatric Institute, is "Tranylcypromine versus Venlafaxine Plus Mirtazapine Following Three Failed Anti-depressant trials for Depression." AJP 2006, 163, 1519-1543.
The second study compared triiodothyronine (T3) vs lithium for a current AD. T3 outperformed lithium on numbers, but the difference again was not statistically significant. However, more participants in the lithium wing dropped out.
The article was supposed to be available as of Sept. 1, although I haven't checked Medline or the actual AJP website.
A third study from July 1, 2006 compared patients who had failed in two trials, who were allowed to switch to nortriptyline or mirtazapine. The results were 20% response to nortriptyline, 12% for mirtazapine, not statistically signficant. That article is by Maurizio Fava of Mass. General.
Jost
Posted by Jost on September 24, 2006, at 23:54:04
In reply to Re: Can't Take it AnyMore ! Bad news - Good news » SLS, posted by Jost on September 24, 2006, at 23:44:49
To be more clear, the T3 and lithium were to boost an AD, presumably from earlier phases of the study, that was already being taken.
But the Star*d while a good start doesn't take into consideration the incredible complexity of individual response to ADs. It's the best study so far, but still the methods are necessarily crude. There are too many possible combinations, and so much must be based on evaluation of individual responses.
I'm with you on the great importance of as many available options as possible, until the biological substrate comes into focus, and/or much better treatments become available, and their uses understood.. Also that Pdocs need to think of treatments as tailored to individual responses, esp. in the case of TRD, rather than general formulas.
Jost
Posted by SLS on September 25, 2006, at 0:06:48
In reply to Re: Can't Take it AnyMore ! Bad news - Good news » SLS, posted by Jost on September 24, 2006, at 23:44:49
Thanks for the citations. Do you have access to the hard copies? Where do you go for them?
> The Parnate study, authored by Philip J. Mcgrath,
First name: Patrick
Good guy. Very accessable. I had a consultation with him about 5 years ago. He didn't have very much novel to offer me in the way of suggestions, but was very big on Parnate. He is quite active. I think his hobby is to study the genetics of affective disorders. That is not his area of investigation and authorship. Anyway, my doctor at the time thought highly enough of him to send a member of his own family to him. Dr. McGrath was actually the fourth doctor who I saw at Columbia Presbyterian, Columbia University / New York State Psychiatric Institute. They really don't know what to call themselves over there. They recently changed their name to New York Presbyterian because Columbia and Cornell merged their medical facilities. Weird.
- Scott
Posted by jaclinhyde on September 25, 2006, at 10:00:25
In reply to Re: Can't Take it AnyMore !!!!!!!!!!!!!!!!!!!!!!He, posted by Jost on September 24, 2006, at 20:51:20
From that same study.....
"Participants were randomly selected to receive either tranylcypromine (Parnate) alone or venlafaxine (Effexor) plus mirtazapine (Remeron). Parnate is an older monoamine oxidase inhibitor while Effexor and Remeron are newer medications.
"The idea is to try to get at the underlying problem by as many possible mechanisms as you can," McGrath said, of the drug combination chosen. "It's similar to the way you might treat cancer with a multi-drug regimen."
Parnate is used infrequently these days but has been effective in people who have not responded to other therapies.
People in the Parnate arm of the trial had remission rates of 6.9 percent and those in the combination arm, 13.8 percent, considered to be roughly comparable results.
"That looks like the combination was twice as effective but, in fact, those differences were not statistically significant," McGrath said."
All depends on how you read it my friend. There are good and bad studies out there for every drug. On the whole though the MAOI's really are the big guns and can work wonders for someone who has not responded to anything else....like Phillipa.
Hugs,
Terri
> The following site has a summary of the most recent papers from STAR*D.
>
> In one study, particpants who'd failed in trials of three prior ADs were given Parnate or a combination of venlafaxine and mirtazapine. The results weren't encouraging-- the responses (I assume remission rates) were 7% for Parnate, 14% for the combination, the differences not considered statistically significant. However, improvement on the scale they use was greater for the combination (about 25%) than Parnate (quite low, can't remember, could have been 4%).
>
> They published several papers, but overall, apparently, non-responders don't do well after earlier rounds of the study.
>
>
> http://69.41.173.145/ww/www.nlm.nih.gov/medlineplus/antidepressants.html
>
> Jost
Posted by jealibeanz on September 25, 2006, at 19:54:59
In reply to Re: Can't Take it AnyMore !!!!!!!!!!!!!!!!!!!!!!Help!! » Phillipa, posted by blueberry on September 24, 2006, at 18:59:37
Do physicians always have to follow Star-D?
I've been contemplating bringing up EMSAM to my doc for a while for depression.
I tried Paxil, Buspar, Wellbutrin, and Effexor. All caused a lot of weight gain and apathy. I don't want to try another SSRI/SNRI because I think it's very likely to happen again. TCA's are known to cause weight gain.
So, would be it be completely out of line to ask my GP about it? Since it hasn't been shown to cause weight gain or apathy (yet!).
I know I've asked this before... mannnyyy times... but this seemed like the appriate thread to reassess people's opinions and recommendations. :)
Posted by Phillipa on September 25, 2006, at 20:09:08
In reply to Re: Can't Take it AnyMore ! Bad news - Good news » Phillipa, posted by SLS on September 24, 2006, at 23:03:12
Scott well I'm not a virgin unless my kids are immaculate conception.
So you think paxil might work again? It really worked at l0mg the first time. And you've jarred my mind as that pdoc did raise it to 20mg after that hospitalization I told you about. That with xanax. He pulled me off it very quickly I think he thought I was getting high? Hard to remember so much time has gone by.
Yes MDD and anxiety number l symptom. And the reason EMSAM was so attractive to me was cause you can see it. And my thought was that if you had a side effect you could just rip it off and it would be gone. See I am very sensitive to all types of things. I tried mono contacts one time before depression made it home ripped it out as it drove me crazy seeing far in one eye and close in the other. Now I hear that it takes 9 days for it the EMSAM to leave your body. So many horrible side effects during perimenopause I couldn't stand them. Love Jan. Scott you are a scientist or my pdoc. How much do I owe you? Seriously.
Posted by Phillipa on September 25, 2006, at 20:13:39
In reply to Re: Can't Take it AnyMore ! Bad news - Good news » SLS, posted by Phillipa on September 25, 2006, at 20:09:08
Dr. Bob I'm not offering Scott money. Just to make it clear. Love Jan
Posted by Jost on September 25, 2006, at 20:26:52
In reply to Re: Can't Take it AnyMore ! Bad news - Good news » Jost, posted by SLS on September 25, 2006, at 0:06:48
Don't have hard copy, or access to it. The article isn't on Medline yet.
My library doesn't have a subscription to Am. J.Psychiatry, unfortunately. Undoubtedly the Medical School Library does, but I'm not doing anything that's caused me to get a card there, recently. I'm not sure how hard it would be to get a card (and online access), but maybe it's worth it now.
If you have access to a library system that gets that journal, and connects you online, which mine does, you could get to it online.
Probably will be on Medline's most up-to-date service in a while.
Jost
Posted by SLS on September 26, 2006, at 1:21:25
In reply to Re: Can't Take it AnyMore ! Bad news - Good news » SLS, posted by Phillipa on September 25, 2006, at 20:09:08
> So you think paxil might work again?
Given your account of how it worked the first time and the circumstances of its discontinuation, I think returning to Paxil would not be unreasonable.
> And the reason EMSAM was so attractive to me was cause you can see it. And my thought was that if you had a side effect you could just rip it off and it would be gone.
Perhaps you could try looking at it from a nurse's perspective. How would you as a nurse advise a patient who was so hypervigilant regarding drug side effects, that they were refusing to take a newly-prescribed medication that could save their life? You know that the drug is relatively safe. You would not tacitly accept in a patient the decisions that you are making for yourself. You would try to persuade them to take the potentially life-saving medication.
> Now I hear that it takes 9 days for it the EMSAM to leave your body.
Technically, it takes 18-25 hours for the drug to leave the body, but probably 10 days or so for MAO activity to recover. I imagine most side effects would take a week or so to dissipate. The side effects are what - insomnia? site reactions? That's pretty much it.
"The only adverse event associated with discontinuation, in at least 1% of EMSAM -treated patients at a rate at least twice that of placebo, was application site reaction (2% EMSAM vs. 0% placebo)." - Drug Monograph
- Scott
Posted by Jost on September 26, 2006, at 10:35:40
In reply to Re: Can't Take it AnyMore ! Bad news - Good news » Phillipa, posted by SLS on September 26, 2006, at 1:21:25
Hi, Phillipa.
You said the your pdoc appointment was today.
Again, I wanted to add my voice to Scott's in his last post.
But if you don't feel ready for the Emsam, why don't you mostly talk to your pdoc about taking it?
Make another appointment with him for next week or two weeks, to talk about it again. Focus on the project of taking small steps over time toward Emsam. Maybe using paxil in the meantime, but with the idea that you have a goal and you'll work toward making it less frightening, and more doable.
Or go to a counselor. There must be someone you can afford on a once a week basis.
Are you depriving yourself of a life, perhaps for historical (your own history) reasons? Didn't you say your husband is a workaholic? Wouldn't he love to have you back again?
Wouldn't you love to have yourself back again?
As the sage says, If I'm not for myself, who will be? If I'm only for myself, who am I? If not now, when?
Try to think about the first and third questions.
Jost
Posted by SLS on September 26, 2006, at 11:26:41
In reply to Re: Can't Take it AnyMore ! Bad news - Good news, posted by Phillipa on September 25, 2006, at 20:13:39
I'm sorry, Phillipa.
I wasn't thinking.
Emsam has a 18-25 hour half-life. The rule-of-thumb (and I don't know whose rule this is) states that most of a drug clears your body after 5 half lives, which in this case would be 5 days.
It is hard to suggest to another person what they should do. The advice given is sometimes a projection of what is right for the advisor, but not for the recipient.
Let's see where your head is at.
What do you feel like doing right now? Really.
- Scott
Posted by SLS on September 26, 2006, at 12:16:11
In reply to If not now, when? ---Phillipa, posted by Jost on September 26, 2006, at 10:35:40
Jost is giving you a gentle nudge again.
I like his approach. You can continue to discuss with your doctor the merits of treatment with Emsam. There really is no rush. You are intelligent enough for this stuff. Start using that nurse brain of yours to consider Emsam and other treatments medically. Use your training to approach things with the medical knowledge and scientific logic you were so good at. You are a professional. Be stronger than your past and allow your professional achievements and survivalist spirit rise above your old and useless fears. Make decisions based on intellect; your motivation powered by a fierce drive to finally have a life filled with rich and rewarding experiences.
If not now, when? You don't have to rush to decide to take a drug. If not now, when? Make now the time that you begin to live the rest of your life. Make now the time you decide to fight to regain control of the inner Jan. Jan is there. Be Jan right now. Leave your fears somewhere else. They are not part of Jan. Let Jan start to make the decisions. Crap. I'm beginning to sound like an evangalist or a psychologist. Really, though. Do it. Do it now. Not later. Not after you read more posts. Do it right now as you are reading and then re-reading this one. There is a forever-young, vital, strong, angry, determined, and adult Jan inside ready and capable of dealing with old and useless fears and putting them in their place. For now, they belong compartmentalized. There are real reasons why they exist, but they do not belong in the present. They belong in a box where you can deal with them at a time of your choosing. Now is not that time. Now is the time to allow the adult Jan to begin to work on the logical consideration of Emsam along with other drugs as treatments for Major Depressive Disorder and possibly Generalized Anxiety Disorder. Take control right now.
Now you can go back to the top and start over.
:-)
- Scott
-------------------------------------------------
> Hi, Phillipa.
>
> You said the your pdoc appointment was today.
>
> Again, I wanted to add my voice to Scott's in his last post.
>
> But if you don't feel ready for the Emsam, why don't you mostly talk to your pdoc about taking it?
>
> Make another appointment with him for next week or two weeks, to talk about it again. Focus on the project of taking small steps over time toward Emsam. Maybe using paxil in the meantime, but with the idea that you have a goal and you'll work toward making it less frightening, and more doable.
>
> Or go to a counselor. There must be someone you can afford on a once a week basis.
>
> Are you depriving yourself of a life, perhaps for historical (your own history) reasons? Didn't you say your husband is a workaholic? Wouldn't he love to have you back again?
>
> Wouldn't you love to have yourself back again?
>
> As the sage says, If I'm not for myself, who will be? If I'm only for myself, who am I? If not now, when?
>
> Try to think about the first and third questions.
>
> Jost
>
>
>
>
Posted by exquilter on September 26, 2006, at 14:33:51
In reply to Re: If not now, when? ---Phillipa » Phillipa, posted by SLS on September 26, 2006, at 12:16:11
What a wonderful post Scott! Good advice for all of us I think.
Exquilter
Posted by ed_uk on September 26, 2006, at 14:34:56
In reply to Can't Take it AnyMore !!!!!!!!!!!!!!!!!!!!!!Help!!, posted by Phillipa on September 23, 2006, at 21:33:16
Dear PJ
I don't believe that Emsam would be a suitable drug for you. I think it would make you agitated. I do think Nardil would help, but you would have to study the dietary restrictions first. I'm sorry you're having such an awful time lately.
(((((PJ)))))
Love
Ed xxx
Posted by SLS on September 26, 2006, at 16:29:51
In reply to Re: Can't Take it AnyMore !!!!!!!!!!!!!!!!!!!!!!Help!! » Phillipa, posted by ed_uk on September 26, 2006, at 14:34:56
> I don't believe that Emsam would be a suitable drug for you. I think it would make you agitated.
What makes you say this?
From the reports here and by my doctor, this drug seems to have anxiolytic properties, even though it is energizing in the beginning. People have even been able to reduce their dosages of Klonopin.
Having said that, I value your knowledge, opinions, and instincts.
I personally think that Nardil is well suited for Phillipa. It would probably be a good idea for her to start at 7.5mg, though, if it is possible to cut the new Nardil pills in half. I haven't seen them yet. Starting low and going slow with Nardil will help avoid any intitial sedation and hypotension.
For the times that I was on Nardil for extended periods of time, I didn't even know I was on the drug except that I had to take the pills every day. No side effects. The diet was no big dea. For the few months that it worked for me, it was a wonderful remission. The response waned and I then entered a mixed state hypomania. I remained in this state quite stable at 30mg for a few months. Things got very ugly after that. I actually entered a psychotic mania once I *discontinued* the Nardil.
Anyway, I don't know what I would do in Phillipa's position. Emsam is attractive for its lack of side effects, except for site reaction and insomnia. I would still follow the diet, though, because I would anticipate needing to go up to 9mg/24hr. I am still dubious of the safety at that dosage and higher.
I think my decision would pivot upon the pervasiveness and magnitude of the anxiety. I don't see Emsam as being a drug capable of treating Axis I anxiety disorders. I could be wrong, of course (I hope I am). Nardil, on the other hand, has been demonstrated for years to be a potent treatment for these disorders. As Phillipa describes her sometimes paralyzing anxiety, I am drawn to the conclusion that the anxiety should be treated as aggressively as the depression. This leaves Nardil.
Phillipa, if you are more comfortable trying Emsam first, then do that. You won't be sacraficing epochs of your life by doing so. If these patches deliver sufficient MAOI, you might end up with a very nice response, including a reduction in anxiety. If Ed is correct, as he often is, and you react to Emsam badly, you should know pretty quick. I am guessing it is the parent compound that would be doing the dirty work directly, not the consequences of MAO inhibition. Like you said, if it happens, you just rip the patch off, and that's that. It will clear up in a couple of days. Then move on to Nardil (or something else or nothing, whichever Jan thinks is right for her).
Remember Phillipa, these are powerful drugs. They are not sugar pills. They do have side effects, and you might feel some weird stuff in the beginning. You MUST expect that these things might occur. You MUST take things one day at a time. Jan, you must be in control here if this thing is going to work. Come here to report your progress and express your concerns. Call your doctor if necessary.
- Scott
Posted by Declan on September 26, 2006, at 17:44:08
In reply to Re: Can't Take it AnyMore !!!!!!!! » Phillipa » ed_uk, posted by SLS on September 26, 2006, at 16:29:51
PJ, I don't think you'd sleep with Emsam. You could take something for that but then you have another drug layer, because I couldn't imagine benzos cutting it for you. Apart than that, and maybe some increased anxiety, it might be OK
Posted by Jost on September 26, 2006, at 19:26:44
In reply to Re: Can't Take it AnyMore !!!!!!!!, posted by Declan on September 26, 2006, at 17:44:08
Insomnia is a problem with Emsam, no question.
First, there's accommodation over time-- perhaps not total, but substantial in reducing insomnia.
Even more, taking the patch off for some part of the night may be a crucal element of successful use for some people (myself included).
I'd also like to emphasize that Scott is, IMO, correct about adherence to the dietary restrictions on higher emsam doses, esp. if the patch isn't removed at night. If absorption stays within expected levels, the dietary restrctions may not be necessary even on stronger patches.
So far, however, the effect of non-standard conditions. such as heat, even during transportation, or individual differences in absorption have not been studied adequately. Therefore, some danger of reaching a level where tyramine could be problematic remains--esp. since it's not tyramine at one meal, but over days, that can be implicated.
Until these issues are further investigated some degree of dietary caution should be practiced.
Jost
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Dr. Bob is Robert Hsiung, MD,
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