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Dr. Bob is Robert Hsiung, MD,
[email protected]Shown: posts 1 to 25 of 49. This is the beginning of the thread.
Posted by Andie on April 13, 1999, at 11:07:08
i take 210mg of lofepramine a day since being taken off seroxat as
it actually seemed to increse my anxiety and insomnia.
i've looked it up on the web and there is very little information about
this drug and what little there is seems to say that
lofepramine and tricyclics in general are 'dirty' drugs
and not terribly reccommended. does anyone have anything good
to say at all about tricyclics? or does anyone have any more info
on lofepramine.
Posted by saintjames on April 16, 1999, at 0:13:56
In reply to Lofepramine and tricyclics, posted by Andie on April 13, 1999, at 11:07:08
i've looked it up on the web and there is very little information about
> this drug and what little there is seems to say that
> lofepramine and tricyclics in general are 'dirty' drugs
> and not terribly reccommended. does anyone have anything good
> to say at all about tricyclics?James here....
TCA's are still the gold standard that all AD's are measured against (~70% of depressives will improve on TCA's) "Dirty" means that TCA's effect many systems and not just mood neurochems. The newer AD's tend to be specific or selective in their action so they (hopefully) have fewer side effects. But as mood is a multi faceted animal that we are just understanding often "dirty" meds
work better in some cases...hince poly drug thearpy for resistant depression.Can't comment on lofepramine
j
Posted by George O. on April 16, 1999, at 17:20:13
In reply to Re: Lofepramine and tricyclics, posted by saintjames on April 16, 1999, at 0:13:56
> i've looked it up on the web and there is very little information about
> > this drug and what little there is seems to say that
> > lofepramine and tricyclics in general are 'dirty' drugs
> > and not terribly reccommended. does anyone have anything good
> > to say at all about tricyclics?
>
> James here....
>
> TCA's are still the gold standard that all AD's are measured against (~70% of depressives will improve on TCA's) "Dirty" means that TCA's effect many systems and not just mood neurochems. The newer AD's tend to be specific or selective in their action so they (hopefully) have fewer side effects. But as mood is a multi faceted animal that we are just understanding often "dirty" meds
> work better in some cases...hince poly drug thearpy for resistant depression.
>
> Can't comment on lofepramine
>
>The only long term success (2yrs or more) I've ever had has been with tricyclics, ssr's sedate me heavily, other new stuff doesn't work. The number one advantage of newer ad'd is that they are not so lethal in cases of overdose. I did a lot of reading on lofepramine, what I can quickly recall is that it is derived from imiprimine (similar to desiprimine, in fact a small portion of lofepramine is converted to desiprimine within the body). Lofepramine is easier on the heart and liver
, it's also not usually sedating. I haven't found it to be very effective, but then again I had already taken desiprimine for years and become resistant to it, the two drugs are awfully closely related. George
Posted by Elizabeth on April 17, 1999, at 23:13:48
In reply to Re: Lofepramine and tricyclics, posted by saintjames on April 16, 1999, at 0:13:56
As has been pointed out, lofepramine is safe and nontoxic compared to other cyclic ADs, with few side effects and relative safety in overdose. The main (only, actually) bad thing I've heard about it is that sometimes it's been known to cause liver damage (I don't think this is very common, though).
The dirtiness of most tricyclics resides in their
affinity for histaminic, muscarinic cholinergic,
and alpha1-adrenergic receptors - resulting in
sedation, constipation, dry mouth, urinary retention, blurred vision, rapid heartbeat, cognitive impairment, orthostatic hypotension - you get the idea. Lofepramine lacks most of these side effects, so I wouldn't call it a dirty drug.I think that it's not so much a question of one type of antidepressant working better than another, as some types being indicated for different depressions. It's still a tricky business deciding when to use what, though!
Posted by Pete6 on October 29, 1999, at 14:48:35
In reply to Lofepramine and tricyclics, posted by Andie on April 13, 1999, at 11:07:08
I have just been prescribed lofepramine 70mg(29.10.99) for depression, anxiety, difficulty getting to sleep due to over active mind (not insomnia where sleep is broken).
Will let you know what happens. I am genuine and not fooling around here - I was interested in what the doctor gave me and looked it up in a search.
Posted by Refractory on October 31, 1999, at 10:46:08
In reply to Lofepramine and tricyclics, posted by Andie on April 13, 1999, at 11:07:08
I have read and been told that the tricyclics are actually oftentimes superior to the SSRIs for severe depression or refractory. Psychiatrists are terribly afraid of being sued for any reason, as are all doctors these days. Part of their reluctance nowadays to prescribe TCAs probably has to do with their fear a patient may use the TCA prescription to overdose and thus commit suicide. Thus they try to stay with the newer, "cleaner" antidepressants like the SSRIs whenever possible. As none of these can be used for overdose.
I am sure there are many, many people out there with more severe depression, who would probably be better off on a TCA or even an MAOI but their doctor wont voluntarily put them on one because of the docs fear of overdose and potential lawsuits. Such is the state of modern day medicine.
Posted by Elizabeth on October 31, 1999, at 12:41:11
In reply to Re: Lofepramine and tricyclics, posted by Refractory on October 31, 1999, at 10:46:08
> I have read and been told that the tricyclics are actually oftentimes superior to the SSRIs for severe depression or refractory.
Yes...in particular for the "melancholic" subtype (which often isn't helped by SSRIs).
> Psychiatrists are terribly afraid of being sued for any reason, as are all doctors these days. Part of their reluctance nowadays to prescribe TCAs probably has to do with their fear a patient may use the TCA prescription to overdose and thus commit suicide. Thus they try to stay with the newer, "cleaner" antidepressants like the SSRIs whenever possible. As none of these can be used for overdose.
Well, they can, but the most that's liable to happen is a great deal of vomiting. I think fear that patients will use a medication as a means to attempt suicide is a legitimate concern. Lofepramine is supposed to be much less cardiotoxic than other TCAs, which makes it an attractive choice. (Does anyone happen to know what company markets it in the UK?)
Another risk of tricyclics is that they seem to cause mania (in particular, dysphoric or mixed mania) or rapid cycling than SSRIs and possibly MAOIs. (Hypomania seems to be very common with MAOIs, though.)
> I am sure there are many, many people out there with more severe depression, who would probably be better off on a TCA or even an MAOI but their doctor wont voluntarily put them on one because of the docs fear of overdose and potential lawsuits. Such is the state of modern day medicine.
My impression is that tricyclics are better for the melancholic end of the spectrum, SSRIs for the atypical end, and MAOIs are more versatile. This is, of course, an extremely broad generalization.
Posted by Stephan on November 1, 1999, at 15:24:34
In reply to Re: Lofepramine and tricyclics, posted by Elizabeth on October 31, 1999, at 12:41:11
>I think fear that patients will use a medication as a means to attempt suicide is a legitimate concern.
Of course it is, but it should always be a rational and balanced concern, not an irrational one. The prolongation of pain and misery caused by doctors who are quite willing to subject a patient to every possible non-tricyclic or non-MAOI antidepressant combination in order to lessen their often irrational litigation paranoia is at least as significant as the suicide-attempt risk of prescribing tricyclics. I would venture to say that far more patients have lost their lives due to under and mal-treatment of their depression than because a doctor prescribed them a tricyclic.
Posted by saint james on November 1, 1999, at 18:40:20
In reply to Re: tricyclics and suicide, posted by Stephan on November 1, 1999, at 15:24:34
> >I think fear that patients will use a medication as a means to attempt suicide is a legitimate concern.
>
> Of course it is, but it should always be a rational and balanced concern, not an irrational one. The prolongation of pain and misery caused by doctors who are quite willing to subject a patient to every possible non-tricyclic or non-MAOI antidepressant combination in order to lessen their often irrational litigation paranoia is at least as significant as the suicide-attempt risk of prescribing tricyclics. I would venture to say that far more patients have lost their lives due to under and mal-treatment of their depression than because a doctor prescribed them a tricyclic.James here....
One months supply of a TCA generally is not enough to kill someone. Doc make this call often, so the write scripts for the smallest amount of time in those that might try suicide.
j
Posted by Refractory on November 1, 1999, at 21:24:13
In reply to Re: Lofepramine and tricyclics, posted by Elizabeth on October 31, 1999, at 12:41:11
> > I have read and been told that the tricyclics are actually oftentimes superior to the SSRIs for severe depression or refractory.
>
> Yes...in particular for the "melancholic" subtype (which often isn't helped by SSRIs).
>
> > Psychiatrists are terribly afraid of being sued for any reason, as are all doctors these days. Part of their reluctance nowadays to prescribe TCAs probably has to do with their fear a patient may use the TCA prescription to overdose and thus commit suicide. Thus they try to stay with the newer, "cleaner" antidepressants like the SSRIs whenever possible. As none of these can be used for overdose.
>
> Well, they can, but the most that's liable to happen is a great deal of vomiting. I think fear that patients will use a medication as a means to attempt suicide is a legitimate concern. Lofepramine is supposed to be much less cardiotoxic than other TCAs, which makes it an attractive choice. (Does anyone happen to know what company markets it in the UK?)
>
> Another risk of tricyclics is that they seem to cause mania (in particular, dysphoric or mixed mania) or rapid cycling than SSRIs and possibly MAOIs. (Hypomania seems to be very common with MAOIs, though.)
>
> > I am sure there are many, many people out there with more severe depression, who would probably be better off on a TCA or even an MAOI but their doctor wont voluntarily put them on one because of the docs fear of overdose and potential lawsuits. Such is the state of modern day medicine.
>
> My impression is that tricyclics are better for the melancholic end of the spectrum, SSRIs for the atypical end, and MAOIs are more versatile. This is, of course, an extremely broad generalization.Hmmmm that is very interesting. I always heard MAOIs were the drugs for the "atypical" form of depression. How come you say SSRIs are good for atypical depression? Very interesting.
Posted by Elizabeth on November 3, 1999, at 11:57:14
In reply to Re: tricyclics and suicide, posted by saint james on November 1, 1999, at 18:40:20
> > Of course it is, but it should always be a rational and balanced concern, not an irrational one. The prolongation of pain and misery caused by doctors who are quite willing to subject a patient to every possible non-tricyclic or non-MAOI antidepressant combination in order to lessen their often irrational litigation paranoia is at least as significant as the suicide-attempt risk of prescribing tricyclics. I would venture to say that far more patients have lost their lives due to under and mal-treatment of their depression than because a doctor prescribed them a tricyclic.
This is well said, and I agree...you have to balance the risks of prescribing vs. the risks of not prescribing. There are some other factors you can look at in making the decision to try a tricyclic, such as the likelihood that it won't work (e.g., the person has atypical depression or "probable atypical depression"), the patient's current level of suicidal ideation and history of suicide attempts, the level of social support available to the patient, etc. As Saint James points out below, you can also write for just a week at a time if the patient is "high-risk."
> One months supply of a TCA generally is not enough to kill someone. Doc make this call often, so the write scripts for the smallest amount of time in those that might try suicide.
This is sort of an oversimplification...because people metabolize tricyclics at widely varying rates (in particular, somewhere around 10% of Caucasians (less in other ethnic groups) are deficient in an enzyme involved in TCA metabolism), the lethal dose varies a lot as well. A month's supply at a starting dose probably wouldn't be lethal for a normal metabolizer, but it could be for a poor metabolizer.
Posted by Elizabeth on November 3, 1999, at 12:05:09
In reply to Re: Lofepramine and tricyclics, posted by Refractory on November 1, 1999, at 21:24:13
> Hmmmm that is very interesting. I always heard MAOIs were the drugs for the "atypical" form of depression. How come you say SSRIs are good for atypical depression? Very interesting.
This was observed pretty early on, I think. My suspicion is that they still don't work as well for atypical depression as MAOIs, though this hasn't been shown.
See, for example:
Pande AC, et al. Fluoxetine versus phenelzine in atypical depression. Biol Psychiatry. 1996 Nov 15;40(10):1017-20.
Posted by Stephan on November 3, 1999, at 12:53:45
In reply to Re: tricyclics and suicide, posted by Elizabeth on November 3, 1999, at 11:57:14
> There are some other factors you can look at in making the decision to try a tricyclic, such as the likelihood that it won't work (e.g., the person has atypical depression or "probable atypical depression
I know there are a lot of studies that support this, but I'm about as atypical as they come, and tricyclics (desipramine and nortriptyline) have given me a better response than any other antidepressant (with the exception of my first trial of Luvox). Parnate gave me only a modest, transient response.
Posted by jamie on November 3, 1999, at 14:48:33
In reply to Re: atypical depression and tricyclics, posted by Stephan on November 3, 1999, at 12:53:45
> > There are some other factors you can look at in making the decision to try a tricyclic, such as the likelihood that it won't work (e.g., the person has atypical depression or "probable atypical depression
>
> I know there are a lot of studies that support this, but I'm about as atypical as they come, and tricyclics (desipramine and nortriptyline) have given me a better response than any other antidepressant (with the exception of my first trial of Luvox). Parnate gave me only a modest, transient response.Stephan...nortriptyline and desipramine in combination? Or separately. ???
Posted by Stephan on November 4, 1999, at 17:13:47
In reply to Re: atypical depression and tricyclics-Stephan, posted by jamie on November 3, 1999, at 14:48:33
> Stephan...nortriptyline and desipramine in combination? Or separately. ???Separately. I've never heard of them being combined. Not sure if it's ok.
Posted by Elizabeth on November 4, 1999, at 23:30:12
In reply to Re: atypical depression and tricyclics, posted by Stephan on November 3, 1999, at 12:53:45
> > There are some other factors you can look at in making the decision to try a tricyclic, such as the likelihood that it won't work (e.g., the person has atypical depression or "probable atypical depression
>
> I know there are a lot of studies that support this, but I'm about as atypical as they come, and tricyclics (desipramine and nortriptyline) have given me a better response than any other antidepressant (with the exception of my first trial of Luvox). Parnate gave me only a modest, transient response.What do you mean when you say you are "about as atypical as they come?" Atypical depression is a specific syndrome -- it doesn't just mean you have an unusual or different presentation.
Posted by Stephan on November 5, 1999, at 19:32:02
In reply to Re: atypical depression and tricyclics, posted by Elizabeth on November 4, 1999, at 23:30:12
> What do you mean when you say you are "about as atypical as they come?" Atypical depression is a specific syndrome -- it doesn't just mean you have an unusual or different presentation.I meant that I seem to have all the classic symptoms of "atypical depression" -hypersomnia, strong cravings for sugary foods, etc.
Posted by Scott L. Schofield on November 7, 1999, at 17:26:35
In reply to Re: atypical depression and tricyclics , posted by Stephan on November 5, 1999, at 19:32:02
> I meant that I seem to have all the classic symptoms of "atypical depression" -hypersomnia, strong cravings for sugary foods, etc.Doesn't it sometimes seem as if the atypical is actually quite typical?
It's funny, but I have not yet come across any literature that presents statistics comparing the occurrences of "typical" versus "atypical" depression. Also, bipolar depression typically appears atypical. Very shortly, I imagine the atypical neuroleptics will typically be the first choice of your typical psychiatrist.
That's typical.
- ScottP.S. I really would like to know the statistics regarding the various presentations of unipolar depression. Does anyone know what they are?
Posted by Noa on November 7, 1999, at 19:25:07
In reply to Re: atypical depression and tricyclics , posted by Scott L. Schofield on November 7, 1999, at 17:26:35
My very uneducated guess is that the "typical" presentation of depression ocurrs more frequently in men than in women, and that early studies of depression used male subjects. So the model of what is "typical" depression was based on the acute major depression occuring in the "typical" male subject. When more and more women started showing up for treatment, presenting with "atypcial" features, the symptoms were compared (contrasted) with what was the textbook version of depression (insomnia, lack of appetite, no mood responsivity to social stimulation, etc.) and called them "atypical". I would guess that there are more "atypicals" than textbook major depression.
Some researchers are grouping the unipolar depressions with bipolar illness--because the "atypical" version is akin to the depressive states of those with bipolar. some researchers are also looking at the so-called mood based personality disorders as cyclical mood disorders, with hypomania presenting more often as irritability, and depression being of the "atypical" type. I think this is a positive move, because the name "personality disorder" sounds like a character fault, which has moral overtones, in the person who is suffering.
Posted by Elizabeth on November 8, 1999, at 0:10:12
In reply to Re: atypical depression -how typical?, posted by Noa on November 7, 1999, at 19:25:07
> My very uneducated guess is that the "typical" presentation of depression ocurrs more frequently in men than in women, and that early studies of depression used male subjects.
It appears that older people are more likely to have typical features; that melancholic features occur about equally in both sexes; and that atypical features occur about twice as often in women as in men. (My guess is that adolescents are likelier to present with reversed vegetative signs than adults are.)
> Some researchers are grouping the unipolar depressions with bipolar illness--because the "atypical" version is akin to the depressive states of those with bipolar.
Not exclusively (bipolar folks can have "typical" depressions too). I think this mainly applies to bipolar II (which is itself sort of a fuzzy category).
> some researchers are also looking at the so-called mood based personality disorders as cyclical mood disorders, with hypomania presenting more often as irritability, and depression being of the "atypical" type.
This is mainly borderline personality disorder, yes? (Maybe histrionic too.)
> I think this is a positive move, because the name "personality disorder" sounds like a character fault, which has moral overtones, in the person who is suffering.
I think it is sort of supposed to sound pejorative. (It is, after all, the category that includes antisocial personality disorder and narcissistic personality disorder.)
Posted by dj on November 8, 1999, at 2:10:19
In reply to Re: atypical depression -how typical?, posted by Elizabeth on November 8, 1999, at 0:10:12
Eliazabeth,
Seeing as you seem to be the most informed about these categories (though Noa seemed pretty familiar with them) perhaps when you've a moment to spare you could sketch out the symptoms of both, a bit..as a quick review of the last part of this thread leaves me little clearer as to the exact distinctions.
I have the impression that typical dep. is melancolic, oversleeping and undereating and that typical is perhaps the reverse however I'm not entirely certain about that and would appreciate some elaboration and explanation so I can better understand these categories.
> > It appears that older people are more likely to have typical features; that melancholic features occur about equally in both sexes; and that atypical features occur about twice as often in women as in men. (My guess is that adolescents are likelier to present with reversed vegetative signs than adults are.)
>
Posted by Scott L. Schofield on November 8, 1999, at 5:39:12
In reply to Re: atypical depression -how typical?, posted by Noa on November 7, 1999, at 19:25:07
> Some researchers are grouping the unipolar depressions with bipolar illness--because the "atypical" version is akin to the depressive states of those with bipolar.Thanks for your more than uneducated reply.
I hope these researchers are put in their place as quickly as possible. There is no question that the epidemiology of unipolar versus bipolar depression is manifestly very different. If the response rates to mood-stablizers turns out to be different between the two, their conceptualization would be extremely counterproductive.
- Scott
Posted by Annie on November 8, 1999, at 9:44:01
In reply to Re: atypical depression -how typical?, posted by Scott L. Schofield on November 8, 1999, at 5:39:12
My "current" psychiatrist is one of the proponents of the theory that there is no such thing as atypical depression. If a person exhibits the atypical subset of symptoms, like me, they are really bipolar whether or not they have ever experienced a manic or hypomanic episode. My irritability is manic, buying things I don't need is manic (hmmm ok maybe), researching my depression online is manic, assertiveness is manic. So now , I have a dx of mixed state bipolar. This explains (to him) why I have not noticed the manic episodes. I was depressed when I had them! This explains my refractory deprssion. I have been on Neurontin for a month. It's still early , but my depression is so severe right now, I'm not sure I will be able to survive long enough to "prove" this is not helping. You know, I just don't care anymore. Let him call it whatever he wants. I'm dying a little bit more every day and soon there won't be enough left to matter. When I am totally gone it won't matter what my dx was.
Annie> > Some researchers are grouping the unipolar depressions with bipolar illness--because the "atypical" version is akin to the depressive states of those with bipolar.
>
> Thanks for your more than uneducated reply.
>
> I hope these researchers are put in their place as quickly as possible. There is no question that the epidemiology of unipolar versus bipolar depression is manifestly very different. If the response rates to mood-stablizers turns out to be different between the two, their conceptualization would be extremely counterproductive.
>
> - Scott
Posted by Scott L. Schofield on November 8, 1999, at 18:25:26
In reply to Re: atypical depression -how typical?, posted by Annie on November 8, 1999, at 9:44:01
> > > Some researchers are grouping the unipolar depressions with bipolar illness--because the "atypical" version is akin to the depressive states of those with bipolar. > I hope these researchers are put in their place as quickly as possible. There is no question that the epidemiology of unipolar versus bipolar depression is manifestly very different. If the response rates to mood-stablizers turns out to be different between the two, their conceptualization would be extremely counterproductive. My "current" psychiatrist is one of the proponents of the theory that there is no such thing as atypical depression. If a person exhibits the atypical subset of symptoms, like me, they are really bipolar whether or not they have ever experienced a manic or hypomanic episode.
... researching my depression online is manic, assertiveness is manic...
...You know, I just don't care anymore. Let him call it whatever he wants. I'm dying a little bit more every day and soon there won't be enough left to matter. When I am totally gone it won't matter what my dx was.
Annie <
Dear Annie,Although your doctor may be accurate in his appraisal of your illness, I think his characterization of your conducting research as being manic is unfair. Because I have seen at least two recent posts regarding the concept that all presentations of atypical depression are actually bipolar, I decided to do a little research of my own. The attitude I expressed in my previous post may have been unfounded.
I was more than just a little surprised at how few studies have been conducted in this area. There is quite a bit more uncertainty now as to the existence of a true atypical unipolar depression than there was ten years ago. I found a few studies in which sequential patients meeting the DSM IV diagnostic criteria for atypical depression were evaluated for bipolar disorder. At least two studies demonstrated that roughly 40% of those meeting the definition of atypical depression were actually bipolar II.
I would like to see a study in which both the 40% bipolar group and the 60% non-bipolar group are first treated with Depakote alone.
Either way, it might not be a bad idea to act under the premise that you are bipolar. It may lead to a successful trial using other mood-stablizers in addition to antidepressants.
Please care for a little while longer.
- Scott
P.S. Today has been a very upsetting one for me. The story is too long to get into here, but I didn't care a whole hell of a lot either. I hope I'm strong enough to take my own advice.
Posted by Scott L. Schofield on November 8, 1999, at 19:01:13
In reply to Re: atypical depression -how typical?, posted by Annie on November 8, 1999, at 9:44:01
> > > Some researchers are grouping the unipolar depressions with bipolar illness--because the "atypical" version is akin to the depressive states of those with bipolar. > I hope these researchers are put in their place as quickly as possible. There is no question that the epidemiology of unipolar versus bipolar depression is manifestly very different. If the response rates to mood-stablizers turns out to be different between the two, their conceptualization would be extremely counterproductive. My "current" psychiatrist is one of the proponents of the theory that there is no such thing as atypical depression. If a person exhibits the atypical subset of symptoms, like me, they are really bipolar whether or not they have ever experienced a manic or hypomanic episode.
... researching my depression online is manic, assertiveness is manic...
...You know, I just don't care anymore. Let him call it whatever he wants. I'm dying a little bit more every day and soon there won't be enough left to matter. When I am totally gone it won't matter what my dx was.
Annie <
Dear Annie,Although your doctor may be accurate in his appraisal of your illness, I think his characterization of your conducting research as being manic is unfair. Because I have seen at least two recent posts regarding the concept that all presentations of atypical depression are actually bipolar, I decided to do a little research of my own. The attitude I expressed in my previous post may have been unfounded.
I was more than just a little surprised at how few studies have been conducted in this area. There is quite a bit more uncertainty now as to the existence of a true atypical unipolar depression than there was ten years ago. I found a few studies in which sequential patients meeting the DSM IV diagnostic criteria for atypical depression were evaluated for bipolar disorder. At least two studies demonstrated that roughly 40% of those meeting the definition of atypical depression were actually bipolar II.
I would like to see a study conducted in which both the 40% bipolar group and the 60% non-bipolar group are first treated with Depakote alone.
Either way, it might not be a bad idea to act under the premise that you are bipolar. It may lead to a successful trial using other mood-stablizers in addition to antidepressants.
Please care for a little while longer.
- Scott
P.S. Today has been a very upsetting one for me. The story is too long to get into here, but I didn't care a whole hell of a lot either. I hope I'm strong enough to take my own advice.
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