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Dr. Bob is Robert Hsiung, MD,
[email protected]Shown: posts 1 to 6 of 6. This is the beginning of the thread.
Posted by medlib on February 25, 2000, at 20:57:43
JohnL-
I really like the idea of your "bang-bang-bang" approach to new Rx initiation and would like very much to take some documentation to my pdoc next week that might convince him to try it with me. Waiting a month between mistakes is the PITS! Do you have any citations you could share with me? I would search Medline myself, but I can't think what to call such an approach. It doesn't correspond to any MeSH term, that's for sure. Any help would be much appreciated.
Thanks!
medlib
Posted by JohnL on February 26, 2000, at 4:35:23
In reply to To JohnL, posted by medlib on February 25, 2000, at 20:57:43
> JohnL-
> I really like the idea of your "bang-bang-bang" approach to new Rx initiation and would like very much to take some documentation to my pdoc next week that might convince him to try it with me. Waiting a month between mistakes is the PITS! Do you have any citations you could share with me? I would search Medline myself, but I can't think what to call such an approach. It doesn't correspond to any MeSH term, that's for sure. Any help would be much appreciated.
> Thanks!
> medlibMedlib, we won't find any documentation on this method. It is a rather new approach. It is being taught in several medical schools however. There are some basic assumptions to this method:
1. The drug that most closely targets the underlying chemical imbalance will produce results fast, often the very first day, or within a week. The doctor I'm seeing is having tremendous success. Six week trials do not occur in his practice, except in rare cases where this method doesn't work and he must revert back to traditional psychiatry. He is getting excellent results with nearly all patients in a maximum of 8 visits. No stone is left unturned.
2. Patients often have a favorite drug within a class of drugs, and this allows comparison of each before committing to any one of them. Superior matches are found, inferior matches are weeded out. The doc routinely expects and gets 4 day responses. It's an organized way of probing for that magic molecule.
3. This approach looks for a bullseye, and tries to avoid the typical time consuming trickle down effect that may or may not ever happen. The longer the wait, the farther the drug is from the real problem.
4. Drugs from different classes often work better than the ones we expect to work (again, depending on the unknown underlying chemical problem), and this method probes all possibilities.
5. Drug reactions, whether good or bad, provide clues as to what the underlying chemical imbalance(s) are.
6. This method is not appropriate for someone who is in the midst of suicidal depression or psychosis. The patient must be somewhat stable to probe different drugs quickly.
7. In case of bad reactions, either Xanax and/or Stelazine are given to the patient as antidotes. Negative reactions are discontinued immediately.
8. A psychiatrist in California has published a book on this approach, called "The Successful Treatment of Brain Chemical Imbalance". It can be reviewed at www.drjensen.com. I was, at first, this book's strongest critic.We are so deeply entrenched in the traditional theories of 6 week trials that it's hard to accept new possibilites. Again, no one objected to this approach more than me. But now that I have a real life doctor who uses this approach with incredible success, I find it nearly impossible to blow any holes in the theory. In the old days we only had a limited number of drugs and often had to wait for a trickle down effect. Nowadays there are so many more choices, of which one will likely target the underlying chemical imblance more directly. It's very hard to accept at first, but when the magic molecule is discovered, long trials become archaic.
When the bangbangbang approach fails (VERY rare), reverting back to traditional 6 week trials and/or MAOIs is the next step. But that hardly ever happens. Somewhere in the quick trials the magic molecule is found. It just takes an open mind on the part of the doc and the patient to probe all possibilities in short order. The ultimate goal is getting the patient well in the shortest amount of time.
Following this post, I'll submit another post of what my pdoc wrote to my family doc about me. It is a real life realtime example of this approach in action. JohnL
Posted by JohnL on February 26, 2000, at 5:09:06
In reply to To JohnL, posted by medlib on February 25, 2000, at 20:57:43
> JohnL-
> I really like the idea of your "bang-bang-bang" approach to new Rx initiation and would like very much to take some documentation to my pdoc next week that might convince him to try it with me. Waiting a month between mistakes is the PITS! Do you have any citations you could share with me? I would search Medline myself, but I can't think what to call such an approach. It doesn't correspond to any MeSH term, that's for sure. Any help would be much appreciated.
> Thanks!
> medlib
This is a copy of what my pdoc wrote to my family doc. It is a real life realtime example of probing for the magic molecule. Since pdocs are merely using educated guesses anyway in choosing medication, this approach organizes trials into a logical step by step probing exploration for superior matches. Superior matches are characterized by quick positive response. Inferior matches are charcterized by negative reactions, excessive side effects, and longer time to achieve results. The underlying philosophy is that medication reactions will guide treatment with more weight than the actual diagnosis. This is because any one of a number of different chemical imbalances can all cause the same exact symptoms. For example, just because someone has depression doesn't mean it is caused by serotonin/NE malfunction or that it will be normalized with an antidepressant. There are other causes that deserve probing.Keep in mind other drugs such as Paxil or Zoloft or tricyclics have already been weeded out, and that's why they aren't mentioned. It's already clear I benefit from SSRIs somewhat, but the pdoc wants to make sure I'm on the best match SSRI for my chemistry. And then he wants to explore uncharted territory to see if other chemical imbalances and/or instabilities are involved. Probing for the magic molecule in an organized manner. I am guessing, but my prediction is he will guide me to the right blend of medications in about 5 visits. To be continued...:)
Dear Dr. Libenson,
Concerning John L...The 43 year old father has suffered from apathy and periodically severe depression since childhood. He meets criteria for major depression. Numerous antidepressants (11) have worsened his condition, yet Prozac 20mg helps moderately. Zyprexa 5mg at bedtime has been markedly helpful for depression and insomnia. He still takes 7.5mg Remeron at bedtime.
Diagnostically he has major depression. Yet underlying slightly manic depressive or psychotic chemistry may be present. The efficacy of Zyprexa proves this. Lithium did not help, while Lamictal in contrast helped mental stability.
Ideas: find out what is his best antidepressant match.
1. He should continue for two weeks Prozac 20mg daily, combined with Zyprexa 5mg at bedtime. Remeron 7.5mg at bedtime should be discontinued.
2. After two weeks, Prozac should be discontinued, and switched to Celexa 20mg 1 to 2 in AM for depression for two weeks.
Celexa did not worsen psychosis, and helped aggression in a study involving 15 schizophrenicss.
Citalopram, a selective serotonin reuptake inhibitor, in the treatment of aggression in schizophrenia. Vartiainen H, et al. Acta Psychiatr Scand. 1995: 91 (5): 348-51, Finland.Celexa is excellent for perfectionists, and is similar to Prozac, but may be a better match for John. It should be given two weeks since Prozac has a 9 day half-life.
3. After Celexa has been tried, it should be switched to Luvox 50mg in AM for one week to make sure he is on the best matching antidepressant for his system.
He could then pick Prozac, Celexa, or Luvox to continue .
Other projects in the future should include briefly testing the following ideas:
1. Compare children's doses of stimulants such as Adderall 5mg: 1-2 in a.m. and at noon (#15) vs. Dexedrine 5mg tablets: 1-2 in a.m. and at noon (#15) for refractory depression.
2. Compare antipsychotics to optimize matching, such as Stelazine 2mg in AM vs. Risperdal 1mg: 1-2 in AM vs. Zyprexa 5mg at bedtime.
3. Compare anticonvulsants such as Depakote 250mg three times daily (#15) vs. Neurontin 300mg three times daily (#15) vs. Lamictal 100mg twice daily (#15).
Posted by medlib on February 26, 2000, at 6:25:38
In reply to Re: Bangbangbang approach....a realtime example., posted by JohnL on February 26, 2000, at 5:09:06
JohnL-
Thank you so much for your prompt and illuminating reply to my query! I was afraid there would be little documentation--designing a study for such an approach seems logistically expensive and difficult. Would you mind if I shared both of your replies with my pdoc if I eliminated your "handle"? It is uncommonly generous of you to share your Rx Hx, so I will understand if you don't wish it to go any further than this board.
One reason this approach seems so intuitively right to me is my memory of the "light switch" reponse I had to Prozac when it first came out.
I think that if my pdoc won't agree to try this process, I may just go shopping for one who will.Your posts on any subject are always interesting; hope you'll also keep us up to date on your own saga.
Again, Many Thanks!
medlib>This a copy of what my pdoc wrote ....
Posted by medlib on February 26, 2000, at 6:48:14
In reply to Re: Bangbangbang approach--Many Thanks!, posted by medlib on February 26, 2000, at 6:25:38
Sorry for the UNINTENDED effect of the subject line above!
In reviewing my post, I didn't read all the way up to the subject line--. Please excuse me while I go put a cold compress on a red face.
medlib
Posted by JohnL on February 26, 2000, at 8:36:09
In reply to Re: OOPS!--Mea culpa, y'all, posted by medlib on February 26, 2000, at 6:48:14
By all means, if anything at all is helpful, please use it. For greater in-depth understanding, you might want to read the book "The Successful Treatment of Brain Chemical Imbalance". The first half is geared for the general public, while the second half is geared toward the physician. All of it is designed in a way to help the physician and the doctor walk through the process in a teamlike and orderly fashion. There are plenty of examples, tidbits, graphs, statistics, and tips that can be very useful for both the patient and the phsycian to make sense out of the seemingly senseless.
This is the end of the thread.
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