![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
[email protected]Shown: posts 9 to 33 of 33. Go back in thread:
Posted by Elizabeth on November 7, 2001, at 12:19:57
In reply to Re: Atypical Depression Actually Very Typical, posted by SLS on November 6, 2001, at 19:46:48
> That sounds good to me. It might be sort of like double-depression, where a major depressive episode lies on top of chronic dysthymia.
That's me!
> There are some doctors that subscribe to the idea that the course and presentation of mood illness for any one individual can be variable.
I think it's complicated. I posted (in response to you) elsewhere about this, just a few minutes ago: http://www.dr-bob.org/babble/20011104/msgs/83434.html
I would chart out the course of my depression except I'm afraid it would be really long and complicated! Basically I've had some problems all my life (attention deficit, generalized anxiety, and social phobia), episodic major depression started around age 10 or 11, had residual symptoms after the first remission (the residual and major depression got worse with each episode), PTSD at 17, panic disorder at 20, anhedonia-anergia at 21.
> Age 17-20: Chronic severe depression; atypical and melancholic features, severe social anxiety, depressed mood, minor impairments of concentration and memory.
Okay, this is where I get confused: atypical and melancholic at the same time? Or alternating? Mood-reactive or not?
> Elizabeth - In 1982, Fred Quitkin labelled my depression as unipolar "atypical reactive-type with endogenomorphic characteristics". At the time, the term "endogenous" was used as a synonym for "melancholic".
I think it still is in Europe. The mood-reactivity thing is hard to figure out. Atypical depression is always supposed to be mood-reactive, but other people I've met who have atypical depression say that they've hit some lows where they weren't mood-reactive, at least.
> I did experience depressed mood and some melancholic thoughts.
What do you mean by "melancholic thoughts?"
> Although, I was able to laugh and become animated at times, my depressive symptomology did not abate at all.
Mood-reactivity doesn't mean that the depression overall gets better -- just the depressed *mood*.
> This, combined with a criminally positive outlook, confused them both.
Criminally positive? < g >
> I think what they were really looking at was what is now recognized as typical of a chronic bipolar depression.
Which is...?
> I sometimes get the impression that your depression demonstrates both melancholic and atypical features. Perhaps it falls into Nierenberg's "neither" category.
I think it's more "both" than "neither." Really, the basic atypical signs and symptoms aren't there at all, but some of the *associated features* make it look more atypical.
-elizabeth
Posted by Sigolène on November 7, 2001, at 13:25:35
In reply to Atypical Depression Actually Very Typical, posted by SLS on November 4, 2001, at 10:30:05
What they say in this article is wrong because i've got atypical depression and i only react positively with tricyclics AD.
Sigolène
Posted by noa on November 7, 2001, at 18:52:48
In reply to Re: Atypical Depression Actually Very Typical » SLS, posted by Elizabeth on November 7, 2001, at 12:19:57
> Okay, this is where I get confused: atypical and melancholic at the same time? Or alternating? Mood-reactive or not?Elizabeth,
I think this is where the double depression idea really makes a lot of sense--ie, you can have a chronic atypical depression, with episodic major depression with melancholic features ocurring sometimes.Scott,
The way I've understood "mood reactivity" is consistent with what your doctors were observing--do you laugh at a joke, brighten at all to something someone says, even if just for a moment, as opposed to inability to laugh, smile respond at all, etc. It can be an extremely temporary reaction.
>
Posted by Adam on November 8, 2001, at 17:41:40
In reply to Atypical Depression Actually Very Typical, posted by SLS on November 4, 2001, at 10:30:05
Actually, the typicality of atypical depression has been mentioned a lot in the past few years. It's hard to call such a term a misnomer when it is also so intrinsically meaningless, though I do find myself even using it for lack of another word. Hopefully somebody will proclaim that we have dispensed with the typical/atypical dichotomy for good, and the rest will follow suit. I'm not holding my breath, though.
> Atypical Depression Actually Very Typical
>
> It's nice to see this in black-and-white (and some red):
>
> http://depression.about.com/library/printable/n082901.htm
>
>
> - Scott
Posted by Elizabeth on November 8, 2001, at 19:27:12
In reply to Re: Atypical Depression Actually Very Typical, posted by Sigolène on November 7, 2001, at 13:25:35
> What they say in this article is wrong because i've got atypical depression and i only react positively with tricyclics AD.
Tricyclics work far *less often* than MAOIs in atypical depression. Many studies have demonstrated this to be true. That doesn't mean they don't work at all, ever. They are a bit better than placebo -- I think the success rate for TCAs in atypical depression is about 50%, compared with 25-33% for placebo and 70-80% for MAOIs.
Have you ever taken MAOIs, BTW? If so, which one(s) and what happened? Also, can you tell us more about the characteristics of your depression (symptoms, course, comorbidity, etc.), and which TCAs have you tried that work?
I have known a few people who have atypical depression that responds to TCAs, and I'm curious as to what characterizes these depressions.
-elizabeth
Posted by Elizabeth on November 8, 2001, at 19:37:56
In reply to Re: Atypical Depression Actually Very Typical, posted by noa on November 7, 2001, at 18:52:48
> I think this is where the double depression idea really makes a lot of sense--ie, you can have a chronic atypical depression, with episodic major depression with melancholic features ocurring sometimes.
I have double depression. My dysthymia is more "typical" than chronic depression often is, but it is mood-reactive and I have a lot of anergia or lethargy, which can be part of atypical depression. I also have panic attacks.
I think that dysthymia is usually mood-reactive. (The degree of mood reactivity is one measure of the severity of depression.)
> The way I've understood "mood reactivity" is consistent with what your doctors were observing--do you laugh at a joke, brighten at all to something someone says, even if just for a moment, as opposed to inability to laugh, smile respond at all, etc. It can be an extremely temporary reaction.
Yes, That's what I think it means too. Or you can enjoy some basic things like food or sex. (People with atypical depression often "self-medicate" with food. I'm not sure if they use sex this way either -- but does anyone happen to know?)
-elizabeth
Posted by Elizabeth on November 8, 2001, at 20:55:23
In reply to Re: Atypical Depression Actually Very Typical » SLS, posted by Adam on November 8, 2001, at 17:41:40
> Hopefully somebody will proclaim that we have dispensed with the typical/atypical dichotomy for good, and the rest will follow suit.
I actually think that the distinction does have some relevance. It's one of the few leads we have on who will respond to which ADs. It may not survive in its present form, but I think it will continue to exist (and, I hope, become more refined until we've figured out the exact differences that are relevant).
-e
Posted by SLS on November 9, 2001, at 9:50:03
In reply to Re: Atypical Depression Actually Very Typical, posted by noa on November 7, 2001, at 18:52:48
Hi Noa.
> The way I've understood "mood reactivity" is consistent with what your doctors were observing--do you laugh at a joke, brighten at all to something someone says, even if just for a moment, as opposed to inability to laugh, smile respond at all, etc. It can be an extremely temporary reaction.
I guess I qualify, then. It must be difficult for doctors who have never experienced one kind of depression or another to express in words how it should feel. I can definitely laugh and become animated at times, except on my worst days. I even tell stupid jokes, which should be obvious to all. However, the overall "feeling" of depression remains unchanged. This would include things like perceived mental and physical energy, anhedonia, impaired concentration and memory, slow-thinking, etc. I think if my doctors at that time had done better than just ask if I feel less depressed at times, I would not have been confused by this. Since I can't know what someone else experiences when they say that their mood is reactive to positive experiences, I could only assume that they meant that they experienced an improvement of their depression in the same way that I do when I respond momentarily to drug treatment.Words.
- Scott
Posted by Elizabeth on November 9, 2001, at 12:55:45
In reply to Re: Atypical Depression Actually Very Typical » noa, posted by SLS on November 9, 2001, at 9:50:03
Scott --
I think that what you're describing would be considered mood-reactive depression. Mood reactivity means that your *mood* improves for a brief time (seconds, minutes, hours) -- not necessarily that the depression resolves completely. Remember that depressed mood is only one symptom of clinical depression.
From personal experience: I have non-mood-reactive depression and I don't *ever* tell jokes, laugh, etc. during a major depressive episode. I rarely even smile, and when I do it's pretty obvious to observers that it's forced. (I'm not very good at faking it.) Maybe someone here knows more about this than we do and can answer this question?
> Since I can't know what someone else experiences when they say that their mood is reactive to positive experiences, I could only assume that they meant that they experienced an improvement of their depression in the same way that I do when I respond momentarily to drug treatment.
What do you mean by that? ("momentarily?")
BTW...do your jokes get stupider when you're depressed? :-)
-elizabeth
Posted by noa on November 9, 2001, at 15:50:01
In reply to Re: mood reactivity » SLS, posted by Elizabeth on November 9, 2001, at 12:55:45
I kind of envision a continuum thing for mood reactivity---there is the momentary smiling at a joke at one end to more significant mood reactivity on the other, like the way kids or teens who are depressed might have better mood for a while in response to a change in the environment,etc. But even that doesn't mean the depression is gone.
I, too have double depression, and it is mostly mood reactive, less so during the acute episodes than during the chronic. Lately, I have been better, with some slumpy periods, but none of the serious episodes; even the dysthymia is mild.
Posted by SLS on November 9, 2001, at 18:07:57
In reply to Re: Atypical Depression Actually Very Typical » SLS, posted by Elizabeth on November 7, 2001, at 12:19:57
Sorry I took so long to get to this.
> I would chart out the course of my depression except I'm afraid it would be really long and complicated!
Maybe it would prove edifying to get a hold of a NIMH life-chart. I don't remember where to get one. You could try the U of Pitt Stanley site.
> Basically I've had some problems all my life (attention deficit, generalized anxiety, and social phobia), episodic major depression started around age 10 or 11, had residual symptoms after the first remission (the residual and major depression got worse with each episode), PTSD at 17, panic disorder at 20, anhedonia-anergia at 21.
I wonder if bipolar depression can overly dysthymia? I guess this would be difficult to differentiate from an incomplete remission of bipolar depression. It is possible, I think. A friend of mine suffers from unequivicol bipolar disorder. Her first major depressive episode occurred at age 18. It was severe and required hospitalization. ECT was employed, and the depression remitted. Supposedly, it is more common for a juvenile or adolescent bipolar to experience a manic episode first. I don't recall whether she did or not. She may have. I vaguely remember her describing a time prior to the depressive episode when she thinks she was hypomanic. Certainly, she did experience a manic episode later on, although it was not severe. Her sister is definitely bipolar I, having had several florid manic episodes, at least one of which required hospitalization. My friend did well on lithium for over 8 years. A new doctor told her that she didn't need it anymore, and it was tapered gradually. Within three months, a severe depression emerged. It was not mood-reactive, although she experienced reverse-vegetative symptoms. She was also suicidal. The reintroduction of lithium had no effect. She responded briefly to Nardil, Parnate and doxepin. Over the last 9 years, she has experienced two mood states: severe depression and dysthymia. Severe depression occurs when effective medications are discontinued (in search of a more complete response). Wellbutrin effectively resolves the severe depressive episode. She is left with a residual minor depression that has thus far remained refractory to treatment, including with mood-stabilizers. Lamictal and Topomax are somewhat helpful. She is not mood-reactive during the severe depressive episodes but is mood-reactive while dysthymic.
Bipolar depression can look like a mixture of atypical and melancholic. For me, my depression was more melancholic initially and grew more atypical later. My mood was not reactive. How can someone be both? If I weren't pressed for time, I would try to research it and try to produce details. I am interested to find out.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9893154&dopt=Abstract
"The cardinal clinical manifestations of major depression with melancholic features include sustained anxiety and dread for the future"
This was me.
I put together a post for someone else regarding bipolar I versus bipolar II symptomology. I came across a few things that indicate that bipolar depression can present as a mixture of melancholic and atypical. You might find a few of the links and quotes informative. Do you see any of yourself there?
I'm just poking at you with a stick. :-)
http://www.dr-bob.org/babble/20011104/msgs/83672.html
By the way, I came across a recent article that defined bipolar III as expressing mania only in association with drug intervention. If this is a separate entity of which I suffer, then it deviates greatly from bipolar II in that the manias can become severe and psychotic. Yours would qualify.
A quick note. My circadian rhythm is triphasic:
morning - better
afternoon - worse
evening - betterSort of like overlapping melancholic and atypical?
- Scott
Posted by Elizabeth on November 9, 2001, at 22:10:53
In reply to Re: Atypical Depression Actually Very Typical » Elizabeth, posted by SLS on November 9, 2001, at 18:07:57
> Sorry I took so long to get to this.
Eh, no problem.
> > I would chart out the course of my depression except I'm afraid it would be really long and complicated!
>
> Maybe it would prove edifying to get a hold of a NIMH life-chart. I don't remember where to get one. You could try the U of Pitt Stanley site.I actually have a big timeline showing the development of my symptoms, along with a list of things I've tried in chronological order. I give these to new pdocs when I have to move (which has happened unfortunately often lately).
> I wonder if bipolar depression can overly dysthymia?
It took me a while to figure out what that was. You mean "overlie," right? Yes, I think so.
> I guess this would be difficult to differentiate from an incomplete remission of bipolar depression.
The way you distinguish between dysthymia and residual depression is: if it was there before the major depression, it's dysthymia; if it only happened after a MDE, it's residual. I see no reason the distinction would be any different for bipolar depression.
I feel for your friend -- residual minor depression can really screw up your life, and it's often hard to treat, I think.
> "The cardinal clinical manifestations of major depression with melancholic features include sustained anxiety and dread for the future"
That could be any depression, I think -- I wouldn't say that those cognitions distinguish a melancholic episode from a nonmelancholic one.
> I put together a post for someone else regarding bipolar I versus bipolar II symptomology. I came across a few things that indicate that bipolar depression can present as a mixture of melancholic and atypical. You might find a few of the links and quotes informative. Do you see any of yourself there?
Uh, not really. Why?
> By the way, I came across a recent article that defined bipolar III as expressing mania only in association with drug intervention.
Yes, that's the definition I heard. I'm not convinced that a manic or hypomanic drug reaction automatically means you must be "bipolar," though. Also, I have had only one clear-cut mania, which was associated with the serotonin syndrome (on Effexor XR) so it might not "count" towards a diagnosis of "bipolar NOS." The other one was some jittery, wired, energetic feelings and irritability, which happened shortly after I started Paxil -- treating doctor said that it "could" be hypomania but never made a diagnosis.
> A quick note. My circadian rhythm is triphasic:
>
> morning - better
> afternoon - worse
> evening - betterHeh. I'm consistently worst in the AM.
> Sort of like overlapping melancholic and atypical?
The worst of both worlds. < sigh >
-elizabeth
Posted by SLS on November 10, 2001, at 7:29:03
In reply to Re: Atypical Depression Actually Very Typical » SLS, posted by Elizabeth on November 9, 2001, at 22:10:53
Hi Elizabeth.
I have been vascilating for quite some time regarding the issue of whether drug-induced mania indicates a bipolar diathesis. To answer this, it might be necessary to use a more detailed set of criteria to differentiate bipolar mania from other presentations of psychosis or hyperarousal that might look similar. For instance, it is not uncommon that corticosteroids produce mental aberrations that include psychosis. The word mania is also used. Is this a true mania or a psychosis that includes hyperarousal? I don't know.I thought that you had experienced multiple instances of mania. That you have not would seem to indicate that it is likely that the altered state that was produced in association with the SS was idiosyncratic of the syndrome and not indicative of a bipolar mania.
The reason I poked you with a stick was to have you look more closely at the possibility that your ailments include a bipolar diathesis, which would indicate a more thorough exploration of using multiple mood-stabilizers and other treatment strategies currently employed for treating bipolar depression. My gut feeling is that you are not bipolar. However, I would not rely on my gut for much more than an occasional indigestion of peanut butter.
Take care.
- Scott
Posted by Elizabeth on November 10, 2001, at 22:01:33
In reply to Re: Atypical Depression Actually Very Typical » Elizabeth, posted by SLS on November 10, 2001, at 7:29:03
> I have been vascilating for quite some time regarding the issue of whether drug-induced mania indicates a bipolar diathesis.
Me too. FWIW, there's no history of bipolar disorder in my family -- only unipolar depression (and some alcoholism on my mom's side).As I mentioned (I think), my parents have both had clinical depression, but it took different forms. My mom has had episodes of atypical depression, and I think she's the atypical depressive/maybe soft bipolar personality type, if you know what I mean: anxious, occasional situational panic attacks, generally very cheerful when not depressed but often oversensitive, needs a lot of sleep, uses "comfort foods" (ironically, she's much thinner than I am -- I think the bupe is making me hungry), etc. Sort of the "hysteroid dysphoric" type that Klein described (although I wouldn't say she's histrionic, she is bubbly and very emotionally expressive).
My father, on the other hand, is dysthymic. My mother used to say that you could always tell when he entered a room because of the black cloud that always hangs over his head. I don't know how it affects his appetite, but my chronic sleep problems are obviously inherited from him. He gets anxious about all sorts of things. He worries a lot about me and my sister, and my half-brother and half-sister (his two other kids) say he was like that with them too. He's often socially isolated; his life is his career, and he has few close friends. He shares a lot of my attentional traits, too -- sometimes he will sit and do one thing for hours, but other times he can't concentrate. He's often tired, which presumably has something to do with his trouble sleeping at night.
> To answer this, it might be necessary to use a more detailed set of criteria to differentiate bipolar mania from other presentations of psychosis or hyperarousal that might look similar.
Yes, I think so.
> For instance, it is not uncommon that corticosteroids produce mental aberrations that include psychosis. The word mania is also used. Is this a true mania or a psychosis that includes hyperarousal? I don't know.
FWIW: I have a friend who takes prednisone occasionally (ulcerative colitis) and has a family history of BP although he doesn't have it himself. He definitely becomes hypomanic on prednisone. (He also gets acne, and his face puffs up.)
> I thought that you had experienced multiple instances of mania.
Well, one definite mania, a couple of possible hypomanias.
> That you have not would seem to indicate that it is likely that the altered state that was produced in association with the SS was idiosyncratic of the syndrome and not indicative of a bipolar mania.
Yes, that's how I feel also.
> The reason I poked you with a stick
Feel free, but be warned that I sometimes poke back. :-)
> was to have you look more closely at the possibility that your ailments include a bipolar diathesis, which would indicate a more thorough exploration of using multiple mood-stabilizers and other treatment strategies currently employed for treating bipolar depression.
Thank you. I really appreciate that you've taken an interest in my problems. I can always use a second, third, fourth, ... opinion. When I was first hospitalized (at McLean), they pursued the bipolar possibility and tried giving me Depakote. That was after Nardil pooped out. What I was going through was really a state of hyperreactive mood -- a withdrawal symptom resulting from tolerance to the Nardil -- not hypomania, IMO.
> My gut feeling is that you are not bipolar. However, I would not rely on my gut for much more than an occasional indigestion of peanut butter.
I'd rely on your gut before I'd rely on most people's brains. < g >
BTW: I'd be interested in meeting you in person, if you are willing. Can you give me an idea of where you are geographically? I seem to recall something you said that made me think we might be neighbors....
-elizabeth
Posted by Adam on November 11, 2001, at 18:34:07
In reply to Re: Atypical Depression Actually Very Typical » Adam, posted by Elizabeth on November 8, 2001, at 20:55:23
Well, you may know best. From my own experience (I know: n=1 is not terribly reliable, but a p-doc I am familiar with non-professionally has corroborated some of my suspicions), the melancholic/atypical dichotomy just doesn't tell the whole story. In practice, all the doctors did pretty much the same thing anyway, regardless of what major sub-catagory they thougth I was: SSRI- >Another SSRI- > SNRI- > buproprion- > TCA- > and so on. I had one doctor tell me I seemed atypical (my having BDD was "clearly indicative" of this), while another said I was clearly melancholic. This was the last doc I had before my little stint in the hospital. Anyway, I responded very well to ECT and a MAOI, which I guess would also indicate that I am "atypical". So was the "melancholic" guy wrong? In the end, did it matter? Does "atypical" mean, effectively, MAOI-responder-in-most-but-not-all cases? If so, is the dx any help in the end? I don't see any answers. I honestly don't know what to make of it. What does appear clear is that there is a pretty common algorithm that many doctors follow, and they often to set this process in motion even from the first appointment, often without even the simplest of diagnostic tests. In practice, it seems many doctors don't pay much attention, really, to category, beyond the "unipolar" layer of the onion, and will send you out the door with a script for Prozac after a 15 minute chat. Prozac, as the "classic" SSRI, is purportedly good for both melancholic and atypical depressives, so, again, what is one to think? On paper it all feels so convincing, and there's certainly a substantial body of science to support the dichotomy, but in the "real world", the emperor starts to look pretty naked. It's enough to make one wonder if there is anything really there. I wonder what more studies, done by unregenerate skeptics, would reveal.
> > Hopefully somebody will proclaim that we have dispensed with the typical/atypical dichotomy for good, and the rest will follow suit.
>
> I actually think that the distinction does have some relevance. It's one of the few leads we have on who will respond to which ADs. It may not survive in its present form, but I think it will continue to exist (and, I hope, become more refined until we've figured out the exact differences that are relevant).
>
> -e
Posted by Katey on November 11, 2001, at 19:01:37
In reply to Re: Atypical Depression Actually Very Typical, posted by Adam on November 11, 2001, at 18:34:07
i'm extremely intrigued by this concept, i actually read this before i saw my pdoc and brought it up with him, but i kind of have a feeling hes stupid. very scientific i know, but he didnt know anything about it. i'm off to go read the other posted articles, and to look up the medical terms that i'm not familiar with so that maybe then i can intellectually participate in this concept.
Posted by Elizabeth on November 11, 2001, at 20:51:50
In reply to Re: Atypical Depression Actually Very Typical, posted by Adam on November 11, 2001, at 18:34:07
> Well, you may know best. From my own experience (I know: n=1 is not terribly reliable, but a p-doc I am familiar with non-professionally has corroborated some of my suspicions), the melancholic/atypical dichotomy just doesn't tell the whole story.
Oh, I agree that it doesn't tell the story. But (to mix metaphors) I think it's one piece of the puzzle.
> In practice, all the doctors did pretty much the same thing anyway, regardless of what major sub-catagory they thougth I was: SSRI- >Another SSRI- > SNRI- > buproprion- > TCA- > and so on. I had one doctor tell me I seemed atypical (my having BDD was "clearly indicative" of this), while another said I was clearly melancholic.
Jeez! They should get their story straight.
> This was the last doc I had before my little stint in the hospital. Anyway, I responded very well to ECT and a MAOI, which I guess would also indicate that I am "atypical".
ECT isn't supposed to work so great for "atypical" depression, and MAOIs are very broad-spectrum (IMO) and work for lots of different kinds of depression as well as social phobia, panic disorder, etc.
> Does "atypical" mean, effectively, MAOI-responder-in-most-but-not-all cases?
Atypical depression became associated with MAOIs because tricyclics didn't work well for it and those were considered the only choices at the time. (Amphetamine was still used -- that's not a new thing -- but it's less effective than ADs for depression.) MAOIs work for a lot of different things, as I said above -- including "typical" depression. As you know, the dangers of MAOIs have been widely exaggerated, so they have generally been considered a "last resort."
> If so, is the dx any help in the end?
I think it's somewhat predictive, although it may not work for one particular individual.
> I don't see any answers.
I think that the answers to these kinds of questions are going to be very complicated, if we ever find them.
> In practice, it seems many doctors don't pay much attention, really, to category, beyond the "unipolar" layer of the onion, and will send you out the door with a script for Prozac after a 15 minute chat.
Yes, I think so too.
> Prozac, as the "classic" SSRI, is purportedly good for both melancholic and atypical depressives, so, again, what is one to think?
Actually, SSRIs are supposed to be less effective than TCAs for melancholia, I think.
Like I said, it's just one piece of the puzzle.
-elizabeth
Posted by jzp on November 12, 2001, at 3:12:22
In reply to Re: Atypical Depression Actually Very Typical, posted by Elizabeth on November 11, 2001, at 20:51:50
A year after finding a med that worked (serzone), I am still trying to pull myself together after 2 years of severe atypical depression. One of the things I'm struggling with most is this incredible self-indulgent streak that I developed, thanks in large part to the mood reactivity issue. When I was so depressed, I felt desperate for whatever small thing would temporarily alleviate it-- I felt like I would actually *die* if I couldn't have that ice cream/book/cd/attention or whatever.
Now, though I'm mostly functional and doing a lot better by most measures, it's still an issue. If my mood slips just a tiny bit, I feel that same desperation. It's causing big problems with my SO. I make these demands on him because I feel this need to make myself temporarily feel better-- like if he goes home, I'll be in the scariest place all by myself and I will die. It's awful. I don't know how to make it better.
How have any of you dealt with this?
(Forgive me for putting this in this thread. If it's inappropriate, I can take it over to the Social side.)
-Jannette
Posted by Elizabeth on November 12, 2001, at 21:35:13
In reply to Re: Atypical Depression/Mood Reactivity, posted by jzp on November 12, 2001, at 3:12:22
> A year after finding a med that worked (serzone), I am still trying to pull myself together after 2 years of severe atypical depression. One of the things I'm struggling with most is this incredible self-indulgent streak that I developed, thanks in large part to the mood reactivity issue. When I was so depressed, I felt desperate for whatever small thing would temporarily alleviate it-- I felt like I would actually *die* if I couldn't have that ice cream/book/cd/attention or whatever.
I think that this kind of compulsive behaviour -- with food, drugs, sex, whatever -- is very common in depressions that are classified as "atypical." It might even be an essential feature of this syndrome. Many people with atypical depression have described experiences and behavioral responses like yours.
I think that atypical depression can be treated successfully with antidepressants (or sometimes, psychostimulants), and psychotherapy can help you get over the emotional scars that may remain as a result of the chronic depression. The support of family and/or friends is important, too, if your life has been disrupted as a result of the depression (I think that relationships can be particularly difficult for people with chronic atypical depression because they are so sensitive to rejection).
-elizabeth
Posted by sjb on November 14, 2001, at 14:32:16
In reply to Re: Atypical Depression/Mood Reactivity » jzp, posted by Elizabeth on November 12, 2001, at 21:35:13
Has anyone had a good experience with a MAOI for atypical depression other than Parnate? I tried Parnate and it increased my appetite. I call it "Parn-ate-a-lot". Please advise. Never tried any other ADs in the MAOI category 'cause was scared away by this one along with some other not insigificant side effects like dulled reaction time as I mentioned before. Feel like I need impatient somewhere - can't cope with the littliest of life stuff, work, marriage, social, etc. Don't want to be cooped up, however. Not on anything right now for more than week - want to die so bad.
Posted by Sparkboy on November 15, 2001, at 15:29:51
In reply to MAOI for Atypical other than Parnate, posted by sjb on November 14, 2001, at 14:32:16
> Has anyone had a good experience with a MAOI for atypical depression other than Parnate? I tried Parnate and it increased my appetite. I call it "Parn-ate-a-lot". Please advise. Never tried any other ADs in the MAOI category 'cause was scared away by this one along with some other not insigificant side effects like dulled reaction time as I mentioned before. Feel like I need impatient somewhere - can't cope with the littliest of life stuff, work, marriage, social, etc. Don't want to be cooped up, however. Not on anything right now for more than week - want to die so bad.
Hi, I have atypical depression too. Parnate worked perfectly for me, but quit after 3 months. That was many years ago. If you really have atypical depression, then you probably need an MAOI. Do be put off by your experience with Parnate; it is the most potent of the lot. I have tried all of them (US). Marplan is almost as stimulating; Nardil was mellower, but neither gave me the true AD effect I got with Parnate.
After many years of trials, I ended up on moclobemide, which I get by mail from Canada. It prevents the oversleeping and seasonal variations, though I get no true AD effect.
Anxiety is a very strong component of atypical depression. I get moderate anxiety control from a low dose of Neurontin (600 mg/day). For sleep, I take Ambien 2-3 nights a week.
Going inpatient might be just what you need. Find a teaching hospital at a university--they are generally up on the latest things and aren't afraid to medicate with an MAOI. I wasted years trying re-uptake inhibitors when what I really needed was an MAOI. Tricyclics, SSRIs, etc. are useless to me.
Anxiety is a terrible trap; you get so boxed in you can't even think. Give the inpatient thing serious consideration. You'll get all kinds of tests you might not on the outside.
Good luck.
--John
Posted by sjb on November 16, 2001, at 7:49:07
In reply to Re: MAOI for Atypical other than Parnate » sjb, posted by Sparkboy on November 15, 2001, at 15:29:51
John,
Thank you so much for your post. I'm printing it out to take to my next appt. Scared right now. Thinking more about what you said and willing to give Parnate a try again. Last time I was still on Topamax, also, so maybe that combo wasn't good for me. Doc told me I have to wait 'till December to start as was taking some Prozac up 'till Oct something. Any recommendations on the teaching hosptials? I'm on the east coast but would consider going ANYWHERE. By the way, if it worked well for you, why did you go off and how are you now?
Posted by Lorraine on November 16, 2001, at 10:33:14
In reply to Re: MAOI for Atypical other than Parnate » sjb, posted by Sparkboy on November 15, 2001, at 15:29:51
John:
This is Lorraine. I have atypical depression and have tried Parnate (too aggitating); Nardil (allergic reaction); Mocloebemide (too much anxiety even with Neurontin thrown in). My anxiety is low grade panic attacks. At this point, I am thinking about Marplan--would you please expand on what you have to say about Marplan? It is very difficult to find info on this drug. I know one woman who is one it and she says that she has the histamine (stuffy nose) side effect and sexual dysfunction. I'd really appreciate your views. I see my pdoc on Monday to decide on a new strategy.
Lorraine
> Hi, I have atypical depression too. Parnate worked perfectly for me, but quit after 3 months. That was many years ago. If you really have atypical depression, then you probably need an MAOI. Do be put off by your experience with Parnate; it is the most potent of the lot. I have tried all of them (US). Marplan is almost as stimulating; Nardil was mellower, but neither gave me the true AD effect I got with Parnate.
>
> After many years of trials, I ended up on moclobemide, which I get by mail from Canada. It prevents the oversleeping and seasonal variations, though I get no true AD effect.
>
> Anxiety is a very strong component of atypical depression. I get moderate anxiety control from a low dose of Neurontin (600 mg/day). For sleep, I take Ambien 2-3 nights a week.
>
> Going inpatient might be just what you need. Find a teaching hospital at a university--they are generally up on the latest things and aren't afraid to medicate with an MAOI. I wasted years trying re-uptake inhibitors when what I really needed was an MAOI. Tricyclics, SSRIs, etc. are useless to me.
>
> Anxiety is a terrible trap; you get so boxed in you can't even think. Give the inpatient thing serious consideration. You'll get all kinds of tests you might not on the outside.
>
> Good luck.
> --John
Posted by Sparkboy on November 17, 2001, at 16:24:06
In reply to Re: MAOI for Atypical other than Parnate, posted by sjb on November 16, 2001, at 7:49:07
> John,
>
> Thank you so much for your post. I'm printing it out to take to my next appt. Scared right now. Thinking more about what you said and willing to give Parnate a try again. Last time I was still on Topamax, also, so maybe that combo wasn't good for me. Doc told me I have to wait 'till December to start as was taking some Prozac up 'till Oct something. Any recommendations on the teaching hosptials? I'm on the east coast but would consider going ANYWHERE. By the way, if it worked well for you, why did you go off and how are you now?sjb,
Check out the Langley-Porter Institute at UC San Francisco. They are thorough and highly competent. They use a team approach where several residents and a team leader work on different cases with one team member assigned as your primary doctor. They do all kinds of tests and check for more mundane physical issues that can manifest psychiatric symptoms as well as EEG, MRI, etc., to address the psychiatric issue. It's possible to get a correct diagnosis much more quickly, compared to wasting several years with doctors in a home town. A correct diagnosis gives you a solid foundation for everything that comes after without the risk and guesswork of endless drug trials.
I went off Parnate because it quit working for me after 3 months. A very unusual experience; I felt a little disoriented at first, to be in such a sea of calm, after so many years of fighting to control anxiety. It only stabilized for 2-3 weeks after the AD effect first kicked in. Then I started having relapses. At first they were only for about 5 minutes once a week. These grew longer and more frequent over the 3 month period, like a mathematical progression. At 3 months, I crashed completely and went off the drug. Side effects weren't bad when it was working, but intensified when the AD effect failed. Retrials of Parnate would work for a while, but I'd crash sooner every time. The experience was still beneficial, however, showing me what I can and should feel like, and what my true capabilities are when unhampered. Such a positive response to a drug demonstrated the biological basis of my case, especially given the lack of a troubled background which the doctors told me is more often what they see.
Do not let my experience with Parnate discourage you. There are things to learn and benefits to be had from the experience, and people can have such different reactions to the same drug. I put more emphasis on getting a correct diagnosis.
Today my regimen keeps the worst at bay, but it's low-grade to moderate depression and varying levels of anxiety. Being out of the social and employment mainstream is my greatest concern, but I've found through experience that forcing it only makes matters worse. The anxiety creates a sense of alienation and unfriendliness; trying to fake it just adds a layer of phoniness. I have found that the signals I send out are most often behind my problems with people (which I'm no doubt exaggerating). Not feeling a positive center leads to constant second-guessing and insecurity, not a good thing for coping with the one or two jerks one must deal with daily in any work setting.
I don't worry about these things like I used to; Parnate restored a mental agility that eliminated failure in those awkward social moments. Things I used to obsess on became non-issues when depression was eliminated. That made it less personal. :-)
--John
Posted by Sparkboy on November 17, 2001, at 18:42:05
In reply to Re: MAOI for Atypical other than Parnate » Sparkboy, posted by Lorraine on November 16, 2001, at 10:33:14
> John:
>
> This is Lorraine. I have atypical depression and have tried Parnate (too aggitating); Nardil (allergic reaction); Mocloebemide (too much anxiety even with Neurontin thrown in). My anxiety is low grade panic attacks. At this point, I am thinking about Marplan--would you please expand on what you have to say about Marplan? It is very difficult to find info on this drug. I know one woman who is one it and she says that she has the histamine (stuffy nose) side effect and sexual dysfunction. I'd really appreciate your views. I see my pdoc on Monday to decide on a new strategy.Lorraine,
Yes, Parnate is a real kick in the pants. Many find the experience too harsh. Before ruling it out, I'd like to know how long you were on it. The first time I took it, it caused every feeling I was trying to escape. The first 10 days consisted of insomnia (3 hours sleep) and anxiety attacks. On the tenth day, the AD effect kicked in. It was like flipping a switch. Imagine your nervous system fouled with a black goo, and suddenly it's washed clean with a flood of hot, soapy water. I'll never forget it. I calmed down quickly and totally. If your agitation was part of this adjustment phase, then a legitimate strategy might be to add a short-term benzo, like Ativan, until the AD effect kicks in. I was on Klonopin when I did a retrial of Parnate one time. After the AD effect kicked in, I took the next dose of Klonopin (out of habit), and it about knocked me out. I stopped the Klonopin cold turkey and stayed off it after the Parnate quit working again. If you get nothing but agitation after 3-4 weeks, then it's probably not the one.
I found Marplan almost as stimulating as Parnate. When that effect peaked, I could feel it one night, off and on, trying to break through the depression, but it couldn't quite do it. Marplan is an old drug. It was taken off the market for a few years because of low sales and questionable effectiveness. I don't agree with this last, since different people often need a different biological key to knock out their depression. I would certainly give it a try. Marplan should be in the latest Physician's Desk Reference, or a kind pharmacist can give you a package insert. Searching MEDLINE or google.com might give some info.
Nardil at 90 mg/day was a bust. Nothing but a craving for sweets.
Speaking of side-effects, I have been fortunate to be able to tolerate most anything, and realize that for others this is often not the case. But, I do feel it important to put up with as much as possible during the initial adjustment period (up to say a month). Anxiety is not always obvious, even to a doctor (I conceal it quite well), and it's important to be in touch with what you're experiencing and keep the doctor informed. Unless you're prone to getting hooked, anti-anxiety meds are a legitimate tool for managing a temporary effect.
Last year, I tried tianeptine, a European anti-depressant. It is a serotonin re-uptake enhancer (serotonin depleter). When it didn't work, I went back to my previous low dose of moclobemide. The result was a severe anxiety reaction (something I didn't get from moclobemide before). This leads me to believe moclobemide exerts its regulating effect on me by keeping serotonin levels up. My first reaction to any MAOI is anxiety.
Moclobemide doesn't give me an AD effect, but lifts the grogginess enough to prevent oversleeping. I have found hours of sleep to be the key. Too much sabotages the anxiety, but leads to grogginess and leaden fatigue. Not enough can cause episodes of high energy and/or intense anxiety. I find this mood instability to be distinct from bipolar disorder, since bipolar meds do not affect it. It can be altogether vicious. I manage my sleep fairly well with Ambien a couple of nights a week.
Neurontin has been good for steadying things down. I don't feel an acute anti-anxiety effect, but it seems to stop that snowball effect of quick escalation when something unexpected comes up. Also controls that initial blast of anxiety on waking in the morning.
I will be so glad when doctors figure out atypical depression. On Parnate, I'd go right to sleep every night and wake up calm and refreshed every morning. It was that heaven known as normal.
--John
This is the end of the thread.
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