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Dr. Bob is Robert Hsiung, MD,
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Posted by Charlotte on March 13, 2002, at 19:31:03
I am currently taking 150 mg. WB 2 x day and Ritalin 2 x day (5 mg AM & 10 mg pm) for depression and potential ADD. I'm currently being evaluated for the ADD (I'm an adult). Anyway, I'm feeling tired STILL throughout the day and am wondering if anyone has had similar experiences with this combination or knows why I'm still tired -- shouldn't I have energy?
Have been taking Wellbutrin for about 9 weeks and Ritalin for maybe 6-7 weeks. Thanks.
Posted by TSA West on March 14, 2002, at 2:00:26
In reply to Wellbutrin Ritalin, posted by Charlotte on March 13, 2002, at 19:31:03
Some possible solutions:
1) Add a stimulating antidepressant like fluoxetine, reboxetine, or protriptyline.
2) Add a stimulant like Modafinil or Adrafinil.
3) Raise your dose to 450 mg of Wellbutrin.
Fluoxetine and Energy Levels:
"More than two thirds of patients with depression present with symptoms of fatigue, low energy, and listlessness. Because daytime sedation may be a concern in such patients, a "nonsedating" antidepressant should be considered. The authors examined the effects of fluoxetine on depression-related disturbances in energy. Data from seven double-blind, placebo-controlled clinical trials in 2,075 patients with major depression were retrospectively analyzed. The Hamilton Rating Scale for Depression (HAM-D) Retardation factor score (total of items 1, 7, 8, and 14) was used as the primary measure of energy improvement, whereas the HAM-D-17 total score was used to assess changes in overall depression. Elderly patients (aged 60 years and older) were included in the overall group and were also analyzed separately. In addition, a subgroup analysis was performed using the HAM-D Retardation factor score to categorize patients as having low (score < 8) or high (score >= 8) levels of retardation at baseline. Beginning at week 3, fluoxetine-treated patients experienced statistically significant reductions in their HAM-D Retardation factor score compared with placebo-treated patients. The reductions for the elderly subgroup were less than those for the overall population, but they were still statistically significant beginning at week 4. Patients in both the low and high baseline retardation groups improved significantly. HAM-D-17 total scores for fluoxetine-treated patients in all groups (total, elderly, high retardation, and low retardation) improved significantly compared with placebo-treated patients. These findings demonstrate that fluoxetine-treated patients experience an improvement in energy symptoms as their overall depression improves."
--Journal of Clinical Psychopharmacology, December 2000. "Changes in Energy During Treatment of Depression: An Analysis of Fluoxetine in Double-Blind, Placebo-Controlled Trials"
--------------------TSA West------------------
Posted by Charlotte on March 14, 2002, at 6:32:45
In reply to Re: Wellbutrin Ritalin » Charlotte, posted by TSA West on March 14, 2002, at 2:00:26
Thanks for your response and all the information. It seems like if I'm already taking Wellbutrin and Ritalin which both act like stimulants, would adding something like Modafinil be too much? I wonder if anyone has taken all of these drugs together.
> Some possible solutions:
>
> 1) Add a stimulating antidepressant like fluoxetine, reboxetine, or protriptyline.
>
> 2) Add a stimulant like Modafinil or Adrafinil.
>
> 3) Raise your dose to 450 mg of Wellbutrin.
>
> Fluoxetine and Energy Levels:
>
> "More than two thirds of patients with depression present with symptoms of fatigue, low energy, and listlessness. Because daytime sedation may be a concern in such patients, a "nonsedating" antidepressant should be considered. The authors examined the effects of fluoxetine on depression-related disturbances in energy. Data from seven double-blind, placebo-controlled clinical trials in 2,075 patients with major depression were retrospectively analyzed. The Hamilton Rating Scale for Depression (HAM-D) Retardation factor score (total of items 1, 7, 8, and 14) was used as the primary measure of energy improvement, whereas the HAM-D-17 total score was used to assess changes in overall depression. Elderly patients (aged 60 years and older) were included in the overall group and were also analyzed separately. In addition, a subgroup analysis was performed using the HAM-D Retardation factor score to categorize patients as having low (score < 8) or high (score >= 8) levels of retardation at baseline. Beginning at week 3, fluoxetine-treated patients experienced statistically significant reductions in their HAM-D Retardation factor score compared with placebo-treated patients. The reductions for the elderly subgroup were less than those for the overall population, but they were still statistically significant beginning at week 4. Patients in both the low and high baseline retardation groups improved significantly. HAM-D-17 total scores for fluoxetine-treated patients in all groups (total, elderly, high retardation, and low retardation) improved significantly compared with placebo-treated patients. These findings demonstrate that fluoxetine-treated patients experience an improvement in energy symptoms as their overall depression improves."
>
> --Journal of Clinical Psychopharmacology, December 2000. "Changes in Energy During Treatment of Depression: An Analysis of Fluoxetine in Double-Blind, Placebo-Controlled Trials"
>
> --------------------TSA West------------------
Posted by TSA West on March 14, 2002, at 8:20:40
In reply to Re: Wellbutrin Ritalin, posted by Charlotte on March 14, 2002, at 6:32:45
Though it might seem innocuous to add another stimulant, modafinil has been proven effective in ADHD symptoms. Adrafinil--the alternative-- is milder and easier to obtain.
> Thanks for your response and all the information. It seems like if I'm already taking Wellbutrin and Ritalin which both act like stimulants, would adding something like Modafinil be too much? I wonder if anyone has taken all of these drugs together.
Posted by fachad on March 14, 2002, at 10:32:23
In reply to Wellbutrin Ritalin, posted by Charlotte on March 13, 2002, at 19:31:03
Your dose of Ritalin is fairly low. Ask your pdoc if a higher dose might be more beneficial.
Also, if you can afford it, Concerta is by far the best way to take Ritalin. It's a very excellent timed release pill that you can take once a day and it lasts all day. It comes in 18 mg, 36 mg and 54 mg pills.
> I am currently taking 150 mg. WB 2 x day and Ritalin 2 x day (5 mg AM & 10 mg pm) for depression and potential ADD. I'm currently being evaluated for the ADD (I'm an adult). Anyway, I'm feeling tired STILL throughout the day and am wondering if anyone has had similar experiences with this combination or knows why I'm still tired -- shouldn't I have energy?
>
> Have been taking Wellbutrin for about 9 weeks and Ritalin for maybe 6-7 weeks. Thanks.
Posted by BLPBart on March 14, 2002, at 10:47:28
In reply to Re: Wellbutrin Ritalin » Charlotte, posted by fachad on March 14, 2002, at 10:32:23
I'm in the same boat as you. I'm an adult who has been on anti-depressants for a few years and is just now starting pstims for ADD. I am also like you in that I'm always tired, my depression was the kind that makes you really lethargic and unmotivated. On top of that my ADD is not the hyper kind, just the inattentive kind which can add to the unmotivated feelings. Anyway, if I were you, I'd talk to your doctor about increasing your dosage of the stimulant. You are on a very low dose and it's easier to try that at first then add a third drug to the mix. In my case I was originally on prozac and I had the opposite reaction to it that a lot of people have. I turned into a complete zombie on it-literally couldn't get out of bed and also had muscle and joint pain and some other bad reactions to it. That's why I switched to wellbutrin. On the wellbutrin alone I was also always tired (I'm on 300 mg/day of the SR). I have been trying a couple of different pstims to help with the ADD and as yet haven't really been able to find the right one to help with the ADD symptoms. As far as being tired, what I'm finding is that I still have a very difficult time waking up in the morning and getting started, but once I get up, have some coffee and take my meds, I feel pretty good for the rest of the day. One thing I had to do though was make a few lifestyle changes. For example, I was training in vain to keep up an exercise program by getting up in the morning and running before work. What I have had to admit is that is just not realistic for me because my mornings are so rough and now I'm trying to fit it in in the evenings. Much harder because I work full time, have a 7 years old, blah blah blah. However, I've found it easier to get in a few runs once in a while than to constantly be beating myself up because I slept in again... Anyway, good luck I know it's tough to get the meds worked out and I'm still trying too.
Posted by Libby Bonine on March 14, 2002, at 17:15:27
In reply to Re: Wellbutrin Ritalin » Charlotte, posted by TSA West on March 14, 2002, at 2:00:26
I've been dealing with this for awhile and have tried some of these solutions, as well as a couple of others. Here's my experience with them. My diagnosis is ADD and chronic major depression with agitation. Prior to starting any of the measures below, I was taking:
Wellbutrin SR 300 mg/day
Ritalin 60 mg/dayAt these doses, I was experiencing extreme daytime sleepiness, extreme lethargy, & occasional agitation (crying).
I was tested for hypothyroid disorder and was told my thyroid was normal - if anything, a bit hyperactive. Still, my doc recommended trying a "subclinical" dose of thyroid hormone. That stimulated me enough so that I wasn't sleepy during the day and felt good - for awhile. In time, however, I began to have a lot of difficulty waking in the morning - so much difficulty that most days I couldn't muster enough energy to take my meds off the nightstand. When I also began experiencing heart palpitations, I was taken off the thyroid medication.
Since then...
> Some possible solutions:
>
> 1) Add a stimulating antidepressant like fluoxetine, reboxetine, or protriptyline.This seems to be the best fix so far. I am currently taking fluoxetine 20 mg/day and it has made a noticable difference. I have more energy; the agitation has disappeared; & my mood has improved slightly. I still experience daytime sleepiness, though. I think I will eventually end up having to take more than 20mg/day, but since the heart palpitations, I have to be careful about taking more energizing drugs.
I'm starting to realize that daytime sleepiness may just be something I have to live with. I've found that exercise, even when I can only muster the energy & motivation for a few minutes each day, helps a great deal. A couple of short walks during the day and a few minutes of stationary cycling after dinner help keep me awake & functioning. However, exercise is tricky with my meds. I have to monitor my heart rate closely.
> 2) Add a stimulant like Modafinil or Adrafinil.
I didn't try another stimulant, but did try increasing my dose of Ritalin up to 80 mg/day. The extra 20 mg/day made me so sleepy that most afternoons I fell asleep sitting at my desk. Yet, in spite of the extra sleepiness, my problems with muscle rigidity & migranes grew. So the extra stimulant didn't help.
Reducing my dose did seem to help a bit. I now take 40 mg/day most days, but have permission from my doc to take up to 60 mg on days when I'm forced to work overtime. My preference is to take as little as I have to take in order to sustain concentration while I'm at work.
> 3) Raise your dose to 450 mg of Wellbutrin.
For me, this was worse than increasing Ritalin. 450 mg/day left me barely functional. Stupor would be a good descriptor. Also, my migraines got stronger, lasted longer, & the constant nausea was unbearable.
I experienced a little less daytime sleepiness when we lowered my dose to 150 mg/day from 300, but my mood became much more depressed, so I returned to my original dose of 300 mg/day.
My current meds:
Wellbutrin SR 300 mg/day
Fluoxetine 20 mg/day
Ritalin 40-60 mg/dayI feel good and function well. I still get sleepy during the day, but I expect my doc will tweak my fluoxetine dose a bit to see if I can tolerate more. My doc & I have discussed the possibility that in time I will end up on fluoxetine and Ritalin, with no Wellbutrin but for now, things are manageable, so I'm not rocking the boat.
Posted by michael on March 14, 2002, at 17:18:35
In reply to Re: Wellbutrin Ritalin, posted by BLPBart on March 14, 2002, at 10:47:28
I'm in the same boat as you two (charlotte & bart)
You might consider dexedrine in place of ritalin. I find it lasts a little longer (about an hour), and you may find it helps a bit more w/energy (as opposed to focus/alertness).
But as mentioned, 5 - 10 mg are pretty low doses... increasing the doses might be a good first step. I take 30mg ritalin, or 20mg dex...
Less than that has no effect for me... I could even nap after 20mg ritalin, or 15mg dex. YMMV
I'm considering trying an maio... that would require giving up the option of stims, which so far have been most helpful (wellbutrin also a little help).
Of course, if I do go that route & it works, I won't need/miss the stims... good luck
Posted by henryO on March 15, 2002, at 1:47:44
In reply to Wellbutrin Ritalin, posted by Charlotte on March 13, 2002, at 19:31:03
That really isn't all that much Ritalin. But when I an very depressed, sometimes even 40mgs of Ritalin won't effect me. I don't take any more than that then. I just acknowledge that for awhile I'll have to deal with a serious slump, maybe I try increasing something else, though. Ever tried Pindolol as an augmentation agent to an AD like Welbutrin? It works well for some people. (Like me)
Posted by BLPBart on March 15, 2002, at 3:25:43
In reply to Re: Wellbutrin Ritalin, posted by henryO on March 15, 2002, at 1:47:44
I'm starting to feel like I must be one of the walking dead. On top of the 300 mg/day of wellbutrin, I worked up to 30 mg/day of dexedrine spansules and I could still take an afternoon nap. My doc switched me to concerta, started at 36 mg/day then doubled to 72. At 72 I was a little edgy, but it still didn't keep me awake at night. All the while never feeling like they were having any effect on the ADD. I tried going up to 40 mg of dexedrine today (I feel better on it than the concerta) and I felt like maybe it was helping. I actually spent hours organizing my files on my computer - something that I've needed to do for years sohey, maybe it's starting to work! I'm just amazed at the dosages I'm on compared to most people and it hardly makes a difference as far as my sleepiness and lethargy goes.
Posted by Charlotte on March 15, 2002, at 4:55:11
In reply to Wellbutrin Ritalin, posted by Charlotte on March 13, 2002, at 19:31:03
Thanks for all the suggestions. I'm a little afraid of taking more WB because of the seizure warnings. I'm not opposed to trying a higher dose of Ritalin and will try that this weekend -- but because I'm 5'4" and 115 lbs., I'm wondering if body size matters in the amount one takes?
The only other med I've tried concerning depression is Prozac and that was 3-4 years ago. It made me totally flat-lined and blank. The ADD thing is a recent discovery, so this is all new to me.
I've been on the WB for about 9-10 weeks and can finally feel the depression lifting. And I do like what the Rit is doing for me mentally -- I take it and about an hour later can just concentrate on what I'm doing. My desk at work hasn't been so clear and organized in 3 years. Too bad it only last about 2.5 - 3 hours after that. But even during this, I'm tired. It's like a rollercoaster all day. At any point in the day I could lie down and nap. Instead, I smoke and drink coffee and, in the afternoon, eat chocolate. I have cut way back on the coffee though.
If this daytime sleepiness doesn't get any better in the next 30 days, I'm asking for something different / more. I did some reading on the Modafinil and it sounds so promising -- but I wonder if the doc would prescribe it w/o a diagnosis of narcolepsy. I'd be a little nervous in self-medicating with the adrafinil -- esp. since there are precautions regarding liver function.
The concerta sounds good too, except Bart says it didn't address his ADD which is important to me now that I've experienced a little focus and concentration on a regular basis. I guess I'll have to resign myself to experimenting for awhile as it sounds like pretty much the norm. If the depression and ADD and sleepiness could all be addressed, I'll bet that would feel wonderful.
Posted by michael on March 15, 2002, at 18:47:33
In reply to Re: Wellbutrin Ritalin, posted by Charlotte on March 15, 2002, at 4:55:11
> Thanks for all the suggestions. I'm a little afraid of taking more WB because of the seizure warnings.
Personally, I wouldn't worry too much about the seizures... Especially if, as you indicate below, the wb is helping. [I may be mistaken, but I think 400mg SR is the "max" dose, and some people - under the care of their doctor - take more.]
> I'm not opposed to trying a higher dose of Ritalin and will try that this weekend -- but because I'm 5'4" and 115 lbs., I'm wondering if body size matters in the amount one takes?
Again, I'm not 100% certain, but I am pretty sure that physical size is not that relevant... moreso your chemistry, and how your body/brain reacts to it.
> The only other med I've tried concerning depression is Prozac and that was 3-4 years ago. It made me totally flat-lined and blank. The ADD thing is a recent discovery, so this is all new to me.
I tried prozac, and for me all it did was make me a bit spacey, and nearly eliminate my short term memory - I'd go to another room (5 or 6 steps) and by the time I got their, I'd forgetten what I was going to get... & this could happen 3 - 5 times in a row, until I started either writing it down, or repeating it to myself until I actually had in my hand what I was going to get... I never really saw that side effect mentioned anywhere... except for 1 other person here at PB.
> I've been on the WB for about 9-10 weeks and can finally feel the depression lifting. And I do like what the Rit is doing for me mentally -- I take it and about an hour later can just concentrate on what I'm doing. My desk at work hasn't been so clear and organized in 3 years. Too bad it only last about 2.5 - 3 hours after that.
I find dexedrine lasts about an hour longer...
> But even during this, I'm tired. It's like a rollercoaster all day. At any point in the day I could lie down and nap. Instead, I smoke and drink coffee and, in the afternoon, eat chocolate.
I know what you mean, it sucks.
> I have cut way back on the coffee though.
> If this daytime sleepiness doesn't get any better in the next 30 days, I'm asking for something different / more. I did some reading on the Modafinil and it sounds so promising -- but I wonder if the doc would prescribe it w/o a diagnosis of narcolepsy.I doubt that would be a problem. If the doc were going to hesitate at prescribing something, it would be the ritalin or dexedrine. Modafinil is Much "safer" in respect to abuse, so usually not a problem.
> I'd be a little nervous in self-medicating with the adrafinil -- esp. since there are precautions regarding liver function.
> The concerta sounds good too, except Bart says it didn't address his ADD which is important to me now that I've experienced a little focus and concentration on a regular basis.Concerta is ritalin, just extended release, so 1 dose covers the time span that would normally require 2 or 3 regular doses. So it *should* help you in the same way (I say should only because you never know with meds... for me, it gave me headaches, even at comparably lower doses...)
> I guess I'll have to resign myself to experimenting for awhile as it sounds like pretty much the norm. If the depression and ADD and sleepiness could all be addressed, I'll bet that would feel wonderful.
Probably. Hope we all get to find out. Good luck.
Posted by michael on March 15, 2002, at 18:51:20
In reply to Re: Wellbutrin Ritalin, posted by henryO on March 15, 2002, at 1:47:44
> That really isn't all that much Ritalin. But when I an very depressed, sometimes even 40mgs of Ritalin won't effect me. I don't take any more than that then. I just acknowledge that for awhile I'll have to deal with a serious slump, maybe I try increasing something else, though. Ever tried Pindolol as an augmentation agent to an AD like Welbutrin? It works well for some people. (Like me)
If I were you, I'd see how dexedrine compares to ritalin for you... Might not be any better, but you never know. Good luck.
Posted by JohnDoenut on March 18, 2002, at 0:08:00
In reply to Re: Wellbutrin Ritalin, posted by Charlotte on March 15, 2002, at 4:55:11
I take these drugs and here's what I have to say for what its worth! :)
>The ADD thing is a recent discovery, so this is all new to me.
Read "Driven To Distraction" and "Answers to Distraction" to start.
I find that while stimulant meds can get you up, in the end you also later get tired from them. You can take more or just let it run through and then maybe youll feel better after that but maybe not.
> Instead, I smoke and drink coffee and, in the afternoon, eat chocolate. I have cut way back on the coffee though.
Good on cutting back. I suggest cutting back on sugar too. A lot! Also try to stop smoking! All of these things I believe contribute to fatigue (besides poor health!).
>on the Modafinil and it sounds so promising --Its results like any drug just depend on the individual.
>I'd be a little nervous in self-medicating with the adrafinil -- esp. since there are precautions regarding liver function.
>Right if you take if you need a baseline liver test before and then every few months.
JohnD
Posted by Charlotte on March 18, 2002, at 5:13:09
In reply to Re: Wellbutrin Ritalin » Charlotte, posted by JohnDoenut on March 18, 2002, at 0:08:00
> Good on cutting back. I suggest cutting back on sugar too. A lot! Also try to stop smoking! All of these things I believe contribute to fatigue (besides poor health!).
=============I agree! I should quit it all, especially smoking. But I've been self-medicating with these three things for YEARS. I can't imagine not smoking right now.
=============> I find that while stimulant meds can get you up, in the end you also later get tired from them. You can take more or just let it run through and then maybe youll feel better after that but maybe not.
=============I've felt that. But I'm tired even after I've taken the Ritalin and WB. I don't like the sleepiness all the time, but am pleased with the focus and potential for organization that I feel for a couple hours after the Ritalin.
=============Charlotte
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