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Dr. Bob is Robert Hsiung, MD,
[email protected]Shown: posts 1 to 17 of 17. This is the beginning of the thread.
Posted by Spriggy on February 5, 2005, at 10:56:33
I don't know if the term agitated depression or hypomania fits here.
I've been extremely restless in my mind, uncomfortable and also extremely depressed. I can not take SSRI's- they make me worse. This is my doctor's conclusion after seeing me go from functioning but a little anxiety THEN (with Lexapro) utterly depressed and unable to function.
What would be a good choice for me? I have some Wellbutrin XL that was prescribed but am terrifie to even try it again ( i took it for 2 days).
I am wondering if I should ask for a mood stabilizer with the Wellbutrin.
I am beginning to realize I have no choice any longer but to be on some type of medicine.
I have two young children, a husband, a ministry, and am finding myself getting worse and worse.
I've done ALL the natural stuff; I exercise 50 minutes a day, eat well, get enough sleep, tried St. John's Wort, Sam-E, and 5 h-tp.
I take a good multivitamin and also Magnesium.
Any ideas?
Posted by Ritch on February 5, 2005, at 12:41:53
In reply to meds for agitated depression?, posted by Spriggy on February 5, 2005, at 10:56:33
> I don't know if the term agitated depression or hypomania fits here.
>
> I've been extremely restless in my mind, uncomfortable and also extremely depressed. I can not take SSRI's- they make me worse. This is my doctor's conclusion after seeing me go from functioning but a little anxiety THEN (with Lexapro) utterly depressed and unable to function.
>
> What would be a good choice for me? I have some Wellbutrin XL that was prescribed but am terrifie to even try it again ( i took it for 2 days).
>
> I am wondering if I should ask for a mood stabilizer with the Wellbutrin.
>
> I am beginning to realize I have no choice any longer but to be on some type of medicine.
>
> I have two young children, a husband, a ministry, and am finding myself getting worse and worse.
>
> I've done ALL the natural stuff; I exercise 50 minutes a day, eat well, get enough sleep, tried St. John's Wort, Sam-E, and 5 h-tp.
>
> I take a good multivitamin and also Magnesium.
>
> Any ideas?The WB might be really agitating for you. I'd give a tricyclic a shot. Nortriptyline is generally one of the most tolerable TCA's. It isn't real sedative or real activating. If you've got really bad insomnia you might want to use amitriptyline instead. Another idea is a combo of amitripytline + chlordiazepoxide (it used to be called Limbitrol-don't know if they still make it or not). When I first saw pdoc long ago for an agitated depression (which was probably a mixed bipolar state) they used Limbitrol (25mg AMI + 10mg CDP) + Doxepin 75mg (another TCA) at bedtime and it clobbered it pretty good. I also started lithium at the same time. If a different class of AD like a TCA boomerangs on you and makes you worse, then I would consider bipolar as the root cause. Hope this helps...
Posted by med_empowered on February 5, 2005, at 12:53:48
In reply to Re: meds for agitated depression? » Spriggy, posted by Ritch on February 5, 2005, at 12:41:53
hey there! Psychitrists are only now catching up with what we patients have known always: it isn't always as simple as depression OR mania; sometimes they overlap in various ways...this has been recognized in bipolar disorder (the creatively named "mixed state"), but has long been ignored in the not-so bipolar. Anyway, I would personally give a mood-stabilizer a try w/ an antidepressant. Since you're in a mental state with seemingly contradictory attributes, you may want to try the short list of antidepressants considered OK for bipolar disorder....this means that, unlike the last poster, I seriously recommend leaving TCAs alone, at least for now. Wellbutrin, Effexor, Celexa/Lexapro, etc. would probably be good first-line antidepressants. In terms of the mood-stabilizer, I'd go for Lamictal, since it's got antidepressant properties. I'd avoid antipsychotics or the antipsychotic/antidepressant combo Symbyax. Klonopin in the day and an occassional sedative at night may help, too. Good luck!
Posted by SLS on February 5, 2005, at 16:29:02
In reply to Re: meds for agitated depression?, posted by med_empowered on February 5, 2005, at 12:53:48
> hey there! Psychitrists are only now catching up with what we patients have known always: it isn't always as simple as depression OR mania; sometimes they overlap in various ways...this has been recognized in bipolar disorder (the creatively named "mixed state"), but has long been ignored in the not-so bipolar. Anyway, I would personally give a mood-stabilizer a try w/ an antidepressant. Since you're in a mental state with seemingly contradictory attributes, you may want to try the short list of antidepressants considered OK for bipolar disorder....this means that, unlike the last poster, I seriously recommend leaving TCAs alone, at least for now. Wellbutrin, Effexor, Celexa/Lexapro, etc. would probably be good first-line antidepressants. In terms of the mood-stabilizer, I'd go for Lamictal, since it's got antidepressant properties. I'd avoid antipsychotics or the antipsychotic/antidepressant combo Symbyax. Klonopin in the day and an occassional sedative at night may help, too. Good luck!
Hi.Here's a case where a thorough interview with the patient is necessary to come to a differential diagnosis. Is the illness an agitated unipolar depression, for which a TCA has the best chance of treating, or bipolar disorder, where a TCA is, by traditional thought, contraindicated?
I am not a doctor, and Spriggy has not described in much detail how the disorder manifests, but it sounds to me more like agitated unipolar depression than bipolar disorder mixed-state. Spriggy states that SSRIs make the depression worse. I guess it would be a good exercise to list specifically which SSRIs have been tried as well as Effexor. Perhaps Remeron would offer an alternative. Perhaps nortriptyline. Lamictal sounds like a good idea. If Spriggy were to enter an anxious suicidal state, I would look to the temporary use of Zyprexa. It can make a good bridge to the next treatment. Zyprexa possesses anxiolytic and antidepressant properties and is usually a rather clean drug in terms of cognition.
- Scott
Posted by Phillipa on February 5, 2005, at 17:31:49
In reply to Re: meds for agitated depression? » med_empowered, posted by SLS on February 5, 2005, at 16:29:02
What about all the side effects you read about with lactimal? Does it really make an anti-depressant work better? None thus far have worked for me, except the very first time Paxil l0mg, and then I quit it and it's never worked since. Oh, I forgot Luvox seemed to help, but then the "bad" pdoc {from my previous Posts} dc'd it. Fondly, Phillipa
Posted by med_empowered on February 5, 2005, at 18:28:18
In reply to meds for agitated depression?, posted by Spriggy on February 5, 2005, at 10:56:33
hey! The reason I recommend checking up on the short list of BP approved meds is that odd reactions to SSRIS and or hypomania/mania are more common in BP disorder; before trying out a tricyclic, which is more likely to cause such a reaction and/or cause, exacerbate a full-blown psychosis, it may be wise to try something like Effexor with a mood-lifting mood-stablizer like lamictal. Good luck!
Posted by Spriggy on February 5, 2005, at 20:44:37
In reply to Re: meds for agitated depression?, posted by med_empowered on February 5, 2005, at 18:28:18
Thank you everyone.
A little more info for medempowered;
I have tried ( in my lifetime) Zoloft, Paxil, and Lexapro.
All are SSRi's, all wigged me out. I took the Zoloft 7 years while pregnant for "depression" that was circumstantial ( son just diagnosed with autism, moved across the country, etc..).
It left me feeling like a zombie with NO emotion.
Paxil made me feel bizarre as well.
Lexapro made me the worst I've ever been. I've never been suicidal in my life.. EVER.
However, after about 2 and a half weeks on Lexapro, I began feeling SOO weird in my head. Hard to explain but it was like I had cotton in my brain, couldn't stop racing thoughts, felt SOO bizarre and extremely uncomfortable, and experienced the DEEPEST, DARKEST, depression ever.
I had to fight every minute of the day to literally not just kill myself. If not for thinking of my children and what effect my suicide would have on them (and my husband) I would definitely be dead right now.
It was some SERIOUS irrational thinking; even had a hallucination at one point.
I know this is not a typical reaction to something like Lexapro but when I saw the psych she said it "can" happen and told me she thought it was the medication.
I have tapered off and am now on day 6 with NO Lexapro. I am feeling better every passing day.
As a matter of fact, today I have felt almost totally normal and like "myself" all day long.
So I am now 100% convinced it was the Lexapro.
If I stay feeling this way, I won't need any medicine.
If I go back to the horrible depression, I know that I won't survive another go round with it and will have to get help.
SO.. I'm guessing I will need something other than an SSRI and a mood stabilizer.
My psych ruled out bipolar although my father (and his mother) are severely bipolar. My grandmother actually committed suicide 10 years ago because of her bipolar.
So it is a family history but I've never displayed any "mania" and up until this point, only have had brief times of depression but nothing life altering like this past episode.
I have concluded two things, Either:
1) I may be bipolar and just be mildly so and can function without meds regularlyOR
2) the medication induced some type of manic behavior (not a fun mania however) and I am not bipolar.
I will just have to wait this out and see how I feel I suppose.
Posted by Ritch on February 5, 2005, at 22:28:39
In reply to Re: meds for agitated depression?, posted by Spriggy on February 5, 2005, at 20:44:37
...
>I have tapered off and am now on day 6 with NO Lexapro. I am feeling better every passing day.
As a matter of fact, today I have felt almost totally normal and like "myself" all day long.
So I am now 100% convinced it was the Lexapro.
If I stay feeling this way, I won't need any medicine.
If I go back to the horrible depression, I know that I won't survive another go round with it and will have to get help.
SO.. I'm guessing I will need something other than an SSRI and a mood stabilizer.
My psych ruled out bipolar although my father (and his mother) are severely bipolar. My grandmother actually committed suicide 10 years ago because of her bipolar.
So it is a family history but I've never displayed any "mania" and up until this point, only have had brief times of depression but nothing life altering like this past episode.
I have concluded two things, Either:
1) I may be bipolar and just be mildly so and can function without meds regularly
OR
2) the medication induced some type of manic behavior (not a fun mania however) and I am not bipolar.
I will just have to wait this out and see how I feel I suppose.
There are people that are super-sensitive to SRI drugs. Some *maybe* "bipolar", but it wouldn't surprise me that they aren't really bipolar at all, but just exhibit these symptoms when exposed to SRI meds. There has been some genetic findings that show hypersensitivity that I've read here recently. Just because a new substance has been invented that can induce a mania in a person, shouldn't by definition result in a bipolar diagnosis in that individual. Substance-induced mania warranting a bp diagnosis isn't "correct" at this time (per the current DSM). There are psychiatrists that believe that *any* substance triggering a mania is doing nothing more than "uncovering" a latent bipolar disorder. I don't believe that is accurate.
Posted by olysi79 on February 6, 2005, at 2:08:52
In reply to Re: meds for agitated depression? » med_empowered, posted by SLS on February 5, 2005, at 16:29:02
Hey Scott,
I think you are right on this. Spriggy needs to document every single one and also look for a history of hypomania with a psychiatrist.I am BP II and have had these awful episodes.
Initially I had always assumed it was a unipolar agitated thing. the first time I ever tried an SSRI for a teary depression, I absolutely flipped and went into a mixed state. I still had no idea what had happened. Eventually When I went into a relatively stable state, I was able to tolerate SSRIS for my OCD a few years later. However, if anything that's mixed starts (an episode occurred in 04, my first in years), I have to be so careful or an SSRI will make me rapid cycle intensely (euphoria alternating with despair and anxiety) or a mix. Those mixed ones are hard to treat so like you said, Spriggy needs to take stock of everything that he/she has taken and look at individual reactions to each one. Hopefulyl everything will work out.
>
> Hi.
>
> Here's a case where a thorough interview with the patient is necessary to come to a differential diagnosis. Is the illness an agitated unipolar depression, for which a TCA has the best chance of treating, or bipolar disorder, where a TCA is, by traditional thought, contraindicated?
>
> I am not a doctor, and Spriggy has not described in much detail how the disorder manifests, but it sounds to me more like agitated unipolar depression than bipolar disorder mixed-state. Spriggy states that SSRIs make the depression worse. I guess it would be a good exercise to list specifically which SSRIs have been tried as well as Effexor. Perhaps Remeron would offer an alternative. Perhaps nortriptyline. Lamictal sounds like a good idea. If Spriggy were to enter an anxious suicidal state, I would look to the temporary use of Zyprexa. It can make a good bridge to the next treatment. Zyprexa possesses anxiolytic and antidepressant properties and is usually a rather clean drug in terms of cognition.
>
>
>
> - Scott
>
>
Posted by SLS on February 6, 2005, at 8:35:24
In reply to Re: meds for agitated depression? » SLS, posted by olysi79 on February 6, 2005, at 2:08:52
> I think you are right on this. Spriggy needs to document every single one and also look for a history of hypomania with a psychiatrist.
Spriggy now informs us that both parents are bipolar. Bipolar disorder is highly heritable. This information would extracted if the psychiatrist does his job properly in an interview. I don't know how this would affect the choice of an antidepressant. There is, however, such a thing as psychotic depression for which the delusions and psychosis exist without mania. Like agitated depression, nortriptyline would probably have a better chance of treating this condition effectively. It probably makes sense to have a mood stabilizer in place while evaluating different antidepressants because of the family history.
You, on the other hand, are unequivocally bipolar. SSRIs seem to destabilize you. I'm glad things are OK for you now. You don't want to rock the boat. Perhaps you can reduce the height of the waves by taking Depakote and further stabilize your condition. You might even be able to tolerate higher dosages of SRIs should it be necessary.
If your OCD seems refractory despite SSRI treatment, it might be interesting to try Anafranil with Depakote as a mood stabilizer.
Just to throw this out there, Zyprexa and Risperdal have been known to be helpful in treating OCD. They also act as anti-manic agents, and help treat psychotic depression as well. You may never want to opt to use these drugs, but I believe it is good to have this information to work with.
Keep posting. I'm sure others will propose better ideas. I would like to hear more from you.
- Scott
Posted by olysi79 on February 6, 2005, at 17:59:55
In reply to Re: meds for agitated depression? » olysi79, posted by SLS on February 6, 2005, at 8:35:24
"Perhaps you can reduce the height of the waves by taking Depakote and further stabilize your condition."
Hey Scott, I'm taking Trileptal right now, I may consider another one as Trileptal got rid of hypomanias but doesn't seem to help with depression. Bummer since it's such a clean med.
"If your OCD seems refractory despite SSRI treatment, it might be interesting to try Anafranil with Depakote as a mood stabilizer."
-SSRIs tend to really help with my OCD, thank god. I am curious about Anafranil though, it is the queen mother treatment for OCD."Just to throw this out there, Zyprexa and Risperdal have been known to be helpful in treating OCD. They also act as anti-manic agents, and help treat psychotic depression as well."
-You're right, I worship Zyprexa! That med has really helped to set things straight when things have gotten out of hand. The only problem is that I get Akathisia if I take an AP too long. I love them because they stop all of the stuff going on upstairs and really set you right. However, the Akathisia is god awful. I've heard that taking a med that increases dopamine availabilty can not only help with depression but also decrease some of those EPS symptoms. I've considered adding in Wellbutrin as I took it solo for over 2 years and did relatively well on it, even though it did tend to make me a bit more on the nervous side. That with my Paxil and Trileptal might be just the right recipe to keep me stabilized. Also, Wellbutrin may help me stop smoking and that I would love!
"Keep posting. I'm sure others will propose better ideas. I would like to hear more from you."-you have great ideas Scott! I will keep everyone informed on how I am doing. I hope you are doing well yourself.
Best,
Chris
Posted by SLS on February 6, 2005, at 19:16:10
In reply to Re: meds for agitated depression? » SLS, posted by olysi79 on February 6, 2005, at 17:59:55
> I've considered adding in Wellbutrin as I took it solo for over 2 years and did relatively well on it, even though it did tend to make me a bit more on the nervous side. That with my Paxil and Trileptal might be just the right recipe to keep me stabilized.
I think you might hit the bullseye with that recipe!
- Scott
Posted by Bill LL on February 7, 2005, at 8:40:08
In reply to meds for agitated depression?, posted by Spriggy on February 5, 2005, at 10:56:33
It sounds like you probably need norepinephrine in addition to serotonin. I felt too much aggitation when on an SSRI alone. But when I added a norepinephrine drug (Strattera), I felt more calm. I take 40 mg Lexapro and 60 mg Strattera.
You could try an SSRI along with a norepinephine drug such as Strattera or Ritalin. Or try a single drug that affects both serotonin and NE such as duloxetine or Effexor.
Posted by ravenstorm on February 7, 2005, at 20:55:16
In reply to meds for agitated depression?, posted by Spriggy on February 5, 2005, at 10:56:33
almost all meds that affect NE make my anxiety much worse, including WB.
Posted by Phillipa on February 7, 2005, at 21:20:16
In reply to Re: meds for agitated depression?, posted by ravenstorm on February 7, 2005, at 20:55:16
Remeron and Zoloft too. I'm on them now. Fondly, Phillipa
Posted by olysi79 on February 7, 2005, at 23:47:58
In reply to Re: meds for agitated depression?, posted by SLS on February 6, 2005, at 19:16:10
Thanks Scott!
I'm hoping this works :)
Chris> > I've considered adding in Wellbutrin as I took it solo for over 2 years and did relatively well on it, even though it did tend to make me a bit more on the nervous side. That with my Paxil and Trileptal might be just the right recipe to keep me stabilized.
>
> I think you might hit the bullseye with that recipe!
>
>
> - Scott
Posted by olysi79 on February 8, 2005, at 0:01:02
In reply to Re: meds for agitated depression?, posted by ravenstorm on February 7, 2005, at 20:55:16
Hey Spriggy, an NE drug might work if your NE receptors downregulate and aren't so sensitive. Wellbutrin makes me jittery qhenI take it too. I still love it because it makes me feel mroe optimistic and whatnot. Perhaps try adding Straterra in and use a benzo as needed or an antihistamine like Vistoril to help control anxiety.
Best,
Chris> almost all meds that affect NE make my anxiety much worse, including WB.
This is the end of the thread.
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