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Dr. Bob is Robert Hsiung, MD,
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Posted by Jost on September 24, 2006, at 18:55:23
In reply to Re: Time for Maoi -- Other stuff too., posted by bassman on September 24, 2006, at 16:49:02
Phillipa, Until today, you have said you were very interested in trying Emsam.
You've said this a lot, for the last month or two. And I think you have really meant it.
You've also said that luvox, while it worked well for you at a higher dose in the past, was not something that you could tolerate at therapeutic doses. I'm not sure of the history of the feelings and experiences you've had with luvox. However, more recently, you've said that benzos are the only meds you trust, and that luvox is one that you'd rather stop.
I support your taking Luvox, or Emsam, or any other AD or treatment that you think will help.
But, as Scott says, you need to take a clear direction, follow through, and see what happens.
I would only add that you need to take that direction and fight against all the second-guessing, revising your strategy in midcourse, and lowering the med again with out an adequate trial, only to find yourself stymied, and at a standstill.
Given the timing of these huge doubts, I have to ask: are you undermining yourself here? pulling the support out from under your determination to carry out a decision you've made?
If so, this is a dilemma that has emotional, and psychological underpinings. One that needs to be addressed, so that you can move forward.
Isn't Scott's suggestion of therapy, someone to talk to, to help you sort out your reactions, and your best interests, one that makes sense here? Even if you take Emsam, or take Luvox, there seem to be some issuess from your past that are getting in your way here. One that don't need to.
Jost
Posted by blueberry on September 24, 2006, at 18:59:37
In reply to Can't Take it AnyMore !!!!!!!!!!!!!!!!!!!!!!Help!!, posted by Phillipa on September 23, 2006, at 21:33:16
So sorry Phillipa! Darn I wish you felt well.
I like the idea of MAOI. But, in the STAR*D research program though, of people who got to the stage where it was time for an maoi only about 20% of them responded. Clinical studies show about 30% to 50% response. I don't know why they are touted so strongly at pbabble. Maybe real world experience is different than clinical experience.
All I can suggest is to look into classes of meds you haven't tried, even if they don't make sense. Actually, especially if they don't make sense. TCAs, stimulants, remeron, antipsychotics, depakote, lithium.
For me, it is ECT at the hospital beginning at 6:00 am. I predict it will either be real good or real bad. But meds have been real bad.
Posted by bassman on September 24, 2006, at 19:32:18
In reply to Re: Can't Take it AnyMore !!!!!!!!!!!!!!!!!!!!!!Help!! » Phillipa, posted by blueberry on September 24, 2006, at 18:59:37
Good luck, blueberry.
Posted by johnnyj on September 24, 2006, at 19:47:46
In reply to Re: Can't Take it AnyMore! - Time for an MAOI » johnnyj, posted by SLS on September 24, 2006, at 11:07:55
Well said Scott, you made me feel better :)
Hope is what we (I) have to cling to. I always try to remember that at one particular moment when I feel bad that that moment is not indicitive of what or who I am. The next moment quite possibly be better.
I cut my lithium dose about 5 weeks ago (pdoc ok this) and last night I didn't take the 300 mg. Today I had some very good moments. I don't know why but I think the lithium was causing some confusion, numbness, and probably other things. I will take it a day at a time and I hope Phillipa you do the same. You have much to live for and enjoy. You are young!
johnnyj
Posted by Phillipa on September 24, 2006, at 20:01:25
In reply to Re: Time for Maoi -- Other stuff too. » Phillipa, posted by SLS on September 24, 2006, at 16:05:30
Scott yes I've had all sorts of thryroid tests done. At the hospitalization time it was 22. Now it's between l-3 the new reccomentations.
It was night when I was given the first dose of luvox and they had us in recliners for relaxtion time. I waited for side effects cause I always got them. I wasn't in a doctor's office.
Well he did say I was catatonic scared me to death. Meds killed my Mother that's why I fear them. And yes in the hospital the doc proceeded to fix things for himself more than me as he didn't want the pdocs I worked with to think I still drank beer. (Last year he was in the New Bern news for the FBI raiding his office cause he overchaged insurance companies and was doing Ptsd testing on veterans and got them all disability). This was the pdoc the hospital I worked for sent all patients to see I had no choice. At first he was great did psychtherapy and had massage therapists for an hour massage before sessions. And after reading this site with poop out I do wonder if 300mg would work. Do You? Did I leave anything out? Love Jan
Posted by Jost on September 24, 2006, at 20:03:37
In reply to Re: Can't Take it AnyMore !!!!!!!!!!!!!!!!!!!!!!Help!! » Phillipa, posted by blueberry on September 24, 2006, at 18:59:37
Take care. blueberry.
Hope it goes well,Jost
Posted by Phillipa on September 24, 2006, at 20:04:04
In reply to Re: Time for Maoi -- Other stuff too., posted by bassman on September 24, 2006, at 16:49:02
So you still drink the beer? Love Jan
Posted by SLS on September 24, 2006, at 20:04:21
In reply to Re: Can't Take it AnyMore !!!!!!!!!!!!!!!!!!!!!!Help!! » Phillipa, posted by blueberry on September 24, 2006, at 18:59:37
Hi Blueberry.
> But, in the STAR*D research program though, of people who got to the stage where it was time for an maoi only about 20% of them responded.
Where can I find these results?
Thanks.
Good luck with your treatment!
- Scott
Posted by bassman on September 24, 2006, at 20:06:21
In reply to Re: Time for Maoi -- Other stuff too. » bassman, posted by Phillipa on September 24, 2006, at 20:04:04
Yes. Wellbutrin, Xanax, Prozac, Klonopin, and beer.
Posted by Phillipa on September 24, 2006, at 20:10:59
In reply to Re: Time for Maoi -- Other stuff too. Phillipa, posted by Jost on September 24, 2006, at 18:55:23
Jost I totally agree. I've tried a lot of therapists that will accept medicaire my only insurance and none want to relive the past. But I feel that to move forward the past has to be left behind and I can think all I want about it but need help in going through each stage. A lot of years. I clicked with one young girl in the ER. Unfortunately she was new to the area too and knew no one and she only works for the hospital. I've had some that only want to talk about religion or their meds. And one believe it or not a man who said Lucky Ducky. Two sessions out of there. And when people say interview a few first where do they get the money? And I've even asked about self=pay and they won't take it. Stupid. Love Jan
Posted by Phillipa on September 24, 2006, at 20:13:23
In reply to Re: Time for Maoi -- Other stuff too., posted by bassman on September 24, 2006, at 20:06:21
So where is this big taboo that pdocs have against drinking? Love Jan
Posted by Phillipa on September 24, 2006, at 20:36:25
In reply to Re: Can't Take it AnyMore !!!!!!!!!!!!!!!!!!!!!!Help!! » Phillipa, posted by blueberry on September 24, 2006, at 18:59:37
Blueberry good luck. Wish I had your e-mail to talk to you. Love Jan
Posted by Jost on September 24, 2006, at 20:51:20
In reply to Re: Can't Take it AnyMore !!!!!!!!!!!!!!!!!!!!!!Help!! » blueberry, posted by SLS on September 24, 2006, at 20:04:21
The following site has a summary of the most recent papers from STAR*D.
In one study, particpants who'd failed in trials of three prior ADs were given Parnate or a combination of venlafaxine and mirtazapine. The results weren't encouraging-- the responses (I assume remission rates) were 7% for Parnate, 14% for the combination, the differences not considered statistically significant. However, improvement on the scale they use was greater for the combination (about 25%) than Parnate (quite low, can't remember, could have been 4%).
They published several papers, but overall, apparently, non-responders don't do well after earlier rounds of the study.
http://69.41.173.145/ww/www.nlm.nih.gov/medlineplus/antidepressants.htmlJost
Posted by SLS on September 24, 2006, at 22:07:42
In reply to Re: Can't Take it AnyMore !!!!!!!!!!!!!!!!!!!!!!He, posted by Jost on September 24, 2006, at 20:51:20
> They published several papers, but overall, apparently, non-responders don't do well after earlier rounds of the study.
I guess we are just going to have to do better, then.
TRD is TRD. That's the bad news.
We have the advantage of using many more drugs in different combinations. I wonder how many more people would get well if they were to add low-dose lithium to their treatment (300-600mg). It is the forgotton miracle drug. Lamictal might be an alternative as an augmenting agent. We have a couple of people who found their miracle pill in Lyrica.
Do you see why it becomes such a good idea to bring as many drugs to market as possible, regardless of their similarity? Creating treatments for people with TRD is sometimes evidence-based and sometimes closer to alchemy. Clinical experience has demonstrated that an individual can respond quite disparately to different drugs within a class. The more SSRIs, the better, as long as it doesn't prevent or delay the development of novel drugs. Let the market weed out the duds. I'm amazed that Ludiomil (maprotiline) is still on the market. That's one drug I haven't tried yet. It's supposed to be a piece of crap, but obviously it works great for some people. I hope it stays on the market. It will give me one more ray of hope to keep me going if I near rock-bottom. That's the great thing about this whole thing - uncertainty. You can't be certain how you are going to respond to anything. There is always the chance that you will respond therapeutically to just about anything. That's the good news.
Where did you find the Parnate study?
- Scott
Posted by Phillipa on September 24, 2006, at 22:24:01
In reply to Re: Can't Take it AnyMore ! Bad news - Good news, posted by SLS on September 24, 2006, at 22:07:42
Scott that's the one TCA I took. One time only. For me it made me feel like I was in a dream during sleep. Next day I had to work I was a new nurse and the spaciness was there all day. I didn't need an ad then. I flushed them down the toilet. Love Jan ps so that means it will probably work for you
Posted by SLS on September 24, 2006, at 23:03:12
In reply to Re: Can't Take it AnyMore ! Bad news - Good news » SLS, posted by Phillipa on September 24, 2006, at 22:24:01
> Scott that's the one TCA I took. One time only. For me it made me feel like I was in a dream during sleep. Next day I had to work I was a new nurse and the spaciness was there all day. I didn't need an ad then. I flushed them down the toilet.
So, then, you haven't taken a TCA or a MAOI?
Gosh, you're practically a virgin!
Remember, sometimes the drugs that work best are the ones that make you feel weird when you first start taking them.
You have at least two worlds to explore: TCA and MAOI, and all of the combinations that can be crafted around them.
Since you have demonstrated responsivity to both Paxil and Luvox, I would remain hopeful that you will find another treatment that you will find effective. Somehow, I get the feeling that you have never had much of a coherent treatment plan in place. I don't doubt that you could revisit Paxil and recapture a response from it at therapeutic dosages that are higher than the 10mg that you took. I see your options increasing in number as we speak. So, now we know that there are a bunch of drugs that you have yet to try at therapeutic dosages for 4-6 weeks. This isn't meant to confuse you any more than you already are as it is to give you real reasons to have hope. Even if Emsam isn't the right drug for you, there are many options available to you, including adding drugs to the Emsam before giving up on it.
To me, it looks like we are dealing with MDD and GAD. Is this correct?
If it is, I would move to Nardil after Emsam.
By the way, why do you find Emsam more attractive than Nardil?
- Scott
Posted by notfred on September 24, 2006, at 23:26:27
In reply to Re: Can't Take it AnyMore ! Bad news - Good news » Phillipa, posted by SLS on September 24, 2006, at 23:03:12
> So, then, you haven't taken a TCA or a MAOI?
>Both are often considered more successful at treating more significant depressions and TRD.
> Gosh, you're practically a virgin!
Indeed there are lots of options; it does not seem many big guns have been tried yet.
Posted by Jost on September 24, 2006, at 23:44:49
In reply to Re: Can't Take it AnyMore ! Bad news - Good news, posted by SLS on September 24, 2006, at 22:07:42
The Parnate study and another study are in the Sept. 2006 issue of the American Journal of Psychiatry (AJP).
The Parnate study, authored by Philip J. Mcgrath, of New York State Psychiatric Institute, is "Tranylcypromine versus Venlafaxine Plus Mirtazapine Following Three Failed Anti-depressant trials for Depression." AJP 2006, 163, 1519-1543.
The second study compared triiodothyronine (T3) vs lithium for a current AD. T3 outperformed lithium on numbers, but the difference again was not statistically significant. However, more participants in the lithium wing dropped out.
The article was supposed to be available as of Sept. 1, although I haven't checked Medline or the actual AJP website.
A third study from July 1, 2006 compared patients who had failed in two trials, who were allowed to switch to nortriptyline or mirtazapine. The results were 20% response to nortriptyline, 12% for mirtazapine, not statistically signficant. That article is by Maurizio Fava of Mass. General.
Jost
Posted by Jost on September 24, 2006, at 23:54:04
In reply to Re: Can't Take it AnyMore ! Bad news - Good news » SLS, posted by Jost on September 24, 2006, at 23:44:49
To be more clear, the T3 and lithium were to boost an AD, presumably from earlier phases of the study, that was already being taken.
But the Star*d while a good start doesn't take into consideration the incredible complexity of individual response to ADs. It's the best study so far, but still the methods are necessarily crude. There are too many possible combinations, and so much must be based on evaluation of individual responses.
I'm with you on the great importance of as many available options as possible, until the biological substrate comes into focus, and/or much better treatments become available, and their uses understood.. Also that Pdocs need to think of treatments as tailored to individual responses, esp. in the case of TRD, rather than general formulas.
Jost
Posted by SLS on September 25, 2006, at 0:06:48
In reply to Re: Can't Take it AnyMore ! Bad news - Good news » SLS, posted by Jost on September 24, 2006, at 23:44:49
Thanks for the citations. Do you have access to the hard copies? Where do you go for them?
> The Parnate study, authored by Philip J. Mcgrath,
First name: Patrick
Good guy. Very accessable. I had a consultation with him about 5 years ago. He didn't have very much novel to offer me in the way of suggestions, but was very big on Parnate. He is quite active. I think his hobby is to study the genetics of affective disorders. That is not his area of investigation and authorship. Anyway, my doctor at the time thought highly enough of him to send a member of his own family to him. Dr. McGrath was actually the fourth doctor who I saw at Columbia Presbyterian, Columbia University / New York State Psychiatric Institute. They really don't know what to call themselves over there. They recently changed their name to New York Presbyterian because Columbia and Cornell merged their medical facilities. Weird.
- Scott
Posted by jaclinhyde on September 25, 2006, at 10:00:25
In reply to Re: Can't Take it AnyMore !!!!!!!!!!!!!!!!!!!!!!He, posted by Jost on September 24, 2006, at 20:51:20
From that same study.....
"Participants were randomly selected to receive either tranylcypromine (Parnate) alone or venlafaxine (Effexor) plus mirtazapine (Remeron). Parnate is an older monoamine oxidase inhibitor while Effexor and Remeron are newer medications.
"The idea is to try to get at the underlying problem by as many possible mechanisms as you can," McGrath said, of the drug combination chosen. "It's similar to the way you might treat cancer with a multi-drug regimen."
Parnate is used infrequently these days but has been effective in people who have not responded to other therapies.
People in the Parnate arm of the trial had remission rates of 6.9 percent and those in the combination arm, 13.8 percent, considered to be roughly comparable results.
"That looks like the combination was twice as effective but, in fact, those differences were not statistically significant," McGrath said."
All depends on how you read it my friend. There are good and bad studies out there for every drug. On the whole though the MAOI's really are the big guns and can work wonders for someone who has not responded to anything else....like Phillipa.
Hugs,
Terri
> The following site has a summary of the most recent papers from STAR*D.
>
> In one study, particpants who'd failed in trials of three prior ADs were given Parnate or a combination of venlafaxine and mirtazapine. The results weren't encouraging-- the responses (I assume remission rates) were 7% for Parnate, 14% for the combination, the differences not considered statistically significant. However, improvement on the scale they use was greater for the combination (about 25%) than Parnate (quite low, can't remember, could have been 4%).
>
> They published several papers, but overall, apparently, non-responders don't do well after earlier rounds of the study.
>
>
> http://69.41.173.145/ww/www.nlm.nih.gov/medlineplus/antidepressants.html
>
> Jost
Posted by jealibeanz on September 25, 2006, at 19:54:59
In reply to Re: Can't Take it AnyMore !!!!!!!!!!!!!!!!!!!!!!Help!! » Phillipa, posted by blueberry on September 24, 2006, at 18:59:37
Do physicians always have to follow Star-D?
I've been contemplating bringing up EMSAM to my doc for a while for depression.
I tried Paxil, Buspar, Wellbutrin, and Effexor. All caused a lot of weight gain and apathy. I don't want to try another SSRI/SNRI because I think it's very likely to happen again. TCA's are known to cause weight gain.
So, would be it be completely out of line to ask my GP about it? Since it hasn't been shown to cause weight gain or apathy (yet!).
I know I've asked this before... mannnyyy times... but this seemed like the appriate thread to reassess people's opinions and recommendations. :)
Posted by Phillipa on September 25, 2006, at 20:09:08
In reply to Re: Can't Take it AnyMore ! Bad news - Good news » Phillipa, posted by SLS on September 24, 2006, at 23:03:12
Scott well I'm not a virgin unless my kids are immaculate conception.
So you think paxil might work again? It really worked at l0mg the first time. And you've jarred my mind as that pdoc did raise it to 20mg after that hospitalization I told you about. That with xanax. He pulled me off it very quickly I think he thought I was getting high? Hard to remember so much time has gone by.
Yes MDD and anxiety number l symptom. And the reason EMSAM was so attractive to me was cause you can see it. And my thought was that if you had a side effect you could just rip it off and it would be gone. See I am very sensitive to all types of things. I tried mono contacts one time before depression made it home ripped it out as it drove me crazy seeing far in one eye and close in the other. Now I hear that it takes 9 days for it the EMSAM to leave your body. So many horrible side effects during perimenopause I couldn't stand them. Love Jan. Scott you are a scientist or my pdoc. How much do I owe you? Seriously.
Posted by Phillipa on September 25, 2006, at 20:13:39
In reply to Re: Can't Take it AnyMore ! Bad news - Good news » SLS, posted by Phillipa on September 25, 2006, at 20:09:08
Dr. Bob I'm not offering Scott money. Just to make it clear. Love Jan
Posted by Jost on September 25, 2006, at 20:26:52
In reply to Re: Can't Take it AnyMore ! Bad news - Good news » Jost, posted by SLS on September 25, 2006, at 0:06:48
Don't have hard copy, or access to it. The article isn't on Medline yet.
My library doesn't have a subscription to Am. J.Psychiatry, unfortunately. Undoubtedly the Medical School Library does, but I'm not doing anything that's caused me to get a card there, recently. I'm not sure how hard it would be to get a card (and online access), but maybe it's worth it now.
If you have access to a library system that gets that journal, and connects you online, which mine does, you could get to it online.
Probably will be on Medline's most up-to-date service in a while.
Jost
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