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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 3 of 3. This is the beginning of the thread.
Posted by g_g_g_unit on August 26, 2009, at 22:34:30
Hey Scott -
i was going to attach these questions to another thread, but didn't wanna steer the focus away from anyone else, so thought i'd post them here - anyway, please excuse the clutter.
i'm seeing a new psychiatrist in a couple of days, and had a couple of questions which i hope you don't mind answering.
firstly, i won't bore you with the specifics, but were i to be diagnosed as having co-morbid bipolar disorder and/or presented with a mood stabilizer is there any which is more forgiving in terms of cognitive side-effects? even if i don't have BP, i really can't tolerate SSRI's/TCA's, and thought a mood stabilizer might be worth a shot - much of my depression presents itself as anhedonia/an inner 'emptiness'/concentration issues, which just ends up worse on most AD's.i read that Lamictal is actually becoming a popular treatment for depersonalization? does it offer a cleaner/more stimulating mechanism than the other mood stabilizers? i have found that my cognition improves significantly with things that affect acetylcholine, but that just makes the OCD worse.
secondly, do you have any advice about presenting a case for Parnate? i've found that most psychs seem to get uppity when i put in a direct request, or present evidence of background research, maybe due to my age (23). many are also pushing Effexor, which i do not want to take. i was on Nardil, which didn't really help my social anxiety; i also found the insomnia quite taxing, but it did eventually pass. to be honest, i have no good reason for quitting Nardil; i became cocky and thought i could manage on my own, so gave up due to (retrospectively) minor issues like bloating and fatigue. i am no longer seeing that psych anyway. i could say that Nardil did help me, which might be incentive for him trying Parnate, but don't want to appear fickle for having no reason for quitting it. ugh, sorry if that's a pedantic question, but i have found that self-presentation in these instances can often make or break a decision on their part ..
thank you and regards
3gu
Posted by SLS on August 27, 2009, at 6:39:58
In reply to question(s) for SLS, posted by g_g_g_unit on August 26, 2009, at 22:34:30
Hi.
Well. Where do we start with you? Ruling out SRIs and TCAs leave us with Remeron, mianserin, Wellbutrin, reboxetine, and maprotiline, and MAOIs as traditional antidepressants. Have you tried desipramine or reboxetine? As you know, desipramine is a TCA that works on NE, but doesn't touch serotonin. Reboxetine does the same thing as desipramine, but is not a TCA. I will state here that, although some people do respond to reboxetine, this seems to be a small minority. For some people, it does nothing more than produce anxiety or even worsen depression. Desipramine, on the other hand, has established itself over a great many years to be clearly effective.
Lamictal is often a very "clean" drug cognitively. It has a habit of affecting short term memory somewhat, but nothing that becomes impairing. For those cases that do experience cognitive side effects, they can be significant. However, one can try to reduce the dosage to try to find the lowest effective dose. For me, going to 300mg really messes me up. Then, at 200mg, my mind clears and I preserve the response. Lamictal is a drug that likes to tease people. You can feel a real improvement early in treatment with dosages as low as 50mg. Then the improvement disappears. It can then reappear upon dosage increases, but it doesn't "stick" until you arrive at a higher dosage threshold. Lamictal can also produce an improvement upon dosage reductions, which fools many people thinking that a lower dosage (below the threshold) is better than a higher dosage. Of course, the individual loses this temporary improvement and either stays there hoping it will return, or go even lower.
Depakote can exert antidepressant effect for a sizeable number of people, but usually for those who have bipolar disorder, perhaps bes for bipolar II. However, some people also experience a worsening of depression, but it is usually a mild to moderate worsening. It is worth trying this drug, in my estimation. Depakote is more likely to produce cognitive side effects than Lamictal. You just never know until you try. I experienced none at dosages as high as 3000mg. Any mental fog that appears early in treatment often disappears with time. I didn't gain any weight or lose any hair, but these things are possible with Depakote.
Trileptal is another mood stabilizer to look into. It is probably as effective as Tegretol, its sister drug, but is a lot cleaner with respect to cognitive side effects and the risk of blood cell abnormalities.
I had a mild improvement of depression with Topamax. I had no cognitive impairments with this drug, although it has a reputation as producing more than the other drugs, leading to its nickname of Dopamax. I found it cleaner than Lamictal. However, I started at a low dosage and raised it very gradually to only 100mg. This was done purposely as to avoid triggering cognitive impairments. It seems that if you don't trigger them by going up in dosage too fast, you can avoid getting them at all.
My titration schedule for Topamax.
Week 1 25 mg
Week 2 50 mg
Week 3 75 mg
Week 4 100 mgAlthough not traditional mood stabilizers, atypical antipsychotics can have antidepressant effects and prevent mania. Doctors are looking more and more at Geodon. Seroquel is actually approved by the US FDA for use in bipolar depression. Many people here have good luck with Abilify.
You do have alternatives.
What happens to you when you take TCA, SSRI, and SNRI?
- Scott
Posted by g_g_g_unit on August 27, 2009, at 9:50:42
In reply to Re: question(s) for SLS, posted by SLS on August 27, 2009, at 6:39:58
hey, thanks for your thorough response.
i find that SSRI's just leave me feeling quite numb, apathetic and sedate - the usual complaints, i guess - which ends up affecting how i function socially and professionally. i understand that i may need some kind of cognitive reorientation to cope with that state, but then again, i don't think SSRI's are the be all and end all; i'd rather try another solution. TCA's - i tried nortriptyline and amitriptyline in low doses for sleep. Amitriptyline helped sleep, but nortrip did not, so i can't say i really gave either a chance as an AD.
Remeron was in fact the worst ad for my anxiety once i went up to 30mg. 15mg helped with sleep, but left me feeling dopey. i was on it maybe a month. i could see how it could be a good augmenting agent, but i don't get much out of it as a standalone drug. i wonder if the terrible response i had on 30mg of Remeron means i am sensitive to NE, or is that overstating things? i have not tried Wellbutrin either. i thought it might just worsen OCD?
maybe it would be better to get back to you once i have a diagnosis. but i did want to get a heads up on mood Stabilizers in case they come up. to be honest, i kind of have my heart set on Parnate.
This is the end of the thread.
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