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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 7 of 7. This is the beginning of the thread.
Posted by Chris A. on May 6, 2000, at 14:56:52
Has anyone gone this route in treating an unstable mood disorder? My docs are suggesting implanting one, but I want to know as many of the pros and cons prior. Any comments would be appreciated.
Thanks,
Chris A.
Posted by SLS on May 6, 2000, at 23:44:03
In reply to Vagal nerve stimulation, posted by Chris A. on May 6, 2000, at 14:56:52
> Has anyone gone this route in treating an unstable mood disorder? My docs are suggesting implanting one, but I want to know as many of the pros and cons prior. Any comments would be appreciated.
>
> Thanks,
>
> Chris A.
Dear Chris,Unfortunately, I can't offer you any personal descriptions of experiences with VNS. I don't know anyone who has tried it.
I am interested as to why you feel you must head in this direction.
What do you mean by "unstable"?
How would you describe the major features of your mood states?
In what ways has your disorder interrupted your life?
Have you tried MAO inhibitors?
Have you tried ECT?
I guess my concern is that you may have overlooked some treatment strategies that you might want to consider before opting for a surgical implant. I am impressed with what I have seen so far regarding the efficacy of VNS. However, I'm not sure the reports generated by clinical trials pay as much attention to the negative aspects of this treatment as one would like. VNS has recently been approved to treat epilepsy.
- Scott
Posted by Chris A. on May 7, 2000, at 2:02:03
In reply to Re: Vagal nerve stimulation, posted by SLS on May 6, 2000, at 23:44:03
Thanks, Scott,
> I am interested as to why you feel you must head in this direction.
Relief hasn't been forthcoming. Right now I'm putting my hope in high dose Omega 3 fatty acids and Choline. I've almost given up on ECT. Monday will be my eighteenth treatment since the end of January.
The only other things, in my thinking, that I haven't tried are rTMS (not available in my part of the country) and ziprasidone, which isn't available yet.> What do you mean by "unstable"?
My diagnosis is mixed bipolar. I thought it was recurrent major depression until 1990 when Prozac caused a switch to hypomania followed by a really nasty major crash that I feel I've never recovered from.
My mood has been mostly depressed, but fluctuates a lot. There is more irritability than I care to admit to. My self esteem is low and my pDoc also has me diagnosed with avoidant personality disorder. Yes, I've always been a tad shy, but sometimes want to argue with that particular designation.>
> How would you describe the major features of your mood states?There's been a lot of obsession with suicide, but it's been eight years since my last serious attempt. The most respite there was from it was for a few months when I was on Prozac, which backfired.
>
> In what ways has your disorder interrupted your life?
I've given up professional aspirations. I'm afraid to volunteer to do anything for fear I won't be able to carry through. My family could use a bit of volunteering - like some meals. Fortunately I still have my wonderful family.
>
> Have you tried MAO inhibitors?Yes. Parnate was to activating for me. Years ago I believe I was on Nardil. I am taking a miniscule dose of selegiline now. ADs have a strong history of causing switching, so I have to be very careful.
> I guess my concern is that you may have overlooked some treatment strategies that you might want to consider before opting for a surgical implant. I am impressed with what I have seen so far regarding the efficacy of VNS. However, I'm not sure the reports generated by clinical trials pay as much attention to the negative aspects of this treatment as one would like. VNS has recently been approved to treat epilepsy.
Thanks for your concern. I hope you're right. Just a short list of what I can remember: Elavil, Triavil, Vivactil, desipramine, Prozac, Wellbutrin, Effexor, atarax, buspar, Ativan, Klonopin, Lamictal, Topomax, Lithium, Depakote, Tegretol, Clozaril, Zyprexa, Serzone, gabapentin, Resperidol, Seroquel, lightbox, perphenazine, ritalin, verapamil, nimodipine, buprenorphrine, exercise, cognitive therapy and a few others I haven't listed because it's past my bedtime and I don't remember what they were. T3 and T4 are always a part of my regimen, as I've had Hashimoto's thyroiditis and am hypothyroid. We keep the TSH low, and it tends to fluctuate widely, just like my mood. That makes me highly suspect something awry with the hypothalmus.
If you have any ideas I am definitely willing to listen. I'll pray that you'll find some answers in your search, too. At this time my brain feels so disorganized that I very much feel at the mercy of my docs. At least I have good ones that do care.
We do have medical friends who recently had a VNS implanted in their child with refractory seizure disorder. Before I make any decision I will definitely talk with them.Blessings,
Chris A.
Posted by SLS on May 7, 2000, at 9:24:52
In reply to Re: Vagal nerve stimulation, posted by Chris A. on May 7, 2000, at 2:02:03
> Relief hasn't been forthcoming. Right now I'm putting my hope in high dose Omega 3 fatty acids and Choline. I've almost given up on ECT. Monday will be my eighteenth treatment since the end of January.
The success rate of ECT is higher for melancholic and psychotic depressions than it is for atypical or bipolar depressions. It was certainly worth trying, since so many other treatments have been unsuccessful. Have you responded in any way at all? How have the electrodes been positioned: unilateral left, unilateral right, or bilateral?
> The only other things, in my thinking, that I haven't tried are rTMS (not available in my part of the country)
This has not shown itself to be as effective as it was initially thought it would be. I don't think you are missing out on any great opportunity. Mark S. George, MD of the Medical University of South Carolina was one of the earliest investigators of rTMS as a treatment for mood disorders. He became disappointed with it and is now one of the principal investigators of VNS. In a recent conversation with a friend of mine, he displayed a great deal of optimism about the treatment, and suggested it to her as an alternative to the many drug treatments she has tried without success.
> and ziprazidone, which isn't available yet.
Why are you considering ziprazidone (a neuroleptic antipsychotic similar to Zyprexa)? What component of your disorder would it address?
> My diagnosis is mixed bipolar. I thought it was recurrent major depression until 1990 when Prozac caused a switch to hypomania followed by a really nasty major crash that I feel I've never recovered from.
> My mood has been mostly depressed, but fluctuates a lot. There is more irritability than I care to admit to.
> My self esteem is low and my pDoc also has me diagnosed with avoidant personality disorder. Yes, I've always been a tad shy, but sometimes want to argue with that particular designation.Speaking for myself, my depressed state produces social inhibition. I tend to avoid social situations and feel inhibited when I am around people. This disappears completely when my depression remits, whereupon I become quite gregarious, outgoing, and self-confident.
> There's been a lot of obsession with suicide, but it's been eight years since my last serious attempt. The most respite there was from it was for a few months when I was on Prozac, which backfired.
> I've given up professional aspirations.
I'm very sorry. I guess I have too.
> I'm afraid to volunteer to do anything for fear I won't be able to carry through.
Ditto.
> My family could use a bit of volunteering - like some meals. Fortunately I still have my wonderful family.
This is a blessing.
> Yes. Parnate was to activating for me. Years ago I believe I was on Nardil. I am taking a miniscule dose of selegiline now. ADs have a strong history of causing switching, so I have to be very careful.
In what way did you find Parnate too activating? Was it simply insomnia? How much did you take and for how long?
Do you recall experiencing any improvement on Parnate? Nardil?
Nardil may be a good choice given that Prozac was helpful and that you experience social anxiety.Have you ever combined Parnate with desipramine?
How do you respond to stimulants? Which ones have you tried?
I am currently looking into the possibility of combining Parnate with either sulpiride or amisulpride. These two drugs are neuroleptic antipsychotics that at low dosages can be effective for treating depression. Zyprexa would also be a candidate to fill this role.
Actually, it might be a good idea to create several lists of the drugs or drug combinations you have tried.
1. Drugs that have produced an improvement, regardless of how much or how long.
2. Drugs that have produced a worsening of depression.
3. Drugs that have induced mania.
4. Mood stabilizers that have been beneficial.
4. Drugs that had no effect.
> Thanks for your concern. I hope you're right. Just a short list of what I can remember: Elavil, Triavil, Vivactil, desipramine, Prozac, Wellbutrin, Effexor, atarax, buspar, Ativan, Klonopin, Lamictal, Topomax, Lithium, Depakote, Tegretol, Clozaril, Zyprexa, Serzone, gabapentin, Resperidol, Seroquel, lightbox, perphenazine, ritalin, verapamil, nimodipine, buprenorphrine, exercise, cognitive therapy and a few others I haven't listed because it's past my bedtime and I don't remember what they were.
A treatment using a combination of drugs is most likely necessary to improve your condition. Any combination that you have not yet tried represents a brand-new treatment opportunity. There are many, many permutations of combinations of the drugs you have listed. It may be necessary to use at least two mood-stabilizers. It is a good idea to be taking the mood stabilizer most likely to prevent mania as you move through successive drug trials. Which mood stabilizer would you choose to fill this role? What do you think of Depakote or Zyprexa? Has lithium ever been helpful to you in any way?
> T3 and T4 are always a part of my regimen, as I've had Hashimoto's thyroiditis and am hypothyroid. We keep the TSH low, and it tends to fluctuate widely, just like my mood. That makes me highly suspect something awry with the hypothalmus.
What has Noa come up with?
> If you have any ideas I am definitely willing to listen.
I wish I were as optimistic for myself as I am for others.
It would be helpful to provide a more detailed description of your depressed state.
> I'll pray that you'll find some answers in your search, too.
Thank-you.
> At this time my brain feels so disorganized that I very much feel at the mercy of my docs. At least I have good ones that do care.
> We do have medical friends who recently had a VNS implanted in their child with refractory seizure disorder. Before I make any decision I will definitely talk with them.
Please post what you discover. How sad it is that a child must experience such a thing.
Sincerely,
Scott
Posted by Noa on May 7, 2000, at 13:33:36
In reply to Re: Vagal nerve stimulation, posted by SLS on May 7, 2000, at 9:24:52
Chris,
What does the endocrinologist say about not being able to stabilize your TSH? Maybe a consult with a different endo is in order? It could, as you say, be another endocrine disorder.
Posted by Chris A. on May 7, 2000, at 23:24:50
In reply to Re: Vagal nerve stimulation, posted by SLS on May 7, 2000, at 9:24:52
Scott,
You're gifted at asking good questions. My memory and cognition aren't too clear, so I won't get them all answered. I am going to save your suggestions for med lists to make up.We've been using mostly right unilateral electrode placements. Bilateral placement seems to really do a job on my memory. It is wierd, but the results seem to be better when one particular doc does the ECT. I sure hope he's on tomorrow. My response to ECT has been about 20% of what would be ideal.
The consultant I see every year or so thought ziprasidone would be promising as a mood stabilizer, having possibly fewer side effects than some of the competition.
Are you taking Parnate now? It switched me to hypomania. Why not try olanzapine in combination with it first rather than sulpiride or amisulpride? I have at least one local friend for whom it has been a miracle drug (olanzapine). I don't remember the specifics of taking Parnate, but know I did more than once and for for fairly lengthy periods. I also have a local friend who does fairly well on a Lithium/Parnate combo. She is very clearly a classical BP I.
Lately my depression has been pretty simple, as described in Jamison and Goodwin. That is not always the case, however. Sometimes I have gotten pretty desperate and gone out in high gear wanting to end it all, driving winding canyon roads far exceeding any safe speed and struggling with indecisiveness about suicide. Once a pDoc dx me with agitated depression - before we knew about the bipolar.
I'm a non-responder to Lithium - we certainly tried. It also complicated the thyroid picture. Lamictal is one mood stabilizer I'm willing to revisit, but I have to be careful with its AD effects.
We've tried all sorts of combos, but I'm sure there more out there. Hopefully I didn't suffer through probability and statistics many years ago for nothing!
Five a.m. comes early, so I'd better turn in.
God Bless,
Chris A.
Posted by Chris A. on May 7, 2000, at 23:39:18
In reply to Re: Vagal nerve stimulation, posted by Noa on May 7, 2000, at 13:33:36
Noa,
I haven't seen my endo for about five years. My pDoc has been following my thyroid, and he just adjusts the dose. My endo is one of the best docs in our area, (and the only endo within 250 miles). I'm a little hesitant to go see him because he has my bone density test results on record and I know they are not at all good. That would put him in a tough spot. Guess I'd better go take some more Calcium and D.Are you continuing to do well?
Blessings,
Chris A.
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