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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 10 of 10. This is the beginning of the thread.
Posted by Kathleen6674 on August 31, 2001, at 9:47:27
I keep reading all sorts of wonderful advice and information here about how combinations of meds have helped refine everyone's responses. Have any of you had a doc who didn't like combos of meds? Mine doesn't seem especially keen on them - I've been jumping from one med to another instead of piling them on, so to speak, over the past year or so. Does anyone have any advice for working with a doctor who doesn't like to combine meds? Or should I get a new doctor or what? Are there different "schools" of psychopharmacology? I do think that part of his reluctance is that my dosage often gets adjusted, and hence he doesn't want to make more than one change at a time, i.e., if we up a dosage AND add a med, then I get bad side effects, how would we know if it's the new med or the increased amount of the old one? But I'm still curious about the one-at-a-time camp vs. the combination camp, if indeed there are competing "schools" of med management.
Posted by jojo on August 31, 2001, at 11:05:28
In reply to Doc doesn't like cocktails, posted by Kathleen6674 on August 31, 2001, at 9:47:27
> I keep reading all sorts of wonderful advice and information here about how combinations of meds have helped refine everyone's responses. Have any of you had a doc who didn't like combos of meds? Mine doesn't seem especially keen on them - I've been jumping from one med to another instead of piling them on, so to speak, over the past year or so. Does anyone have any advice for working with a doctor who doesn't like to combine meds? Or should I get a new doctor or what? Are there different "schools" of psychopharmacology? I do think that part of his reluctance is that my dosage often gets adjusted, and hence he doesn't want to make more than one change at a time, i.e., if we up a dosage AND add a med, then I get bad side effects, how would we know if it's the new med or the increased amount of the old one? But I'm still curious about the one-at-a-time camp vs. the combination camp, if indeed there are competing "schools" of med management.
Kathleen-Sounds like you have a very careful doc, possibly somewhat older. Textbooks from the '70s used to recommend against polypharmacy, but it is my impression that combinations are more common now, as the drugs used, even though they are used to treat the same condition, act in different ways (all of which are "poorly understood").
If you have 20 years or so to find the right drug and dose, your doc may be correct. In my experience, however, one never finds the ideal drug or combination, as the drug that you are taking is altering your neurological status, and your life situation is constantly changing, so that it is impossible to scientifically isolate the "ideal drug for you".
My advice, for what it's worth, is to try combinations, or look for a different physician.jojo
Posted by susan C on August 31, 2001, at 14:19:24
In reply to Re: Doc doesn't like cocktails » Kathleen6674, posted by jojo on August 31, 2001, at 11:05:28
Hi,
I too, have been overwhelmed by the number of different meds people take, as described on this board, but then, I realize, too, some things I do not have. For example, I do not have hallucinations, nor am I paranoid. I am starting a list of things I do not have !
I am very conservative, and so is my doctor, and want to see if anything works. I try one thing at a time. After trying antiseizure meds in order of least potential side effects and having dramatic, negative results, (within a week or two weeks)I have ended up with depakote. I messed around with the dosage and blood levels on that for 8 months. I am sincerely frightened to stop, because, even though it didn't help a lot, it helped some. And I dont want to go back to the way I was. (Depakote, interestingly, gave me very few side effects) and am now trying Keppra, in addition. These were all my decisions in consultation with the pdoc on what makes sense to try with light of his experience. I am not sure how I feel about Keppra. I am giving it a 'good go' as the pdoc says, but I cant seem to get over the wozzy tiredness. The only way I will know is to stop. There are so many things going on....I know some people just stop everything, because the meds make them feel so terrible, even though the emotional stuff is terrible too. So, what to do? What to do? I remind myself not to give up.
Yours in med land
Susan C.
Posted by JohnL on August 31, 2001, at 17:33:40
In reply to Doc doesn't like cocktails, posted by Kathleen6674 on August 31, 2001, at 9:47:27
> I keep reading all sorts of wonderful advice and information here about how combinations of meds have helped refine everyone's responses. Have any of you had a doc who didn't like combos of meds? Mine doesn't seem especially keen on them - I've been jumping from one med to another instead of piling them on, so to speak, over the past year or so. Does anyone have any advice for working with a doctor who doesn't like to combine meds? Or should I get a new doctor or what? Are there different "schools" of psychopharmacology? I do think that part of his reluctance is that my dosage often gets adjusted, and hence he doesn't want to make more than one change at a time, i.e., if we up a dosage AND add a med, then I get bad side effects, how would we know if it's the new med or the increased amount of the old one? But I'm still curious about the one-at-a-time camp vs. the combination camp, if indeed there are competing "schools" of med management.
I happen to be in the camp that likes cocktails. The reasons are because:
1. I think brain malfunctions are too complex to be completely fixed by a single agent, in most cases (not all). With single agent treatments, we don't often hear things like "I feel better than ever in my life", or "Wow!", or anything like that. Instead, we hear things like "I think it's working", or "I feel a little better", or "at least I'm not having crying fits any more", or "it's been 4 weeks already, how can I tell when it kicks in?" etc. You get the picture.
2. Cocktails can have counteracting side effects, which is good. For example, I take Prozac minimum dose plus Adrafinil minimum dose plus Zyprexa minimum dose. While Prozac is generally known for stimulation and weight loss, Zyprexa is generally known for sleep and weight gain. So the side effects cancel out. And while I felt about 80% better on that combo, I could still tell there was something not quite right. Maybe a little of that SSRI emotional numbness that we hear about. The addition of Adrafinil fixed that better than completely.
3. The different mechanisms of different drugs can potentiate each other, allowing one to actually do better overall with smaller doses. I feel better than ever in my life, and yet I am on minimum doses, have been for over a year with no sign of poopout or tolerance. The best part is that the side effects cancel out. I have no side effects to report, other than a bit of grogginess from the Zyprexa when I first wake up. Prozac alone gave me tons of side effects. Zyprexa alone gave me tons of side effects. Together they cancel out the side effects and simultaneously turbocharge each other.
If someone can do great with just one drug, then I am very excited for that person. But if they can't get completely well on just one drug, I have no problem at all in suggesting the cocktail approach.
If a doctor is unaware or unaccepting of the cocktail benefits I mentioned above, then personally I would try to bargain with him/her to bend for me, or find someone else. After all, you are the paying customer. You should get the kind of service you personally want.
John
Posted by Mitch on August 31, 2001, at 17:48:41
In reply to Doc doesn't like cocktails, posted by Kathleen6674 on August 31, 2001, at 9:47:27
> I keep reading all sorts of wonderful advice and information here about how combinations of meds have helped refine everyone's responses. Have any of you had a doc who didn't like combos of meds? Mine doesn't seem especially keen on them - I've been jumping from one med to another instead of piling them on, so to speak, over the past year or so. Does anyone have any advice for working with a doctor who doesn't like to combine meds? Or should I get a new doctor or what? Are there different "schools" of psychopharmacology? I do think that part of his reluctance is that my dosage often gets adjusted, and hence he doesn't want to make more than one change at a time, i.e., if we up a dosage AND add a med, then I get bad side effects, how would we know if it's the new med or the increased amount of the old one? But I'm still curious about the one-at-a-time camp vs. the combination camp, if indeed there are competing "schools" of med management.
That all depends on what your diagnosis is to a great degree and how long the doc insists you take something before switching to something else. I think bipolar and treatment-resistant unipolars have the highest degree of polypharmacy. One-at-a-time might be okay if your symptoms aren't that severe. Also, if you are quite *patient* with all of this then you will have a clearer idea of what med you respond the best to, *then* you can add-on something else to counter a side-effect of the efficacious med or to augment your response. But a lot of us aren't that lucky either due to sensitivies to side-effects or lack of response. Which makes a schema of more rapid switches/combos a necessity-see the Martin Jensen book posts.
Posted by Andre Allard on September 1, 2001, at 1:17:52
In reply to Doc doesn't like cocktails, posted by Kathleen6674 on August 31, 2001, at 9:47:27
I come across it all the time - inadequate dosages when disorder is not improving. My last hospital stay, which lasted four weeks, I began getting involved with other patients med regimen. I found that almost half the inpatients were not improving because they were stuck with a pdoc who was either young and inexperienced, from the old school and was way past their time or a conservative geek that titrated dosages twice a year and came to work late every day because they had to walk their twenty year old child to university, making sure that they get there safe and that they looked twice before crossing the road. I could not believe how many inpatients were suffering because their pdoc was an idiot. In some cases my sister (she is five) could have done a better job.
In my experience, out of the four pdocs I have been followed by over the past three years, only one was good to me, treated me with adequate dosages and actually helped me with my problems. That is the sad truth. And this problem is not only in psychiatry. When I was at college I saw the school doctor on a regular basis. He was semi-retired and I swear to God he must have been a 120. He was so old and out of date that he had not heard of any of the medications that I had been on or was currently taking. This includes the likes of celexa, paxil, effexor, trazadone, olanzapine, xanax. That is rediculous!
One day, while I was getting my perscription filled and explaining to the 180 year old doctor what SSRI meant, I asked him why he didn't know anything. His answer was "And you are here to teach me!" I said, "Sir, you havn't even heard of any of the medications I have taken. The newer antidepressants are the most commonly prescribed meds today and you don't know anything about them." To summarize what he said next he kicked my ass out of his office and told me never to come back.
If I could give you one peice of advice it would be to learn all that you can about your illness and psychopharmacology so that you can treat yourself.
Good luck!
Posted by shelliR on September 1, 2001, at 9:32:00
In reply to Doc doesn't like cocktails, posted by Kathleen6674 on August 31, 2001, at 9:47:27
> I keep reading all sorts of wonderful advice and information here about how combinations of meds have helped refine everyone's responses. Have any of you had a doc who didn't like combos of meds? Mine doesn't seem especially keen on them - I've been jumping from one med to another instead of piling them on, so to speak, over the past year or so. Does anyone have any advice for working with a doctor who doesn't like to combine meds? Or should I get a new doctor or what? Are there different "schools" of psychopharmacology? I do think that part of his reluctance is that my dosage often gets adjusted, and hence he doesn't want to make more than one change at a time, i.e., if we up a dosage AND add a med, then I get bad side effects, how would we know if it's the new med or the increased amount of the old one? But I'm still curious about the one-at-a-time camp vs. the combination camp, if indeed there are competing "schools" of med management.
I think Mitch offered you some good perspective here. Many of us on this board have long term major depression in which treatment has not been successful with one anti-depressant. But, I have a sister, for example, who has been on prozac on the last twelve years (I think it was the second AD she tried) and has had no need to explore further options. I would hope that your doctor would be open to adding a second medication if one is helping you, but not to the extent you would like.
If you are feeling that your depression is not being resolved to your satisfaction, I might go to another pdoc, at least for a consultation. You are under no moral obligation to tell your pdoc about a consultation (and actually if he is acting in a professional manner , he should understand the value of a second opinion if you do decide to tell him). A consult may clarify whether or not your pdoc is on the right course for you.
Again, this board may throw you off or point you in the right direction. Most people taking ADs are only taking one AD and tweeking the dose.
Shellli
Posted by Squiggles on September 1, 2001, at 17:41:15
In reply to Doc doesn't like cocktails, posted by Kathleen6674 on August 31, 2001, at 9:47:27
> I keep reading all sorts of wonderful advice and information here about how combinations of meds have helped refine everyone's responses. Have any of you had a doc who didn't like combos of meds? Mine doesn't seem especially keen on them - I've been jumping from one med to another instead of piling them on, so to speak, over the past year or so. Does anyone have any advice for working with a doctor who doesn't like to combine meds? Or should I get a new doctor or what? Are there different "schools" of psychopharmacology? I do think that part of his reluctance is that my dosage often gets adjusted, and hence he doesn't want to make more than one change at a time, i.e., if we up a dosage AND add a med, then I get bad side effects, how would we know if it's the new med or the increased amount of the old one? But I'm still curious about the one-at-a-time camp vs. the combination camp, if indeed there are competing "schools" of med management.
This is just a hunch I have - the greater
the number of meds prescribed for a condtion,
the greater the inability to treat the right
condition with the right drug. Secondly, many
drugs create so many side effects that other
drugs are necessary to treat them. And, one
more problem - if treatment is inaccurate or
the dose is wrong, a further drug is added to
correct an unrecognized problem.Polypharmacy more commonly compounds problems
rather than solve them. I think that luck
as well as skill and experience of the doctor
have a lot to do with hitting the mark.If I were to be cautious, I would choose an
older doctor, choose a pychiatrist or team
of psychiatrists (there is strength in numbers)
and rely on a conservative GP.Having said that, there is the matter of Luck.
Diagnosis is difficult without physical criteria.
Maybe things will change.Squiggles
Posted by jay on September 7, 2001, at 9:51:02
In reply to Doc doesn't like cocktails, posted by Kathleen6674 on August 31, 2001, at 9:47:27
I had that problem with two psychiatrists. So, I went and interviewed docs, and found a young family doc who is very willing to try anything (with cautions, of course). In fact, besides talking therapy, I see LITTLE difference between knowledge of psych meds between psychiatrists and regular family docs. In fact, it seems psychiatrists have all sorts of prejudice, preconcieved notions (as in, you can't mix this with that...even though billions of others are..).
My psych docs REFUSED to give me anything but antidepressants, and I am BPII!!! That WAS my problem, and THEY contributed to making it worse by giving me just antidepressants!Go to as many docs as needed, most importantly find one who cares, is sincere, and willing to do almost ANYTHING to help you get better. So many psych docs think they are GODS, and many can just be as much as an arsehole as anybody. There are also many good ones too....so again, just shop around. It IS your life..it is YOUR right!
Good luck..
Jay
> I keep reading all sorts of wonderful advice and information here about how combinations of meds have helped refine everyone's responses. Have any of you had a doc who didn't like combos of meds? Mine doesn't seem especially keen on them - I've been jumping from one med to another instead of piling them on, so to speak, over the past year or so. Does anyone have any advice for working with a doctor who doesn't like to combine meds? Or should I get a new doctor or what? Are there different "schools" of psychopharmacology? I do think that part of his reluctance is that my dosage often gets adjusted, and hence he doesn't want to make more than one change at a time, i.e., if we up a dosage AND add a med, then I get bad side effects, how would we know if it's the new med or the increased amount of the old one? But I'm still curious about the one-at-a-time camp vs. the combination camp, if indeed there are competing "schools" of med management.
Posted by Jane D on September 11, 2001, at 2:34:44
In reply to Doc doesn't like cocktails, posted by Kathleen6674 on August 31, 2001, at 9:47:27
> I keep reading all sorts of wonderful advice and information here about how combinations of meds have helped refine everyone's responses. Have any of you had a doc who didn't like combos of meds? Mine doesn't seem especially keen on them - I've been jumping from one med to another instead of piling them on, so to speak, over the past year or so. Does anyone have any advice for working with a doctor who doesn't like to combine meds? Or should I get a new doctor or what? Are there different "schools" of psychopharmacology? I do think that part of his reluctance is that my dosage often gets adjusted, and hence he doesn't want to make more than one change at a time, i.e., if we up a dosage AND add a med, then I get bad side effects, how would we know if it's the new med or the increased amount of the old one? But I'm still curious about the one-at-a-time camp vs. the combination camp, if indeed there are competing "schools" of med management.
Kathleen,
Have any of the drugs you tried worked even a little bit? One thing I've read is that a combination is justified when the first drug is working partially. I can't remember the sites where I read this but it makes sense. This is the way I was treated. I added another drug after the first one caused some improvement but not total recovery. If the first one had done nothing we would have tried another drug instead of the combination and we had already tried raising the dosage unsuccessfully. When the combination worked we tried removing drug 1 to see if drug 2 would work by itself. When it didn't we went back to the combo.There are different schools of thought but I think the use of combinations under the right circumstances is common now. If your doctor doesn't believe in combinations in any case I'd follow Shelli's suggestion of getting a second opinion. If he just feels that this is not a good idea for you ask him to explain why. He may have reasons (the dosage changes sounds like a good one).
Hang in there. I know how frustrating it is to go from one drug to another. It seems endless but it isn't really.
Jane
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