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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 8 of 8. This is the beginning of the thread.
Posted by nephron on May 9, 2004, at 9:35:26
I have a friend with depression- almost constantly since he was a child (6 or so). It's always there at least at a low level, but gets much worse from time to time.
He's taken sertraline/ citalopram and others from the SSRIs- none had any appreciable effect.
He tried Effexor but had projectile vomiting :(
He was taking moclobemide at 2x the recommended max. dose, which had no effect on the depression but was awful to get off.
Was taking Seroquel for sleeping and nightmares which seemed to be working pretty well but they took him off it because of the cost. He tried temazepam for sleep which made him groggy but didn't help with sleep.
He's currently taking lithium and sodium valproate. They don't seem to be having much of an effect but it's hard to tell.
He hasn't tried the tricyclics or MAOIs.
His psych seems unwilling to try new things- I was hoping some people here might have some suggestions to look into?
Sorry if this post doesn't make sense.
Thanks,
Sarah
Posted by King Vultan on May 9, 2004, at 10:23:35
In reply to Friend with long-term depression, posted by nephron on May 9, 2004, at 9:35:26
> I have a friend with depression- almost constantly since he was a child (6 or so). It's always there at least at a low level, but gets much worse from time to time.
>
> He's taken sertraline/ citalopram and others from the SSRIs- none had any appreciable effect.
>
> He tried Effexor but had projectile vomiting :(
>
> He was taking moclobemide at 2x the recommended max. dose, which had no effect on the depression but was awful to get off.
>
> Was taking Seroquel for sleeping and nightmares which seemed to be working pretty well but they took him off it because of the cost. He tried temazepam for sleep which made him groggy but didn't help with sleep.
>
> He's currently taking lithium and sodium valproate. They don't seem to be having much of an effect but it's hard to tell.
>
> He hasn't tried the tricyclics or MAOIs.
>
> His psych seems unwilling to try new things- I was hoping some people here might have some suggestions to look into?
>
> Sorry if this post doesn't make sense.
>
> Thanks,
>
> Sarah
>
The tricyclics work on a different neurotransmitter (norepinephrine) than do the SSRIs, have a rather different side effect profile, and are relatively cheap because they have been around for decades and are available as generics. There is a school of thought that people who have chronic, long term depression might do well to try an antidepressant that works on norepinephrine.A couple of tricyclics that I've tried are nortriptyline, which is somewhat sedating, and desipramine, which is more activating. These two drugs have the fewest side effects in the tricyclic class, but both can still cause constipation and dry mouth. I found the side effects somewhat annoying at times but still relatively manageable.
Beyond the tricyclics are the MAOIs, one of which (Nardil) I'm currently taking, but my opinion is that it's more conservative to try a tricyclic first. Your friend might also want to consider Wellbutrin, which works on yet another neurotransmitter (dopamine).
Todd
Posted by nephron on May 9, 2004, at 11:13:25
In reply to Re: Friend with long-term depression, posted by King Vultan on May 9, 2004, at 10:23:35
Apparently Wellbutrin isn't covered as an antidepressant under the Australian PBS (pharmaceutical benefits scheme) making the cost of it prohibitive... you can only get it govt. subsidised if you're using it as a stop smoking tool.
I'll have a look into it, though :)
Any other ideas?
Thanks!
Posted by Sad Panda on May 9, 2004, at 13:00:46
In reply to Re: Friend with long-term depression, posted by King Vultan on May 9, 2004, at 10:23:35
> > I have a friend with depression- almost constantly since he was a child (6 or so). It's always there at least at a low level, but gets much worse from time to time.
> >
> > He's taken sertraline/ citalopram and others from the SSRIs- none had any appreciable effect.
> >
> > He tried Effexor but had projectile vomiting :(
> >
> > He was taking moclobemide at 2x the recommended max. dose, which had no effect on the depression but was awful to get off.
> >
> > Was taking Seroquel for sleeping and nightmares which seemed to be working pretty well but they took him off it because of the cost. He tried temazepam for sleep which made him groggy but didn't help with sleep.
> >
> > He's currently taking lithium and sodium valproate. They don't seem to be having much of an effect but it's hard to tell.
> >
> > He hasn't tried the tricyclics or MAOIs.
> >
> > His psych seems unwilling to try new things- I was hoping some people here might have some suggestions to look into?
> >
> > Sorry if this post doesn't make sense.
> >
> > Thanks,
> >
> > Sarah
> >
>
>
> The tricyclics work on a different neurotransmitter (norepinephrine) than do the SSRIs, have a rather different side effect profile, and are relatively cheap because they have been around for decades and are available as generics. There is a school of thought that people who have chronic, long term depression might do well to try an antidepressant that works on norepinephrine.
>
> A couple of tricyclics that I've tried are nortriptyline, which is somewhat sedating, and desipramine, which is more activating. These two drugs have the fewest side effects in the tricyclic class, but both can still cause constipation and dry mouth. I found the side effects somewhat annoying at times but still relatively manageable.
>
> Beyond the tricyclics are the MAOIs, one of which (Nardil) I'm currently taking, but my opinion is that it's more conservative to try a tricyclic first. Your friend might also want to consider Wellbutrin, which works on yet another neurotransmitter (dopamine).
>
> Todd
>I agree with Todd, nortriptyline would be a good TCA to try if the SSRI's give no positive effect. Nort would help him sleep too.
"He's currently taking lithium and sodium valproate"
Is he Bipolar? Lamictal may be good to try too, but's it's more expensive than Valproate.Cheers,
Panda.
Posted by finelinebob on May 9, 2004, at 14:04:51
In reply to Friend with long-term depression, posted by nephron on May 9, 2004, at 9:35:26
Hey nephron
First of all -- good for you, doing this for your friend! You sound like the kind of friend we could all use.
Second of all, let me quote from Dr. Bob's disclaimer statement: "Don't necessarily believe everything you hear. Your mileage may vary." Especially YMMV. Your friend, your friend's doctor and you know more about his situation than we will, and we're speaking from what has and hasn't worked for us. Now...
Panda's comments raise one important question: do you know what his diagnosis is? That could have a big impact on what sort of advice people would want to give.
All the same, I'm another vote for suggesting tricyclics. I've been depressed at least since I was 8, so I fall in the same boat -- long term chronic depression. My pdoc had me go through just about every SSRI, and each of them ripped me apart in their own unique ways. Seems to me that if a med doesn't cure what ails you, then its ALL side effect and NO therapeutic effect. Apparently, my seratonin is doing just fine, thank you.
When he finally had me try nortriptyline, it was like night and day. Apparently, my norepinephrine is NOT doing just fine, thank you very much. I also tried desiprimine for a short time, but my response wasn't nearly as good as it was to nortriptyline.
From what I've read, King Vultan is right about Wellbutrin affecting dopamine, but I've also read it works more on seratonin and norepinephrine. As someone who has had some bad reactions to SSRIs, I'd say try something else. Wellbutrin hit me harder than any SSRI did. But, again, that's my personal experience.
Sounds like his pdoc is ONLY willing to try new things -- tricyclics and MAOIs are older classes of meds ;^). SSRIs are supposed to have such better side effect profiles, I think that can blind people to other choices ... I know MY pdoc was hesitant to try anything else, even though he'd been in practice for 30 years or so. So if your friend's pdoc isn't willing to consider a different class of meds, your friend should probably look for a different doctor. You didn't say how long he's been working with this doctor ... giving up what may otherwise be a good working relationship should not be taken lightly. Has your friend addressed this issue directly? I mean sitting down and saying flat out, "Seratonin-based meds aren't working for me. Look at my response to these meds if you want verification. Isn't it time we took a different approach?" If he doesn't feel that he can, if he doesn't think his doctor will accept this from him, then it IS time to head to someone else. Whether the doctor would actually respond that way or not isn't the issue -- what is the issue is that there's no trust in the relationship.
I see my pdoc more often than I see most of the people I consider my closest friends. I imagine the same may be true for a lot of people around here. It's an important relationship.
One last thing: documentation. Doctors can't make good decisions without reliable data. So, if your friend is having difficulty finding a med that works, try to get him to keep a meds journal, recording what he is taking and how it is affecting him. If he has records of what he has taken in the past, he should try to reconstruct this. For me, it took 2.5 years to finally get around to nortriptyline. That was 2.5 years of various altered states of mind, most of which weren't very pleasant. Of course, I found this out AFTER it all, when it finally occurred to me to chart what I had been through. When a doctor is seeing you once a month and all you have to share is some version of "I don't feel any better", it can be hard for that expert to pull together your reflections and his past session notes and see the big picture -- doctors are only human, too. The more data they have to work with, the better chance they have of coming up with the best course of treatment. It's in your friend's best interests to help his doctor out on this as much as he can.
take care (you and your friend both!)
flb
Posted by harryp on May 9, 2004, at 14:48:57
In reply to Friend with long-term depression, posted by nephron on May 9, 2004, at 9:35:26
From what you have said, it sounds like your friend is not bipolar, so I'm making that assumption with these suggestions:
I agree that it is time to try TCA's or MAOI's. It is a marketing myth that these drugs generally have worse side effects than the newer drugs. The older drugs often prove more effective, too.
I agree that Nortriptyline would be a good TCA to try.
I would recommend Trazodone for the insomnia.
A real MAOI (moclobemide doesn't count) might really make a difference as well. I would suggest a trial of Nardil if the TCA doesn't work. The dietary restrictions are usually more than worth the results.
Posted by nephron on May 9, 2004, at 18:28:19
In reply to Re: Friend with long-term depression, posted by harryp on May 9, 2004, at 14:48:57
In response to a couple of posts-
He was diagnosed bipolar a year or so ago, but that diagnosis has been changed to dysthymia with episodes of major depression.
Apparently his doc gets annoyed if he goes out and brings back suggestions :( which is pretty awful- but because he's in the public health system of Australia, it's really difficult to be able to change your psychiatrist.
One of the troubles with charting etc. is that his head is so fuzzy- he doesn't remember to eat half the time so I'm not sure how he can remember to chart reactions. I'll try to see if he can do that, though.
Thanks for all the help to everyone who posted :)
Posted by finelinebob on May 9, 2004, at 21:17:47
In reply to Re: Friend with long-term depression, posted by nephron on May 9, 2004, at 18:28:19
Fuzzy head means it's all the more important!
How about this -- IF your friend has a computer. Most calendar/planner programs allow you to set up an event and have it email yourself a reminder.
Pick a frequency (daily, MWF, weekly, whatever), a time of day that would work best (he's usually at the computer and usually has a few minutes to type), and set up the event to repeat for the next year.
If he has it together working on the computer, he could use it to keep his journal. He could even reply to the event reminder and email his entries to himself. I personally prefer writing in a blank book so I can carry it around with me, but keeping it on the computer works for others just as well.
cheers,
flb
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