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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 15 of 15. This is the beginning of the thread.
Posted by Racer on August 15, 2004, at 15:22:37
This is mostly academic, but I'm still curious, so thought I'd ask now, while it's still on my mind.
With all the talk of SSRI "poop out", it struck me that I'd never heard of TCAs losing their effectiveness. And then it occurred to me that I didn't know anything about long term effects of TCAs. Has anyone here taken any of the TCAs for long periods? If so, what were your experiences? Did it continue to be effective?
Specific to desimpramine, let's here those stories about its effect on your weight: did anyone gain weight? If so, how much? And, if so, have other A/Ds also caused you to gain weight, and was it more or less than on the desimpramine? Did desipramine cause you to feel sedated, apathetic, or emotionally numb? And did the effects on your mood change over time? What side effects did you experience on it?
Extra credit questions: for anyone who's taken a TCA, or MAOI for that matter, who has experienced problems with hypotension, did you try Florinef? If so, how was it? And, if not, did the hypotension resolve itself at all once you'd gotten through the adjustment period, or did it continue to be a problem? (And, how much of a problem was it?)
Basically, I'm looking for information that will help me both adjust to the idea of being medicated for life in the first place, and also to help in choosing the best medications for that long term treatment. If TCAs have a better long term track record than the newer drugs, and the hypotension can be mitigated or will resolve once I've adjusted to the medication, *and* they don't cause you to suddenly grow new limbs or something after several years, then that's the route I'm likely to explore -- once I get out of Dr EyeCandy's Treats Shoppe and into a private psychiatrist's office where there will be better resources for minimizing the adverse effects and treating both hypotension and weight gain.
Thanks, everyone!
Posted by linkadge on August 15, 2004, at 15:44:52
In reply to Questions about long term TCA (esp desipramine), posted by Racer on August 15, 2004, at 15:22:37
I think there is definately more long term experience with TCA's than there is with the newer AD's ie SSri's etc.
Generally, I believe that TCA's arguably are the gold standard of AD medication. It is true that you generally hear less about AD poop out.
I think that because of their broad spectrum activity they tend to induce less apathy. I knew of a few people who had been on TCA's for 20+ years and were urged to change to a newer AD by their docotors in hopes of reducing some of the potential hazards that TCA's can impose. After a full trial of several of the newer AD's the patients confess that the newer AD's have specific limitations and seem to work only 'half as well' as their older medication.
one thing that I believe owes to the increased effectivness of the older TCA's is the fact that they are generally better at activating the prefrontal cortex. The SSRi's can lead to prefrontal hypofunction over the course of months.
Linkadge
Posted by zeugma on August 15, 2004, at 19:39:41
In reply to Re: Questions about long term TCA (esp desipramine), posted by linkadge on August 15, 2004, at 15:44:52
I would take nortriptyline over the variety of more selective meds that I have tried over the years.
I remember my pdoc was in love with strattera, and urged me to drop nortriptyline in favor of it. Lowering nortriptyline brought back depression and I realized that the equation 'more selectivity=less side effects' is seriously flawed. It assumes that the newer meds are simply zeroing in on serotonin or norepinephrine or whatever and not doing anything else in the body. That proved not to be the case with Strattera, whose main metabolite, 4-hydroxyatomoxetine, was shown to be a kappa opiate partial agonist, resulting in fatigue and dysphoria for a lot of people, including myself.
The TCA's have been around for 50 years or so, so if they did anything of this insidious nature, it would long since have come to light.
Oh yes, I am growing another arm (j/k).
Posted by zeebop on August 16, 2004, at 5:55:29
In reply to Re: Questions about long term TCA (esp desipramine), posted by linkadge on August 15, 2004, at 15:44:52
> I think there is definately more long term experience with TCA's than there is with the newer AD's ie SSri's etc.
>
> Generally, I believe that TCA's arguably are the gold standard of AD medication. It is true that you generally hear less about AD poop out.
>
> I think that because of their broad spectrum activity they tend to induce less apathy. I knew of a few people who had been on TCA's for 20+ years and were urged to change to a newer AD by their docotors in hopes of reducing some of the potential hazards that TCA's can impose. After a full trial of several of the newer AD's the patients confess that the newer AD's have specific limitations and seem to work only 'half as well' as their older medication.
>
> one thing that I believe owes to the increased effectivness of the older TCA's is the fact that they are generally better at activating the prefrontal cortex. The SSRi's can lead to prefrontal hypofunction over the course of months.
>
> Linkadge
Hi,
I cannot agree more :
I took all 6 SSRis,Traz,Nefaz,Effex,Wellbut,Remer,Moclobemide,Tianeptine,Viloxazine,Reboxetine,Milnacipran..and all other "new" AD'd
I also took TCA's like Imipramine,Desipramine,Amitriptyline,Nortriptyilne,Maprotiline....etc and I think that Tca's are much more effective than all those new ones,especially for me (in this order) : Imipramine,Amitriptyline,Maprotiline and Nortriptyline
TCA's side effects diminsh quoqly with time,and they have instant relief from insomnia and anxiety,and most are effective in ADD,and unlike the SSRIs,are energizing+no sexual effects (Except Anafranil which is the only one that isvery similar to Effex and SSRis)Unfortunatly, I gained weight in ALL of AD's,but on TCA's weight gain is dose- related...but WG on newer AD's is accumelative and has no way of stopping it except terminatind the drug...so the soulotion to weight gain ? :
SELEGILINE : it is the most underated AD on the planet : in 5-10 mg it gives a very rapid response (increase in energy,motivation,positivity,concentration ) and NO APATHY OR WEIGHT GAIN...and if it makes you alittle anxious you could add a low- dose BZ,like Bromazepam (Lexotan)......
This is my limited experience I'll be glad to recieve commentsAll the best
Posted by BrittPark on August 16, 2004, at 9:34:28
In reply to Re: Questions about long term TCA (esp desipramine), posted by zeebop on August 16, 2004, at 5:55:29
I've been taking imipramine for 23 years more or less continuously, and though I've had breakthrough depressions it has generally just worked. The only long term problem with TCAs in general (as long as you can get along with the side-effects) is cardiotoxicity. This does concern me and I therefore get EKGs done fairly regularly and so far nothing dangerous has shown up. Mild tachychardia, increased rate of PVCs (palpitations) but nothing fundamentally damaging. My psychiatrist tells me that for certain heart disorders TCAs are in fact cardio-protective. I do have some concern for the future as I get older, but the benefits have so far outweighed the drawbacks.
BTW I have at various times tried paxil, remeron, and lexapro and all were decidedly uneffective for me. If ever my imipramine starts doing bad things to my heart I'm holding effexor, duloxetine, and any new multiple receptor acting ADs that come along, in reserve.
Posted by TheOutsider on August 16, 2004, at 9:49:03
In reply to Re: Questions about long term TCA (esp desipramine), posted by zeebop on August 16, 2004, at 5:55:29
Sorry if this is a stupid question!
I'm currently taking clomipramine but it doesn't seem to be doing much good.
Unfortunatly tiredness and ADHD are part of my problems, so I would have thought clomipramine would not be the ideal choice.
Posted by King Vultan on August 16, 2004, at 12:21:41
In reply to Questions about long term TCA (esp desipramine), posted by Racer on August 15, 2004, at 15:22:37
>
> Specific to desimpramine, let's here those stories about its effect on your weight: did anyone gain weight? If so, how much? And, if so, have other A/Ds also caused you to gain weight, and was it more or less than on the desimpramine? Did desipramine cause you to feel sedated, apathetic, or emotionally numb? And did the effects on your mood change over time? What side effects did you experience on it?
>
Desipramine acted as a relatively strong appetite suppressant for me, and I lost more weight than I have on any other med, even though I am not overweight to begin with. The only two ADs I've experienced weight gain on (which was fairly minor in my case) were Zoloft, due to an increase in appetite, and Nardil, due to some kind of metabolic thing. Desipramine was one of the more positive meds I've taken, being very good in the areas of emotionality and spirituality. After being atheistic or agnostic my entire life, I had a rather profound experience about ten days after starting desipramine that actually caused me to start believing in God. I've been off it for over six months now but still choose to maintain that belief. If MAOIs wind up not working out for me, this is probably the drug I would choose to go back on for the long term.As for side effects, I suffered dry mouth, constipation, moderate but not severe insomnia, urinary hesitation, hypotension, tachycardia, and probably some others I've forgotten. That all sounds bad, but this was actually the first AD I had tried that had few enough side effects for me to tolerate a full therapeutic dose of it (200 mg/day). The hypotension, especially of the orthostatic variety, was probably the most annoying side effect, and I have borderline hypertension to begin with. Well, at least I was able to drop my BP med while on the stuff.
Todd
Posted by Ilene on August 16, 2004, at 15:50:19
In reply to Questions about long term TCA (esp desipramine), posted by Racer on August 15, 2004, at 15:22:37
I've read that *all* ADs are subject to poop-out. It's certainly happened with everything I've taken.
I took desipramine for a year or so. I stopped when I was trying to conceive. I was depressed during my pregnancy, and when I started the desipramine again it didn't work. I don't know what would have happened if I had not stopped taking it. I tried it again last year and it didn't work. It might have been different if my pdoc had augmented it with Cytomel (T3), which is what we finally did with the MAOI I'm currently taking.
I don't think it affected my weight. The side effects were constipation (easy to deal with), postural hypotension (again, easy to deal with if you are used to it--just get up slowly and grab a piece of furniture), and dry mouth (this was the hardest to deal with, but now I know to carry sugarless hard candies with me).
I had good experiences with Prozac for several years, until I was under significant stress. I don't think I ever returned to that level of functioning.
I'm taking Florinef for another reason. I haven't experienced any side effects from it. It helps, but not completely. Sugarless electrolyte solution helps, too. I started having dizzy spells with a slightly higher dosage of Marplan (MAOI) but I think I am more acclimated now. I want to go higher again but I have to wait until I can see a new pdoc.
I think the dizzy spells were more of a problem for my pdoc than for me. I never passed out. I was just uncomfortable. I don't think my pdoc would have prescribed Florinef on her own. In my experience pdocs aren't very sophisticated with drugs.
I don't know if TCAs have a better track record in terms of effectiveness. They're not as safe as the SSRIs. I've read that MAOIs are better for atypical depression.I don't think there's any way to know ahead of time how a given drug is going to affect you. I actually find the side effects of an MAOI easier to deal with than other drugs I've taken. Dry mouth doesn't sound so bad, but it's with you all the time and can affect your teeth. My biggest problem is that I miss eating cheese. I had a cheeseless pizza last night and it was awful.
I reconciled myself to being on drugs for the rest of my life years ago. I just wish they worked better.
Posted by King Vultan on August 16, 2004, at 17:21:05
In reply to Re: Questions about long term TCA (esp desipramine), posted by Ilene on August 16, 2004, at 15:50:19
>
> I don't think there's any way to know ahead of time how a given drug is going to affect you. I actually find the side effects of an MAOI easier to deal with than other drugs I've taken. Dry mouth doesn't sound so bad, but it's with you all the time and can affect your teeth. My biggest problem is that I miss eating cheese. I had a cheeseless pizza last night and it was awful.
>
Mozzarella is generally considered to be okay for MAOI users, particularly if one is on Nardil or Marplan, which are not as apt to generate hypertensive crises as is Parnate. I ate tons of pizza while on high dosages of Nardil and never had the slightest problem, but I always made sure that the cheese was mozzarella only. It's some of the other things they put on pizza that are more of a concern, particularly, pepperoni.Todd
Posted by Ilene on August 16, 2004, at 19:56:37
In reply to Re: Questions about long term TCA (esp desipramine) » Ilene, posted by King Vultan on August 16, 2004, at 17:21:05
> Mozzarella is generally considered to be okay for MAOI users, particularly if one is on Nardil or Marplan, which are not as apt to generate hypertensive crises as is Parnate. I ate tons of pizza while on high dosages of Nardil and never had the slightest problem, but I always made sure that the cheese was mozzarella only. It's some of the other things they put on pizza that are more of a concern, particularly, pepperoni.
>
> ToddThis was a non-chain pizza joint that used Monterey jack and something else. I forget the "something else", but I knew the jack was risky. Why ruin a day's excursion with a trip to the ER, accompanied by spouse, 2 kids, and a teenage houseguest?
I'm not a big pizza fan anyway. I was trying to be a good sport, since this is a place we used to go when the kids were younger. Everything that I considered edible at this restaurant involved cheese, but the other choice in restaurants was Mexican.
I think the kind of pepperoni that Domino's and the other chains put on their pizzas is okay, since it bears the same relationship to aged sausage that chain-pizza cheese bears to real cheese. In other words, it's not actually aged.
I did quite a bit of research when I started taking Marplan. The most significant thing I read was that 80% of reactions are caused by cheese. (I don't know if that includes drugs or just food.)
I've actually done very well on Marplan, if you conveniently ignore the fact that I'm depressed, but my dose may be too low and I'm between pdocs. I've eaten at a variety of ethnic restaurants with no problem. Overall, I think the MAOIs are underprescribed.
Posted by chemist on August 17, 2004, at 17:52:26
In reply to Questions about long term TCA (esp desipramine), posted by Racer on August 15, 2004, at 15:22:37
hello racer, chemist here...i have recently become more familiar with the TCA class, and am far from being a fount of knowledge on this one (one might argue i am ignorant of everything, as an aside). i note that there are mixed reviews in this thread, and wanted to enlist the words of the posters who appear to be frequent commentators and/or long-term users about these meds. it is my personal experience with the MAOI parnate that it was/is an excellent anti-depressant, in the truest sense of the definition. the orthostatic hypotension was fleeting for me, and did not preclude my daily 50 km bicycle ride or trip to the gymnasium: i give it high marks, and it was (in concert with a low-dose benzo such as klonopin and later valium) exceptional at the 30 mg/day dose level (divided). my understanding of the TCAs is that - as King Vultan notes in a thread below - desipramine and protryptyline are the most ``activating'' ones, and i have read that nortriptyline exhibits a lower incidence of orthostatic hypotension than the 2 mentioned afore, although some baseline and semi-frequent blood testing are recommended, as for desipramine. in any event, i hope that folks more in the know than i can comment and get you straightened out on the quick....all the best, chemist
> This is mostly academic, but I'm still curious, so thought I'd ask now, while it's still on my mind.
>
> With all the talk of SSRI "poop out", it struck me that I'd never heard of TCAs losing their effectiveness. And then it occurred to me that I didn't know anything about long term effects of TCAs. Has anyone here taken any of the TCAs for long periods? If so, what were your experiences? Did it continue to be effective?
>
> Specific to desimpramine, let's here those stories about its effect on your weight: did anyone gain weight? If so, how much? And, if so, have other A/Ds also caused you to gain weight, and was it more or less than on the desimpramine? Did desipramine cause you to feel sedated, apathetic, or emotionally numb? And did the effects on your mood change over time? What side effects did you experience on it?
>
> Extra credit questions: for anyone who's taken a TCA, or MAOI for that matter, who has experienced problems with hypotension, did you try Florinef? If so, how was it? And, if not, did the hypotension resolve itself at all once you'd gotten through the adjustment period, or did it continue to be a problem? (And, how much of a problem was it?)
>
> Basically, I'm looking for information that will help me both adjust to the idea of being medicated for life in the first place, and also to help in choosing the best medications for that long term treatment. If TCAs have a better long term track record than the newer drugs, and the hypotension can be mitigated or will resolve once I've adjusted to the medication, *and* they don't cause you to suddenly grow new limbs or something after several years, then that's the route I'm likely to explore -- once I get out of Dr EyeCandy's Treats Shoppe and into a private psychiatrist's office where there will be better resources for minimizing the adverse effects and treating both hypotension and weight gain.
>
> Thanks, everyone!
Posted by zeugma on August 17, 2004, at 20:41:10
In reply to input? panda, vultan, sls, larry, others...? » Racer, posted by chemist on August 17, 2004, at 17:52:26
hi chemist (and it's great to have you back):
the TCA's are pharmacologically complex drugs, and have many variations both in how they are metabolized and in their pharmacodynamic effects. For example, it seems that the metabolites of all the TCA's (both tertiary and secondary amine) get progressively more selective for NE vs. 5-HT reuptake and less sedating and side-effect-ridden (for example the hydroxylated metabolite of nortriptyline is about 18 times less anti-muscarinic than its parent form). since the enzyme responsible is the polymorphic 2D6 this leads to great variation in terms of how nasty (to put it bluntly) the drug is perceived to be. Also, as someone once said, one person's side effect is another person's good night's sleep; I have found this to be true of nortriptyline, and I have no trouble at all running several miles after administration, then going to sleep several hours later.
others will have more enlightening things to say.
-z
Posted by chemist on August 17, 2004, at 21:07:15
In reply to Re: input? panda, vultan, sls, larry, others...?, posted by zeugma on August 17, 2004, at 20:41:10
hello, zeugma - thanks for the kind words, and i apologize for not including your nom-de-plume in the tagline....i was just replying to one of your posts down the way, in re: stimulant/benzo combinations.....thank you much for the info in re: the TCAs. i can only read so much of this stuff in the literature before going to real-life adventures.....your point about one person's solution being another's problem is well-put, and i am sensing that the TCAs are indeed more reactive on an individual basis than, say, the SSRIs....in any event, thanks again for the info, and thank you for the welcome back.....be well, chemist
> hi chemist (and it's great to have you back):
>
> the TCA's are pharmacologically complex drugs, and have many variations both in how they are metabolized and in their pharmacodynamic effects. For example, it seems that the metabolites of all the TCA's (both tertiary and secondary amine) get progressively more selective for NE vs. 5-HT reuptake and less sedating and side-effect-ridden (for example the hydroxylated metabolite of nortriptyline is about 18 times less anti-muscarinic than its parent form). since the enzyme responsible is the polymorphic 2D6 this leads to great variation in terms of how nasty (to put it bluntly) the drug is perceived to be. Also, as someone once said, one person's side effect is another person's good night's sleep; I have found this to be true of nortriptyline, and I have no trouble at all running several miles after administration, then going to sleep several hours later.
>
> others will have more enlightening things to say.
>
> -z
Posted by Nohope on August 18, 2004, at 4:00:18
In reply to input? panda, vultan, sls, larry, others...? » Racer, posted by chemist on August 17, 2004, at 17:52:26
> it is my personal experience with the MAOI parnate that it was/is an excellent anti-depressant, in the truest sense of the definition.
> and it was (in concert with a low-dose benzo such as klonopin and later valium) exceptional at the 30 mg/day dose level (divided).Hi Chemist.
I have been on Parnate for a whole 1.5 weeks now (30mg/day). I noticed almost immediate improvement in many areas (e.g. my general anxiety levels) but the antidepressant response has been more modest. How long should I wait for full antidepressant effect before considering upping the dosage? (I realize that 1.5 weeks - after a 2week washout - is not very long.)
Thanks.Nohope
Posted by chemist on August 18, 2004, at 8:36:04
In reply to Re: input? panda, vultan, sls, larry, others...?, posted by Nohope on August 18, 2004, at 4:00:18
> > it is my personal experience with the MAOI parnate that it was/is an excellent anti-depressant, in the truest sense of the definition.
> > and it was (in concert with a low-dose benzo such as klonopin and later valium) exceptional at the 30 mg/day dose level (divided).
>
> Hi Chemist.
>
> I have been on Parnate for a whole 1.5 weeks now (30mg/day). I noticed almost immediate improvement in many areas (e.g. my general anxiety levels) but the antidepressant response has been more modest. How long should I wait for full antidepressant effect before considering upping the dosage? (I realize that 1.5 weeks - after a 2week washout - is not very long.)
> Thanks.
>
> Nohope
>
>
hello nohope, chemist here...like you, i was immediately gratified by parnate, in terms of anxiety....i do recall that about a month passed before i can say that i was feeling the brunt of it...i think your plan to give it more time is wise before upping the dose, and again, more of a personal variation at work.....i know of a couple of folks who have been in the 60 mg/day range (personally), and their experience in terms of onset was/is similar to yours/mine. i would give it another week or two, personally, and look into another 15 mg if you are still not up to par....please do keep us informed, and all the best, chemist
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