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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 19 to 43 of 48. Go back in thread:
Posted by SLS on June 14, 2005, at 16:38:43
In reply to Re: Trileptal 600mg » SLS, posted by emme on June 13, 2005, at 20:46:13
Hi Emme.
> Hi Scott,
>
> Thanks for your input.
> > Actually, I think it might be worth discontinuing the memantine briefly to see if it isn't the culprit.
> I thought of that, but I don't think my doctor will like that idea b/c it's been so hard to find things that work for my depression.I was thinking in terms of a few days - even with its long half-life. Being off of it a full week should be plenty of time to see if a trend establishes itself.
> It’s hard for me to believe the microdose I’m taking now is making me a zombie, but anything is possible.
:-)
A little logic here, Emme. This same microdose is capable of exerting a psychotropic effect as an antidepressant - why not also as a cause of other psychotropic effects that are undesirable?
> > I think we had a conversation about this earlier in the year. We both reacted to memantine in the same way the second time around - weakness and fatigue.
> Yeah, you're right, we did. I'm glad one of us has a memory. :)
> > I have not had Lamictal affect me this way - even at 450mg. I just experienced some cognitive impairments.
> When I've been on minimal meds, with mostly lamictal and a benzo, it hasn't killed the depression and I've been tired and apathetic. So maybe Lamictal makes me tired in the long run even though it seemed activating at the outset. Either that or the fatigue is caused by depression.How much Lamictal are you taking? It is possible that it is causing some flattening of affect that feels like apathy and making you a bit "stupid".
> Anyway, my options for adding antidepressant power aren’t great.Then how about mood stabilizers?
> My last two tries with Paxil made me terribly irritable or too sedated.
Irritability is not necessarily a bad thing. If it is a startup side effect, it might pass. Irritability also emerges as a sign of improvement of depression.
> Celexa went south after about 6 weeks.
Can you describe the magnitude and scope of your response to Celexa. Did you feel you had reached remission?
> Lex = apathetic and numb beyond belief.
Me too.
> Wellbutrin: 37.5 did nothing. 75 was awfully stimulating.
Stimulation is a good thing, even if it feels uncomfortable in the beginning. How long were you on 75mg before you discontinued it?
> Effexor made me feel sick and increased my pulse hugely, but the dose may have been too high.
Don't worry about pulse. People all too often discontinue TCAs simply because their heart rates increases to 100-120 bpm. This is tragic. This is an expected effect, and a sign that the drug is doing what it is supposed to do, even if only peripherally.
> My pdoc isn’t keen on me having tricyclics around b/c of their lethality in overdose
Awe, poor doctor doesn't want to take the risks necessary to get the patient well. Oh, how I empathize with him - NOT. How often have you attempted suicide?
> (plus higher s/e profiles).
You want to play - you've got to pay. Get tough. The side effects are more nuissances than anything else, and I would much rather have a dry mouth than anorgasmia and apathy. In my mind, the side effect profile of tricyclics are favorable. I like nortriptyline followed by desipramine. If you don't respond to one, you might respond to the other. It happens.
> MAOIs = my dietary habits would make the diet very difficult.
Come on, Emme. Do a little self-talk here. That is a pretty poor reason not to join the life of the living again. Life is waiting for you, Emme. Pay the price and get on with it. You will find that it is a very small one.
> Selegiline = what appeared to me to be cycling. Much better w/o it.
Hmm.
Can you describe in better detail what you experienced?
> SSRIs haven’t panned out for the long term, but maybe try prozac anyway?
Prozac is a drug that makes no sense to neglect. It is different from all the other SSRIs in several ways. It is more noradrenergic and binds to certain 5-HT receptors. However, I would go for nortriptyline or an MAOI first if I were in your situation. You might prefer to start with Nardil because it is less amphetamine-like than Parnate. Even this amphetamine effect is only temporary in my experience. I would not give up before trying both drugs. They are far too different to generalize your experience of one to the others.
> I gotta get less tired and have more spark and initiative.Parnate?
One nice thing about Parnate is that it is safer than Nardil to add a TCA to it. You can also add Wellbutrin to it. The only true contraindication is a SRI and clomipramine.
Listen, these stimulating drugs that cause complete insomnia are the ones that are going to blow a hole through your wall of treatment-resistance. Just go for it. Treat the insomnia aggressively when it appears. Then just sit back and get well.
I guess I should acknowledge that a drug does not have to be stimulating to make you feel less tired and have more spark and initiative. Anything that attacks the depression effectively will resolve these things, even if it is sedating at first. Nardil is no less apt to treat your anergia than Parnate.
> It's going to hit situation cricital if I don't become more productive.
How so?
> I’m getting more impatient and less and less willing to put up with side effects. And I complain a lot. :)
ME TOO!
It is quite a paradox. The less treatable you are the less treatment you are willing to tolerate.
Get well.
Oh, about me, I decided to stay at 600mg of Trileptal and allow the cognitive stuff to pass. I was encouraged by what a doctor I spoke to yesterday had to say. The "yuckies" should dissipate entirely.
- Scott
Posted by emme on June 14, 2005, at 23:48:10
In reply to Re: Trileptal 600mg » emme, posted by SLS on June 14, 2005, at 16:38:43
Hi Scott,
>I was thinking in terms of a few days - even with its long half-life. Being off of it a full week should be plenty of time to see if a trend establishes itself.
I’ll think about bringing that up when I see my doctor next.
> A little logic here, Emme.
Er..are you teasing, or are you angry and frustrated with me?
> This same microdose is capable of exerting a psychotropic effect as an antidepressant - why not also as a cause of other psychotropic effects that are undesirable?
Yeah, I know. Point taken. :)
>How much Lamictal are you taking? It is possible that it is causing some flattening of affect that feels like apathy and making you a bit "stupid".
150 mg right now. I dunno…it doesn’t feel flat the way Lex or higher dose Memantine did. But if I’m flattened, I might not be aware of it b/c I’ve been on Lamictal for a long time.
> Then how about mood stabilizers?
The others really haven’t panned out. Trileptal didn’t really seem to help me. Topomax, lithium, Zonegran, all either didn’t help or made me worse. Given my symptoms, we haven’t had depakote on the radar.
>> My last two tries with Paxil made me terribly irritable or too sedated.
> Irritability is not necessarily a bad thing. If it is a startup side effect, it might pass. Irritability also emerges as a sign of improvement of depression.I know irritability can pass. I understated things. Unfortunately this showed up as something closer to rage, with me yelling at people on the phone and throwing things (food, a bowl) down the hall at work. It was pretty disturbing.. The other time I tried it with Lamictal it made me too sedated.
> Can you describe the magnitude and scope of your response to Celexa. Did you feel you had reached remission?
Not full remission, but a definite improvement. Then after 6 weeks or so I became very depressed again and my moods were erratic.
>Stimulation is a good thing, even if it feels uncomfortable in the beginning. How long were you on 75mg before you discontinued it?
I forget how long I was on it last time. For several months I was on it with Serzone and did well. Then things changed and I wasn’t able to tolerate its stimulating effects as well.
> Don't worry about pulse. People all too often discontinue TCAs simply because their heart rates increases to 100-120 bpm. This is tragic. This is an expected effect, and a sign that the drug is doing what it is supposed to do, even if only peripherally.
But how does one exercise or even do fun outdoor things like hiking or biking if your pulse is too high to begin with?
The overstimulation I had with Wellbutrin – and Effexor - is actually a problem. I feel pretty ill when my body is that revved and it runs me into the ground until I cannot function. It’s difficult for me to find the right amount of activation w/o going too far – like looking for the Holy Grail.
> Awe, poor doctor doesn't want to take the risks necessary to get the patient well. Oh, how I empathize with him - NOT. How often have you attempted suicide?
Not fair to judge her on one issue. She’s a conscientious doctor and a good pharmacologist. I don’t think she’s opposed to any class of drugs. I think she was nervous about me having tricyclics at that point b/c I have had so many suicidal thoughts (never attempted). She’s generally open to my input and I think I’ll ask again.
> You want to play - you've got to pay. Get tough.
Ouch. That really hurt. Let’s see….sedation, wired-ness, insomnia, sweating/hot flashes, weak arms and legs, incessant yawning, reduced stamina, feeling icy cold, water retention, burning hot face, postural hypotension, the list goes on. I’m tough and I’ve been playing and paying and trying to be patient. Like the rest of us, I put up with side effects as best I can if the drug is helping.
> and I would much rather have a dry mouth than anorgasmia and apathy.
If it were discrete things like dry mouth and anorgasmia that would be easier to deal with. Heck, I even *liked* the visual trails I had with Serzone. :~). I’m tired of feeling just plain ill overall on some of these drugs – and having my functioning compromised. We both hate cognitive effects and we agreed that apathy can trash your life.
> In my mind, the side effect profiles of tricyclics are favorable. I like nortriptyline followed by desipramine. If you don't respond to one, you might respond to the other. It happens.
That’s good that you find them acceptable. It seems that those two are pretty well liked around here.
>> MAOIs = my dietary habits would make the diet very difficult.
> Come on, Emme. Do a little self-talk here. That is a pretty poor reason not to join the life of the living again. Life is waiting for you, Emme. Pay the price and get on with it. You will find that it is a very small one.Ouch. That really hurt. I’m starting to feel attacked here.
I know the diet is manageable for a lot of people. I’ve thought about it and read a lot of posts and references on the diet. Because of my lifestyle and social life, navigating the diet would be a greater price for me than you realize. I feel much more grounded psychologically if I can keep at least some aspects of my lifestyle intact. As a dyed-in-the-wool vegetarian, I eat a lot of questionable ingredients. When I meet with friends for dinner or go to parties, there are lots of questionable foods. Now I’m not going to say *never ever* or *completely impossible*, but the MAOIs have been low on my list. This may seem trivial to you, but it means an awful lot to me. (That’s why I asked my doctor about tricyclics.)
A psychopharmacologist that I had a consultation with thought that MAOIs might not be a good choice based on how I did with Selegiline, so it may be a moot point.>> Selegiline = what appeared to me to be cycling. Much better w/o it.
>Can you describe in better detail what you experienced?Selegiline gave me some really great, perky, good mood days and yanked me out of some slumps. It seemed really helpful. But over time I was also having periods when the stimulation it would make me too anxious, and then periods when I was very depressed. I was having a number of bad crashes, where my mood would dive right off the cliff and I’d be in intense emotional torment for a day or two and then feel exhausted and burnt out afterwards. I was always trying to either calm down jitteriness or drag myself out of a low, or recover from a bad hell-day. A lot of that eased up when I stopped taking Selegiline.
> Prozac is a drug that makes no sense to neglect. It is different from all the other SSRIs in several ways. It is more noradrenergic and binds to certain 5-HT receptors.
I often wonder why doctors rush to the other SSRIs before trying Prozac.
> Listen, these stimulating drugs that cause complete insomnia are the ones that are going to blow a hole through your wall of treatment-resistance. Just go for it. Treat the insomnia aggressively when it appears. Then just sit back and get well.
Some sort of kick seems to be in order. The general crappy feeling is a worse problem than the insomnia. Benzos or seroquel could help some of that (in addition to insomnia). If my doctor doesn’t have any more appealing ideas, I think I’ll try to reopen discussion on the tricyclics and prozac for starters. I make no promises yet on the MAOIs.
>> It's going to hit situation critical if I don't become more productive.
>How so?Gotta find more work and get a professional life back. More of a personal life wouldn’t hurt either.
>> I’m getting more impatient and less and less willing to put up with side effects. And I complain a lot. :)
> ME TOO!I think you report, not complain. You never whine.
>It is quite a paradox. The less treatable you are the less treatment you are willing to tolerate.
I think part of being hard to treat is the difficulty tolerating meds. And the worse we tolerate meds, the more frustrated we get trying to take them. After a while, you get burned out.
>Get well.
Thanks. I hope you do too.
> Oh, about me, I decided to stay at 600mg of Trileptal and allow the cognitive stuff to pass. I was encouraged by what a doctor I spoke to yesterday had to say. The "yuckies" should dissipate entirely.
Did he say how long it typically takes for this to pass? Good luck. Hang in there.
em
Posted by SLS on June 15, 2005, at 7:00:27
In reply to Re: Trileptal 600mg » SLS, posted by emme on June 14, 2005, at 23:48:10
Hi Emme.
I apologize for the tone I took with you in my last post. I was frustrated that you aren't doing well, and that so many treatments seemed to be excluded from consideration. Now I see that they have been considered and understand more why they have not been placed high on your list of things to try. I guess I poked at you just to make sure. Sorry. It is hard to watch someone else suffer if you think there is something available to treat the illness that they haven't tried yet. I like you, so I think I was overly stiff with my tone.
Again, I apologize.
> If my doctor doesn’t have any more appealing ideas, I think I’ll try to reopen discussion on the tricyclics and prozac for starters. I make no promises yet on the MAOIs.
Obviously, I didn't have an appreciation for the fact that you have had suicidal ideations in the past. Perhaps your doctor could give you only enough TCA medication to last one week at a time if there are safety concerns. Weekly visits over the first three weeks is probably indicated anyway. You might like nortriptyline better than desipramine. For me, it has always seemed like a milder drug with more mood brightening effect.
I think your short-term plan makes a lot of sense. I think I would have tried Prozac again at some point because I never gave it a fair trial at dosages above 20mg.
Do you think your acting out by throwing things is a sign of a mixed state, or is it due to the irritability that can often accompany depression? When I was younger and the depression was first beginning to manifest, irritability was a primary symptom. I do believe I had my fair share of acting out. However, although I hadn't experienced any overt manias, perhaps the irritability and rage indicated a bipolar temperament or bipolar diathesis.
I'm glad you have not completely excluded MAOIs. I guess it is my hopes that you will respond to them as robustly as I did when I first began taking them. It was in 1987 that I was brought into remission with a combination of Parnate and desipramine.
If what you experience as irritability is actually episodes of rage, you might consider returning to Trileptal or Tegretol if you have not responded fully to antidepressants or if it persists afterwards.
Don't forget about Keppra. I had a consultation with a doctor who found it enormously effective for one of his bipolar patients who cycled between mixed states and depression. He found that it was effective for her as monotherapy.
Paradoxically, many people report irritability as a startup side effect with Keppra.
On another note, I am getting scared that I am beginning to plateau with Trileptal. I know that I can be very impatient with a drug unless I am convinced that there is a trend towards improvement beyond a month of the beginnings of a response.
The doctor I spoke to didn't say exactly how long it takes for the cognitive or affective side effects of Trileptal to dissipate, but he gave me the impression that it doesn't linger for very long at all. I find that it comes in waves. I don't recall it being present yesterday at a dosage of 600mg. This morning there is a slight residual. I believe it will pass completely. I did feel something positive even at 300mg, so perhaps you can find utility in a relatively low dosage.
I'm really hoping you get well *soon*. You deserve it.
- Scott
Posted by Ron Hill on June 15, 2005, at 17:00:56
In reply to Trileptal 600mg, posted by SLS on June 11, 2005, at 15:58:46
Scott,
I hope it works. You deserve relief.
-- Ron
-------------------------> I am beginning to respond to the addition of Trileptal 600mg. Quantitatively, the improvement is only mild. However, qualitatively, it is very broad in the features of depression that are beginning to improve. It is a true antidepressant response. I have a good feeling about this. Improvement is very gradual, but the trend is towards remission. Will it poop-out? Who can say? I am betting on full remission. It is logical.
>
>
> Currently:
>
> Lamictal 150mg
> Parnate 80mg
> nortriptyline 100mg
> Abilify 10mg
> Trileptal 600mg
>
>
> - Scott
Posted by emme on June 15, 2005, at 17:28:09
In reply to Re: Trileptal 600mg » emme, posted by SLS on June 15, 2005, at 7:00:27
Hi Scott,> I apologize for the tone I took with you in my last post. I was frustrated that you aren't doing well, and that so many treatments seemed to be excluded from consideration. Now I see that they have been considered and understand more why they have not been placed high on your list of things to try. I guess I poked at you just to make sure. Sorry. It is hard to watch someone else suffer if you think there is something available to treat the illness that they haven't tried yet. I like you, so I think I was overly stiff with my tone.
Thanks. I’ll let ya get away with it this time. ;)
I appreciate the kindness that motivated your post even if a few lines landed badly. I know you’re a very good person. I tend to be sensitive – maybe oversensitive – and electronic media make it easy to miscommunicate. Next time you poke at me, I’ll know what it means.> Perhaps your doctor could give you only enough TCA medication to last one week at a time if there are safety concerns.
That’s true.
> Do you think your acting out by throwing things is a sign of a mixed state, or is it due to the irritability that can often accompany depression?
Tough distinction, isn’t it? Every once in a blue moon I have some sort of nasty but brief outburst. These are pretty rare but distressing. In this case, my doctor took this as a sign of bipolar tendencies and had me stop the Paxil since it happened within about a week of starting it. She had already suspected a few soft bipolar signs. I’ve actually never been 100% convinced I’m bipolar, but I’m not convinced I’m NOT either. So I don’t get hung up on having a label.
> Don't forget about Keppra. I had a consultation with a doctor who found it enormously effective for one of his bipolar patients who cycled between mixed states and depression. He found that it was effective for her as monotherapy.
I liked it. It’s on my list of “helpful things that I can tolerate a teeny bit of”. Of course w/o Selegiline in my system, I didn’t need to keep taking it regularly.
> On another note, I am getting scared that I am beginning to plateau with Trileptal. I know that I can be very impatient with a drug unless I am convinced that there is a trend towards improvement beyond a month of the beginnings of a response.
You’re not sliding backwards, though, are you? It’s still easing your depression? I completely understand about being impatient. I believe that even if a drug starts helping fairly quickly, it can still take time for your brain to recover after being down for so long. IF the drug is tolerable and you are sustaining some benefit, it’s probably worth seeing how much additional improvement you see over the next couple of months or so. You’ve got nothing to loose.
> The doctor I spoke to didn't say exactly how long it takes for the cognitive or affective side effects of Trileptal to dissipate, but he gave me the impression that it doesn't linger for very long at all. I find that it comes in waves. I don't recall it being present yesterday at a dosage of 600mg.
Okay, so this sounds potentially workable. Are you finding Trileptal energizing or calming?
> I'm really hoping you get well *soon*. You deserve it.Thanks. I’m hoping the same for you.
em
Posted by SLS on June 15, 2005, at 19:26:42
In reply to Re: Trileptal 600mg » SLS, posted by emme on June 15, 2005, at 17:28:09
Hi Emme.
I'm glad that I am forgiven.
:-)
It is difficult to say whether I feel energized by Trileptal or not. Not really. However, I have more mental energy and motivation to do stuff. I know that sounds contradictory, but the balance between motivation and energy does not feel stimulating. I don't feel like I am taking a stimulating drug. It is more of a mitigation of the depression than it is an input of nervous energy.
- Scott
Posted by SLS on June 15, 2005, at 19:28:17
In reply to Re: Trileptal 600mg » SLS, posted by Ron Hill on June 15, 2005, at 17:00:56
> Scott,
>
> I hope it works. You deserve relief.
>
> -- Ron
Thanks, Ron. It is always nice to see your name appear on the board. I hope we get to see more of you.:-)
Be well.
- Scott
Posted by EERRIICC on June 15, 2005, at 20:37:41
In reply to Trileptal 600mg, posted by SLS on June 11, 2005, at 15:58:46
Hey Scott, hope your current combination works out for you!
When you took Memantine, did you take it with Parnate? Parnate always works for me for a couple months and then quits, do you think Memantine could stop this and perhaps potentiate Parnate's effects?
Thanks,
Eric
Posted by emme on June 15, 2005, at 22:14:49
In reply to Re: Trileptal 600mg » emme, posted by SLS on June 15, 2005, at 19:26:42
Hi Scott,
> It is difficult to say whether I feel energized by Trileptal or not. Not really. However, I have more mental energy and motivation to do stuff. I know that sounds contradictory, but the balance between motivation and energy does not feel stimulating.
Actuallly, that doesn't sound half bad.
> I don't feel like I am taking a stimulating drug. It is more of a mitigation of the depression than it is an input of nervous energy.
It seems like this is the most promising treatment you've reported in eons.
em
Posted by SLS on June 16, 2005, at 8:14:05
In reply to Re: Trileptal 600mg » SLS, posted by emme on June 15, 2005, at 22:14:49
How much higher do people go with Trileptal?
I know I can go higher on the Trileptal. I wish I knew how many people absolutely need higher dosages to glean a therapeutic effect, especially an antidepressant effect.
> It seems like this is the most promising treatment you've reported in eons.
>
> emYes. But...
It feels like I have plateaud already. I feel about as good this week as I did last week. It's hard to tell sometimes, but I would like to feel things that are indicative of an unequivocal trend in the direction of further improvement. The problem with my response to medication in drug trials is that improvements never persist beyond two weeks once they appear. Since I have not been feeling better for two weeks yet, I am still in that zone of uncertainty. If two weeks from now I am feeling better than I am today, I will then feel reassured that things are headed in the direction of a robust response. At this point, I would rate myself as a total of 20% improved over my unmedicated baseline state. Of that, Trileptal is responsible for 5%, so the degree of improvement is small. However, the rate of improvement I experienced the time I did respond well to medication was very gradual.
Today, I am feeling more pessimistic than optimistic.
I know I can go higher on the Trileptal. I wish I knew how many people absolutely need higher dosages to glean a therapeutic effect, especially and antidepressant effect.
- Scott
Posted by ed_uk on June 16, 2005, at 9:03:40
In reply to Re: Trileptal 600mg - How much higher can I go?, posted by SLS on June 16, 2005, at 8:14:05
Hi Scott,
>Trileptal 600mg - How much higher can I go?
You could go up to 2400mg if you can tolerate it! I very much doubt you'd need that much though. Perhaps you should wait until the cognitive side effects have worn off and then increase to 750mg or 900mg.
Kind regards,
Ed.
Posted by emme on June 16, 2005, at 12:12:47
In reply to Re: Trileptal 600mg » emme, posted by SLS on June 15, 2005, at 19:26:42
Hi Scott,
Update. In case you were waiting with bated breath. We're keeping memantine where it is for now (don't want to risk losing any more AD effect). She wants me to try a little Cymbalta. She said her patients have been tolerating it pretty well. 15 mg...here we go...
Do you feel ready to raise the Trileptal? Maybe better to wait a few more days while the cognitive effects dissipate?
em
Posted by SLS on June 17, 2005, at 3:23:15
In reply to Lookin' like Cymbalta » SLS, posted by emme on June 16, 2005, at 12:12:47
> Hi Scott,
>
> Update. In case you were waiting with bated breath. We're keeping memantine where it is for now (don't want to risk losing any more AD effect). She wants me to try a little Cymbalta. She said her patients have been tolerating it pretty well. 15 mg...here we go...
>
> Do you feel ready to raise the Trileptal? Maybe better to wait a few more days while the cognitive effects dissipate?
>
> em
Hi Emme.I'm happy that you are taking yet another step. Let's hope your foot lands on the first step of the stairway to recovery. I look forward to watching you smile.
:-)
Good luck.
- Scott
Posted by SLS on June 17, 2005, at 3:29:31
In reply to Re: Trileptal 600mg - How much higher can I go? » SLS, posted by ed_uk on June 16, 2005, at 9:03:40
> >Trileptal 600mg - How much higher can I go?
> You could go up to 2400mg if you can tolerate it! I very much doubt you'd need that much though. Perhaps you should wait until the cognitive side effects have worn off and then increase to 750mg or 900mg.
>
> Kind regards,
> Ed.
Thanks, Ed.Today was not a good day. I got hit by two waves of depression. I seem to have plateaud, if not moved backwards. Your advice is great. It's what I would tell anyone else in my position. But I am extremely impatient and tend to judge drugs perhaps too quickly. I am tempted to increase the dosage now, but I'll try to hold out until I see the doctor a week from today.
- Scott
Posted by ed_uk on June 17, 2005, at 7:44:15
In reply to Re: Trileptal 600mg - How much higher can I go? » ed_uk, posted by SLS on June 17, 2005, at 3:29:31
Hi Scott,
>Today was not a good day. I got hit by two waves of depression.
I'm sorry to hear that.
>I am tempted to increase the dosage now, but I'll try to hold out until I see the doctor a week from today.
Well.....perhaps you could try taking 750mg for a few days. You could 'play it by ear' and return to 600mg if the higher dose causes cognitive side effects.
Kind regards,
Ed.
Posted by emme on June 17, 2005, at 10:29:00
In reply to Re: Lookin' like Cymbalta » emme, posted by SLS on June 17, 2005, at 3:23:15
Hi Scott,
>
> I'm happy that you are taking yet another step. Let's hope your foot lands on the first step of the stairway to recovery. I look forward to watching you smile.Thanks for the good wishes. I don't know why, but I was a little surprised she suggested Cymbalta when I talked about antidepressants. Maybe it's that "It's new so I'm gonna start prescribing it a lot" thing. Or maybe she's just happy with what it's doing for some of her patients. Even though I was envisioning trying an older drug, I have no reason to not be open-minded about it. I used to feel hopeful when trying new medication. Now I just dread it. Will report back in a week or so.
I am sorry you're backsliding. I really hope it's temporary. If this persists another day or two, then yeah, maybe you're ready to try an increase and see if you can avoid going too far down.
Feel better,
em
Posted by Ron Hill on June 17, 2005, at 14:04:30
In reply to Re: Trileptal 600mg - How much higher can I go?, posted by SLS on June 16, 2005, at 8:14:05
> How much higher do people go with Trileptal?
> I know I can go higher on the Trileptal. I wish I knew how many people absolutely need higher dosages to glean a therapeutic effect, especially an antidepressant effect.> - Scott
---------------------Scott,
FWIW, I've been on Trileptal for one year. I use it as a moodstabilizer and I currently take 900 mg/day. I've been as high as 1200 mg/day for a couple of weeks, and once I bumped up to 1600 mg/day for a day or two. The side effects were worse at 1200 and 1600 and, for me, the benefits did not increase at the higher dosages. So early on in the trial, I backed down the dosage and ended up setting in at 900 mg/day.
Sometimes I toy with the idea of reducing to 600 to see if I have more energy and to see if I spend less time in the depressive (atypical) phase of my BP II cycling. But for now, I need the moodstablizing power of 900 mg/day to prevent hypomania during my current (3 week old) Selegiline trial.
I had some trouble with side effects (including cognitive blunting, among others) during Trileptal startup. To minimize these startup effects, I ramped up slowly (i.e.; 300, 450, 600, 750, 900, 1200, 1600 mg/day) with at least a couple weeks between incremental increases.
The startup side effects have long since subsided, but for me, any of the moodstabilizers (including Trileptal) cause some amount of ongoing cognitive blunting. It just seems to come with the MS territory (in my case).
I really like Trileptal (as a moodstabilizer). It is the best med I've found for the tx of hypomania. Further, it reduces (but does not eliminate) my dysphoric irritability, and it is an absolutely excellent sleep agent. However, in my case, I have never attributed any antidepressant action to Trileptal. To the contrary, in a manner reminiscent of Depakote (but much less severe), I sometimes think that Trileptal "holds me in" the depressive phase of my BP II cycling longer than I would reside there otherwise. Are there research data that indicate Trileptal may have antidepressant qualities in certain cases?
Your situation is different than mine, so my anecdotal report is likely of little value to you. None-the-less, just thought I'd relay my experience FWIW.
I hope Trileptal helps you Scotty. You're a good man and I have a ton of respect for you.
-- Ron
BP II and OCPD
600 mg/day Lithobid
900 mg/day Trileptal
50 mg/day Lamictal (level limited by rash)
5 mg/day Deprenyl (as tx for atypical depression)
Posted by SLS on June 17, 2005, at 15:49:15
In reply to Re: Trileptal 600mg - How much higher can I go? » SLS, posted by Ron Hill on June 17, 2005, at 14:04:30
Hi Ron.
Thanks for the feedback. I just spoke to my doctor on the phone. He'll let me go from 600mg to 750mg to 900mg. I'm torn apart here. I see him in one week. I don't know whether to remain at 600mg for another week or begin to increase the dosage now. The goal is to use the minimum amount necessary that will extract 100% of the drug's therapeutic potential. I wish I had a better idea as to what is the average dosage used by people with bipolar disorder.
I am gleaning an antidepressant effect from Trileptal at 600mg. However, it is episodic and of inadequate magnitude. I expect that my improvement with the right drugs will be extremely slow because of the severity and chronicity of my depression. Therefore, it is possible that I wouldn't improve any quicker than this anyway. I am just concerned that I have already reached a plateau and will be experiencing diminished returns.
Bipolar Depression; drug-induced manias:
Lamictal 150mg
Parnate 80mg
nortriptyline 100mg
Abilify 10mg
Trileptal 600mgI am so damned impatient!
- Scott
Posted by Ron Hill on June 17, 2005, at 18:40:41
In reply to Re: Trileptal 600mg - How much higher can I go? » Ron Hill, posted by SLS on June 17, 2005, at 15:49:15
> I wish I had a better idea as to what is the average dosage used by people with bipolar disorder.
Scott,
I think that a dosage of 1200 mg/day for adults (or 1800 mg/day for kids) is about average for BP. This is consistent with woolav’s post further down on this PB page at http://www.dr-bob.org/babble/20050617/msgs/514305.html . But it’s like any other p-med, the correct dosage (if any) is the one that works for you personally. So you know the drill (much better that I do); trial-and-error experimentation while keeping a symptom tracking diary and then analyze the data collected.
I’m sure you’ve already reviewed the Prescribing Information document for Trileptal ( http://www.crazymeds.org/trileptalpi.pdf ). The Dosage and Administration section begins on page 33 for its use as an antiepileptic. Since the use of Trileptal for BP is off label, I’ve not seen any BP dosage recommendations from the manufacturer. But the AED dosage and administration guidelines do serve to define the safe dosage range. I wouldn’t take more than 2400 mg/day.
I’d say it’s safe to use the Trileptal dosage guidleines as if you were on a monotherapy treatment. I say this because the only other AED you have on board is Lamictal and there is very little drug-drug interaction between Trileptal and Lamictal (and vise versa). See the applicable drug-drug interaction information (e.g.; pg 42 and other related pages) in the Lamictal Prescribing Information document ( http://us.gsk.com/products/assets/us_lamictal.pdf ). However, I have no idea of the interactions of Trileptal and the other meds that you take.
> Lamictal 150mg
> Parnate 80mg
> nortriptyline 100mg
> Abilify 10mg
> Trileptal 600mgWow, you’ve got some big guns onboard.
> I am so damned impatient!
That’s understandable. You’ve been battling a long long time, so who wouldn’t be eager if even a glimmer of hope appears.
-- Ron
Posted by SLS on June 18, 2005, at 10:01:08
In reply to Re: Trileptal 600mg - How much higher can I go? » SLS, posted by Ron Hill on June 17, 2005, at 18:40:41
Hi Ron.
I am leaning in the direction of staying on 600mg until I see my doctor a week from now. It seems like the logical thing to do. It just requires a little more patience, which, unfortunately, I don't seem to have a lot of.
By the way, it is really cool to have you around again. You are always a good source of information, sensibility, and positive energy. Glad you're back...
- Scott
Posted by SLS on June 19, 2005, at 11:04:19
In reply to Re: Trileptal 600mg - How much higher can I go? » Ron Hill, posted by SLS on June 18, 2005, at 10:01:08
> I am leaning in the direction of staying on 600mg until I see my doctor a week from now. It seems like the logical thing to do. It just requires a little more patience, which, unfortunately, I don't seem to have a lot of.I went ahead and popped 900mg. It just felt like the right thing to do. I see my doctor in a week. I'd like to see how I react to the higher dosage so that I can bring in more information with me to make decisions upon. I didn't want to waste another week at the same dosage I had been at for many weeks. I increased my dosage yesterday evening. I feel more stable today. So far, I haven't been hit by the waves of depression that I experienced at 600mg. Whether or not I actually improve is another story.
Still a believer.
- Scott
Posted by ed_uk on June 19, 2005, at 12:05:36
In reply to Re: Trileptal 600mg - How much higher can I go?, posted by SLS on June 19, 2005, at 11:04:19
Looks like 900mg is going to work out :-)
Keep on believing!
~Ed
Posted by 4WD on June 19, 2005, at 23:18:34
In reply to Re: Trileptal 600mg - How much higher can I go?, posted by SLS on June 19, 2005, at 11:04:19
>
> > I am leaning in the direction of staying on 600mg until I see my doctor a week from now. It seems like the logical thing to do. It just requires a little more patience, which, unfortunately, I don't seem to have a lot of.
>
> I went ahead and popped 900mg. It just felt like the right thing to do. I see my doctor in a week. I'd like to see how I react to the higher dosage so that I can bring in more information with me to make decisions upon. I didn't want to waste another week at the same dosage I had been at for many weeks. I increased my dosage yesterday evening. I feel more stable today. So far, I haven't been hit by the waves of depression that I experienced at 600mg. Whether or not I actually improve is another story.
>
> Still a believer.
>
>
> - Scott
Scott,I think that's a good idea. This way you'll have more of an idea what an increased dosage will do. If you'd stayed at 600 til your visit, he'd just tell you to increase it and then you'd have to wait for your next appt. to tell him how that's going.
I'd go ahead and ask for a backup plan while you're there, though. I mean, ask about raising it further if necessary. And/or what to do if the improvement isn't (perish the thought) sustained.
I hate it when I go to an appt. and my doc makes some very minor change and then I have to wait another month for another very minor change. I want a plan and a backup plan and a second backup plan.
Marsha
Posted by Ron Hill on June 20, 2005, at 11:23:50
In reply to Re: Trileptal 600mg - How much higher can I go? » Ron Hill, posted by SLS on June 18, 2005, at 10:01:08
SLS,
> By the way, it is really cool to have you around again. You are always a good source of information, sensibility, and positive energy. Glad you're back...
Thank you very much for your kind words. When it comes to tx of p-disorders with p-meds and/or supplements, I'm just a monkey-see-monkey-do trial-and-error kind of a guy. On the other hand, you and many other learned individuals on this site actually understand the pharmacological actions of p-meds and the associated brain functioning.
It's like you smart guys and gals are the horticulturists who determine the best genetics, optimal seed germinating requirements, soil conditioners and nutrients, optimal watering amounts and frequency, optimal quantity and intensity and wavelength of light, etc. All I do is stop by the garden, pick and sample a particular variety of the produce, and see if it gives me a boost or if it's a dud.
When I first found this site in 1999, I knew virtually nothing about p-meds and p-disorders. All I knew was that my brain was all screwed up from a p-doc giving me the wrong meds. But over the years I've read the posts of you horticulturists and now I have a lot better idea of which type of produce would have the best chance of giving me a boost and which would likely be a dud. Scott, thank you for sharing your knowledge over the years!
Hey with regard to your current Trileptal trial, do you think it might be worthwhile to keep the Trileptal on board even if the antidepressant action turns out to be merely a startup phenomenon? I say this because for several years I've thought there might be a bipolar component to your dx. In fact, I think I may have shared this opinion with you in the past. My only point is that if you do have some BP in your dx (as you currently believe to be the case), then it would seem prudent to have more mood stabilization on board than what the Lamictal and Abilify bring to the table. Just my 2 cents, FWIW.
-- Ron
Posted by Ron Hill on June 21, 2005, at 21:20:18
In reply to Re: Trileptal 600mg - How much higher can I go?, posted by SLS on June 19, 2005, at 11:04:19
Scott,
FYI: The only ongoing long-term adverse side effect that I experience with Trileptal is a very noticeable short-term memory problem. I forget things s lot! I use various aids and coping mechanisms to compensate for the memory deficit.
-- Ron
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