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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 9 of 9. This is the beginning of the thread.
Posted by europerep on August 27, 2010, at 14:19:56
hello there...
I have started adding methylphenidate to my 600mg/d venlafaxine regimen, as the next step against treatment-resistant depression... I started with 5mg instant release in the morning, then went to 10mg IR, and now since a couple of days I switched to 20mg extended release in the morning..
at first it gave me some headaches, but now, if it has an impact on my mood, it is actually negative. I can't say whether it's due to methylphenidate or whether it's just "conjunctional", but somehow I feel even more empty, and instead of decreased libido I now have basically none.. like I really couldn't care less.
my question would be up to which dose I should try it out before considering it failed? I personally do not believe that increasing dopamine, or any other of the "notorious three" neurotransmitters will actually help me.. I mean, 600mg of venlafaxine is certainly a lot, and it does help, but only marginally, and I do not think that there is still much too come by inhibiting even more reuptake of anything. in the one placebo-controlled trial of methylphenidate as an augmentation in TRD (which failed to show efficacy beyond placebo btw) they went to 54mg XR, should I go to 60mg XR then? I really want to give it a thorough trial to be able to say definitely whether it worked or not, but I just wanted to hear what some people on here would recommend as a target dose, be it from experience, knowledge, intuition, whatever ;-)..thanks in advance!
eR
Posted by linkadge on August 27, 2010, at 14:46:16
In reply to methylphenidate augmentation of venlafaxine, posted by europerep on August 27, 2010, at 14:19:56
Hi Europerep,
From the studies I have read, when methyphenidate augmentation does work it works very rapidly.
If you have not experienced any improvement at this stage, you probably won't. Thats not conclusive of course, just my guess.
That being said, there is a small chance that the venlafaxine is actually negating the effects of the methylphenidate. I remember when I was on SSRIs, the methylphenidate effect was greatly reduced, if present at all (the exception being in conjunction with fluoxetine for some reason).
Any how, as a side question, have you experienced any benefit from the massive dose of venlafaxine? I.e. did you notice any increased effect going from 300 -> 600mg?
My personal opinion is that you are on too much venlafaxine, and that you are probably creating more imballance with it.
Sorry if you have said before, but which ADs have you tried?
Linkadge
Posted by europerep on August 27, 2010, at 15:01:12
In reply to Re: methylphenidate augmentation of venlafaxine, posted by linkadge on August 27, 2010, at 14:46:16
hey link..
yeah, totally, I do not expect it to do anything anymore either, it's just that I want to really make sure, you know?
it was my doc's suspicion too that I was taking too much venlafaxine. I did then actually reduce it in steps of 75mg down to 375mg/d, and within relatively short time, I was feeling very very much worse.. couldn't get up before 2PM etc. that subsided when I went back up to 600. so, in a certain sense, the 600mg are what allows me to function half-decently, and at least go to university and stuff. it does also have an effect on depression as I perceive it, in terms of emotions etc., but it is very, very far away from giving me what I need, so I definitely have to find something else.
no problem for the question, here are my meds so far:
- Amitriptyline (always extended release, 300mg/d)
- Amitriptyline (300mg/d) + Nortriptyline (75mg/d)
- Venlafaxine (always XR, 375mg/d)+ Amitriptyline (150mg/d)
- Venlafaxine (600mg/d)
- Venlafaxine (600mg/d) + Amitriptyline (25mg/d) + Aripiprazole (5mg/d)
- Venlafaxine (600mg/d) + Mirtazapine (60mg/d)
- Venlafaxine (600mg/d) + Lithium (500mg/d)
- Venlafaxine (525mg/d) + Buprenorphine (9mg/d)I just copied and pasted it from an email I wrote recently, thats why there are the specifications of extended release etc.
Posted by bleauberry on August 27, 2010, at 16:45:22
In reply to methylphenidate augmentation of venlafaxine, posted by europerep on August 27, 2010, at 14:19:56
I agree with Link. If it is going to work, it will usually do so rather quickly. Probably 1 to 4 days. The bottom line I think is that we have to listen to what our bodies are telling us.
I personally think the whole idea of a "target dose" is foolish. I realize it is mainstream and widely accepted, but I disagree with it. There are too many individual variables from one person to another. 1mg of lexapro might be perfect for one person, while another needs 40mg. Again, it comes back to listening to what your body is telling you.
My intuition would be to back down in dosage instead of up and give it more time. And as is the case with a lot of people here, I think it might be time to start thinking about things that are not so ordinary to the psychiatrist's office. Things like LDN, DLPA, and others. I think part of the reason for treatment resistance is due to getting stuck thinking inside a confined box. But that's the way it is. There is a lot more to depression than what psych drugs can impact
Posted by linkadge on August 27, 2010, at 16:49:58
In reply to Re: methylphenidate augmentation of venlafaxine, posted by europerep on August 27, 2010, at 15:01:12
Hmm. Bupropion (wellbutrin) might be worth a shot if you havn't taken it.
Methylphenidate (ritalin) can work as an anidepressant for some people, but wellbutrin has certainly been better studied.
I'd personally take as little venlafaxine as possible (even if this is just 75mg less).
Other augmentation agnets might include:
zinc, an SSRI, desipramine, caffiene, folic acid, omega3, nicotine, b12, tyrosine, phenylalaine, SAMe, selegeline, seroquel, buspar...
Linkadge
Posted by utopizen on August 31, 2010, at 23:31:17
In reply to Re: methylphenidate augmentation of venlafaxine, posted by bleauberry on August 27, 2010, at 16:45:22
>>
I think it might be time to start thinking about things that are not so ordinary to the psychiatrist's office. Things like LDN, DLPA, and others. I think part of the reason for treatment resistance is due to getting stuck thinking inside a confined box. But that's the way it is. There is a lot more to depression than what psych drugs can impact
>
>First, I was on Lexapro for 3 months straight; it did nothing. I still craved sleep in the dorms while in class. Then, one day, I realized two weeks had passed, and I hadn't yet craved sleep for that last 2 weeks.
Yet it wasn't Lexapro. I had received a shipment abroad of DLPA + selegilene(sp), took 2 5mg tabs/day along with DLPA. And I swear, effect was immediate. Don't try this @ home: Lexapro + Selegilene is a very risky combo; I just got lucky. I didn't tell my doc I added it, as I knew he couldn't be on board for something that could have cost him his license.
as for effexor:
it's nice to think a drug will get you out of bed. The reality is, if you find that happening, awesome; more power to you. However, this is an unrealistic expectation for _any_ medicine, and an unhealthy one at that.
Is it nice to think a drug will get you out of bed? Is that not a sure sign of depression? You betchya.
But using *any* medicine as a crutch to avoid following CBT therapy visits weekly + regular, vigorous outside of your doc's office--+ actually following those worksheets the therapists gives is not doing anyone with treatment-resistant therapy any favors. And just trust me: your CBT therapy has better odds at changing certain behaviors like getting out of bed than any drug.
Moreover: the Ritalin is, I hope, needed for your ADD, not depression. Psychostimulants all can drive the neurons crazy when they are depressed. They can take even the slightest case of the blues and drain, deplete+exhaust already limited dopamine reserves until you have chronic depression in a matter of months. Your are describing dysphoria. Most likely, the Ritalin is too high given the Effexor dose; they're both hitting at similar transmitters. So basically, your Effexor dose is super high, making your Ritalin dose effectively super high as well and high doses of a psychostimulant makes one prone to dysphoria.
One of the adaptive things about depression is this: it does actually let your body know you may have gone too far in stretching it, in not appreciating we all have a finite amount of energy levels each day. What stimulants do is tell our brains otherwise, and we wind up exhausting ourselves through sustained mental concentration without knowing to pace ourselves. It's like running on a broken leg with regular morphine injections.
But while you figure out exercise: (vigorous, not walking! no one walks themselves out of depression!)
set your alarm clock for, say, 8AM. Then, take your morning dose of the Ritalin, and set it to buzz again at 8:30 AM. By time it kicks in, you'll be out of bed. And then, ride a bike/run/go to gym so you can actually feel proud of yourself for the rest of the day.
I know this is long; but there's a lot of stuff here I think you deserve to have cleared up. Good luck =D
Posted by Conundrum on September 1, 2010, at 8:42:26
In reply to Re: methylphenidate augmentation of venlafaxine » bleauberry, posted by utopizen on August 31, 2010, at 23:31:17
I don't doubt that ritalin can cause one to become exhaust, but that is probably due to causes other than dopamine reuptake blockade. Remember ritalin at normal prescribed doses is not a dopamine releaser. It increase the dopamine and norepinephrine that is already available. I could see this with a drug like amphetamine which is a releaser.
Are you still taking DPLA + selegiline? What did it do for you?
Posted by linkadge on September 1, 2010, at 15:02:07
In reply to Re: methylphenidate augmentation of venlafaxine » bleauberry, posted by utopizen on August 31, 2010, at 23:31:17
>Moreover: the Ritalin is, I hope, needed for >your ADD, not depression. Psychostimulants all >can drive the neurons crazy when they are >depressed.
I think it depends on the type of depression. My depression transformed from typical to atypical over the years and SSRIs stopped working. I have been using ritalin at a constant dose for a while now without apparent tollerance. It seems to be the cleanest thing which blocks the feelings of extreme hopelessness.
>They can take even the slightest case of the >blues and drain, deplete+exhaust already limited >dopamine reserves until you have chronic >depression in a matter of months.
I wouldn't go so far as to say that. The cause of depression is not really known. There is more evidence that amphetamine depleats catacholamine stores. Ritalin has little / no effect on monoamine release. Besides, ritalin calms me down more than revs me up. It seems to help shut down the oversensitivity to light / sound. Perhaps this is more a sign of ADD that a stimulant actually supresses neural overactivity.
>One of the adaptive things about depression is >this: it does actually let your body know you >may have gone too far in stretching it, in not >appreciating we all have a finite amount of >energy levels each day. What stimulants do is >tell our brains otherwise, and we wind up >exhausting ourselves through sustained mental >concentration without knowing to pace ourselves.
Well, the causes of depression are not really known. Although nicotine is a "stimulant" it exerts antidepressant effects in mice at doses that are lower than needed to produce locomotor stimulation.
>It's like running on a broken leg with regular >morphine injections.
Perhaps. I wouldn't recomend ritalin for those who are recovering from a nervous breakdown. However, I simply feel that ritalin helps rests some catecholamine / cholinergic ballance. Ritalin can work for years in ADHD without really producing tollerance. Its hard to know what its doing there. In ADHD patients who respond to ritalin, there is a dramatic increase in urinary PEA levels. Perhaps the drug affects PEA metabolism in some way. I get a U shaped effect. Up to 5mg calms me down above 10mg revs me up.
Linkadge
Posted by linkadge on September 1, 2010, at 15:03:01
In reply to Re: methylphenidate augmentation of venlafaxine » utopizen, posted by Conundrum on September 1, 2010, at 8:42:26
PEA acts like an endogenous amphetamine --> producing catecholamine release.
Linkadge
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