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About browri

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  • Birthday 05/14/1991

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  1. Agree with you 100% on this, @dtac. I'm not sure that Trintellix really did anything for my anxiety. It wasn't until I added the Rexulti that things started to get better. I've done a lot of research on Trintellix and anxiety and found a couple things that may be of interest: Vortioxetine (2.5mg, 5mg, and 10mg) has been tested in placebo-controlled studies with duloxetine (Cymbalta) 60mg as an active reference. While vortioxetine was inferior to duloxetine on anxiety rating scales, duloxetine was associated with more people leaving the study prematurely due to side effects; and vortioxetine, unlike duloxetine wasn't associated with treatment-emergent sexual dysfunction: https://www.ncbi.nlm.nih.gov/pubmed/24341301 One critique that others have given to this study, post-hoc, is that the 15mg and 20mg doses were never used, and those doses were associated with a far greater rate of remission than <= 10mg in depression trials. Based on my own reading of other people's subjective experiences with vortioxetine and anxiety, 50% of the time it helps, and 50% of the time it does nothing or makes your anxiety worse. What's interesting is that one of vortioxetine's primary effects is antagonism of 5HT3. Unlike most of the serotonin receptors, which are G-coupled receptors, the 5HT3 receptors are ion channel receptors and are located on GABA interneurons. Vortioxetine's activity there actually reduces GABA firing and increases the release of glutamate, which for people with anxiety, not always but oftentimes is not a good thing. I've felt that for me, Depakote has played an important role here because valproate inhibits the breakdown of GABA and increases its synthesis to ensure this activity by vortioxetine doesn't get out of control. I'm not entirely sure where this is going to go yet, but a review has determined that pre-treatment function is a major determining factor of whether or not vortioxetine will work for anxiety. See this article: https://www.psychiatryadvisor.com/anxiety/vortioxetine-generalized-anxiety-disorder-tx-pre-treatment-functioning/article/737747/ Of course the Trintellix+Rexulti combo has been great for my depression and my anxiety. But it's insufficient to keep my hypomania and mixed episodes under control. The Depakote is really the backbone in that regard. And after those three are put together my ADHD symptoms are most pronounced, which is what the Vyvanse is for. And I do feel that aside from helping with my ADHD, the Vyvanse does augment the Trintellix and the Rexulti. Keep in mind that most of what Trintellix does actually causes dopamine release unlike most of your run-of-the-mill SSRIs, which actually end up inhibiting dopamine release without the serotonin antagonist actions. The increased dopamine release combined with Rexulti's dopamine partial agonism really helps to control Trintellix's "outflow" if you want to call it that. A truly modulating combo. Another thing that changes from Rexulti when you add Trintellix is that Rexulti is a partial agonist of 5HT1A, whereas Trintellix has a lower affinity but MUCH higher intrinsic activity at that receptor making it mostly a full agonist, a modification of Rexulti's pharmacology, essentially.
  2. Wellbutrin is pretty much the only antidepressant that has been studied and regarded as having a low rate of manic switch relative to other available antidepressant agents like SSRIs/SNRIs/SMSs/tricyclics. I'm not currently aware of any studies where the rate of manic switch was compared among other antidepressants, but they might be out there. However, @argh is right that of the predominantly serotonergic antidepressants tricyclics as a class are generally regarded as having the highest rate of manic switch, and of the current generation antidepressants (SSRIs/SNRIs/SMSs), venlafaxine does have a somewhat higher rate of manic switch than others, keeping in mind of course that all of these rates of manic switch were measured when no mood stabilizer was present. So many of these agents may be quite useful after a patient has been stabilized on a proper bipolar medication regimen.
  3. Of all the SSRIs, Zoloft made me feel the most robotic. Like I was sometimes experiencing a life around me that I wasn't actually living or that I was just going through the motions and not actually controlling my body. Not in a psychotic way, just a profound internal sense of monotony. Celexa and Lexapro both were very demotivating and made me feel apathetic, but they didn't make me feel "robotic" the way that Zoloft did. Additionally, Zoloft did actually make me agitated at 75mg and kind of cold and stern. This never really got better for me. I don't really feel that way though on Trintellix, which is the AD that I'm taking now. Works really well for me. What it does for anxiety though is pretty hit or miss, and you just have to try it to find out. Based on my own experience though, the robotic feeling with Zoloft never really went away. You just stopped noticing it after a while or you got used to it to the point of not really caring. Prozac also did this a little bit but not to the same extent as Zoloft. I did not feel as robotic on Effexor, Pristiq, Viibryd, Cymbalta.
  4. @brianjoy The sedation from Seroquel starts to lessen after 200mg. Additionally, sometimes switching to the XR can make a big difference in sedation according to a lot of people's reports. It may also improve the weight gain problem for some people. @mikl_pls's suggestions above are definitely good ones. I have personally never tried ziprasidone, but he has and it's definitely going to be more activating at the lower doses and sedating at the higher ones. Only frustrating thing is that every time you take it, you have to take it with 500 calories, and it has to be taken twice a day. Although you can take larger doses all at once at night. Abilify will definitely be activating, although for some that starts to smooth out after getting to 10-15mg. I personally never made it past 7.5mg. I found it to be too agitating. Rexulti, however, has been awesome. Don't let anyone tell you that Rexulti is pharmaceutical evergreening and that it's just "the new Abilify". While it was fully intended to replace Abilify, it is definitely a different medication. I actually find it to be more sedating, and I take it at night, but it doesn't make me feel tired during the day and I think it provides a little bit of extra stimulation to the Vyvanse. Since starting Rexulti, I've gone from taking Xanax 2-3 times a week to taking it once a month or less. And it has a very strong antidepressant effect. Works really well with the Trintellix. Vraylar would definitely be more stimulating like Abilify. Although I've heard plenty of people find it makes them feel tired in the beginning even if they take it in the morning. So your mileage may vary there. Lamictal is also a great option for both bipolar and unipolar depression, although there are some that would disagree. Could definitely work if you need more stimulation. Effexor starts to hit dopamine at these higher doses which might help to enervate you a bit. Interestingly enough, the dose-dependence of Remeron's sedation could be fundamentally altered in the presence of Effexor if they are being taken together. Effexor, especially at 225mg, will have a fairly strong effect on norepinephrine reuptake inhibition. Remeron's blockade of adrenergic receptors should amplify this activity to make Effexor more stimulating. Even going along with the last suggestion, 300mg venlafaxine ER + 30mg mirtazapine would be one helluva combo. Also great options, although doctors are less receptive to augmentation of SSRI/SNRIs/SMSs with tricyclics because of serotonin syndrome. However, all of the above suggested tricyclics are actually not very serotonergic. nortriptyline is a metabolite of amitriptyline and while amitriptyline is regarded as one of the most serotonergic tricyclics, nortriptyline is quite the opposite, much more noradrenergic. Desipramine is the metabolite of imipramine and shares a similar relationship with its parent as nortriptyline does to amitriptyline. And protripyline is a different beast altogether in that it's the most dopaminergic. Low dose protriptyline would mean you wouldn't have to go to 300-375mg on Effexor to get the dopamine effects. All of these are great suggestions, @brianjoy. So comparing their pros and cons is all that's really left. Increasing the Effexor to 300-375mg will likely be the least intrusive as it's a medication you're already on and something your body is already mostly adjusted to. However, it isn't a very "complete" or "well-rounded" approach if you've been shown to be treatment-resistant historically and your condition has an array of symptoms ranging from depression (either situational or endogenous), to social anxiety, to obsessions. Effexor has shown to be one of the more effective antidepressants for treatment-resistant depression.....if it works for you. If it works partially, sometimes switching to Pristiq can make a difference. Augmenting with Remeron is a very appealing combination because it has repeatedly demonstrated positive efficacy in clinical practice. Dr. Stephen Stahl calls Effexor+Remeron "California Rocket Fuel". Downsides would be sedation and weight gain. However, at least from Remeron's perspective, a lot of weight gain does come from an increased appetite. So with some discipline the includes a diet and exercise you may be able to avoid some of the weight gain. Additionally, the more potent adrenergic effects combined with Effexor at the top end may help to fend off some of that weight gain and sedation. It would really depend on whether or not Effexor on its own has caused you to gain or lose weight. The other two augmenting options being tricyclics or Lamictal. I don't have any experience myself with tricyclics, so I can't comment much there except to say that pdocs will be more wary prescribing two antidepressants than they would be prescribing a combo of Effexor+Remeron or Effexor+Lamictal. Some pdocs, however, may be receptive, and if they're feeling adventurous, I would recommend that you go with it. The two downsides to Lamictal are that it takes a while to get titrated up and the titration itself can be a bit rocky. After increasing the dose, you may feel some anxiety, which may go away and you'll feel fine for a few days, then you might get depressed for a few days. After 1-2 weeks at the same dose it always levels out and that whole process is lessened after you get past 100mg. The only real deal-breaker with Lamictal is whether or not you get the rash. But if you don't get it, then Lamictal can be a very useful medication. Thinking like a pdoc, if I felt that you really weren't bipolar or psychotic in any way, I would be hesitant to go to antipsychotics as a FIRST augmentation strategy simply because they will carry more risks than other augmentation options like lamotrigine (Lamictal), tricyclics, mirtazapine (Remeron). However, if I had ruled out Lamictal and Remeron, I would go right to some of the atypicals that were mentioned here because they have demonstrated positive efficacy as antidepressant adjuncts with the most compelling evidence going to Abilify and Rexulti. Additionally, I've found that I require for depression and mood stabilization far lower doses of Rexulti than the prescribing information calls for. I started for the first 2 weeks at 0.5mg and by the end of the two weeks it was just too much and I couldn't tolerate it. So I dropped down to 0.25mg and stayed there for a few months. I just went back up to 0.5mg about two weeks ago and it feels totally different this time around, and I LOVE IT. Prescribing information though calls for a target dose of 2mg. Rexulti is by far my FAVORITE AAP of all the ones I've tried with Zyprexa coming in second. I know @mikl_pls did mention the risk of type 2 diabetes with Zyprexa. It is by far the riskiest AP when it comes to metabolic side effects. However, if you don't already have a family history of type 2 diabetes and you maintain a good diet and physical activity, Zyprexa is an option you should consider if other augmentation options don't work out. At even 2.5mg I found it to be very calming and good for depression. I never went higher than 5mg. I did gain a bit of weight and my blood glucose and triglycerides did increase. However, I did not take my own advice and eat better and work out while I was taking it. The Zydis form (sublingual) can sometimes cause less weight gain. I would second this one. You'll get better round-the-clock coverage of anxiety from Klonopin because it has a much longer half-life. So taking 1mg before bedtime may accomplish what you're getting out of the 0.5mg Xanax around noon during the day with less of a chance of building a tolerance. And if you do build a tolerance, it may take longer. Agree 100% with @dtac, if you can get Rexulti to take with your Effexor, go for it. Another thing to consider would be to switch the Effexor out for Pristiq at like 100mg.
  5. Very interesting. What I can say would make the most sense is that maybe your body actually has difficulty catalyzing the reaction to cleave the L-lysine from the dextroamphetamine. You can modify this by consuming foods that affect trypsin. Trypsin inhibitors like soy can slow down the metabolism of Vyvanse and make it last longer, just the same an inducer would cause you to metabolize it more quickly. Very interesting though. And yes I asked my pdoc about Dexedrine one time and he gave me a funny look. I can't fathom why pdocs think Dexedrine is so different from Adderall or Vyvanse. Adderall CONTAINS Dexedrine, and Vyvanse is just MODIFIED Dexedrine. So why it has this stigma among pdocs is beyond me. No problem! Glad I could be of assistance and welcome to the boards! We're glad to have you!
  6. Click your name at the top of the page in the right-hand corner. Click Account Settings. Then click the Signature section. Also you will notice in the drop-down under your name that there is a Profile section where you can also list them and/or go into more depth.
  7. Dexedrine and Vyvanse really aren't that different. Adderall is mixed amphetamine salts containing both levoamphetamine and dextroamphetamine. Dexedrine contains just dextroamphetamine, as does Vyvanse. But Vyvanse is bound to lysine as an abuse-deterrant and also to improve pharmacokinetics (makes it last longer and come down smoother). The problem with Dexedrine is that the pH of your digestive tract can greatly affect how it is metabolized. Whereas Vyvanse is not impacted by these kinds of parameters. How much Dexedrine do you take?
  8. Binaural beats

    binaural beats can be a very powerful thing, and they aren't all the same either. Different tracks run at different frequencies, which SUPPOSEDLY do different things. Sorry I don't have much more information on this. These audio tracks can induce neurotransmitter release which theoretically could trigger a hypomanic episode. I know that after I've listened to them for 15 mins or so I feel a bit dazed/dizzy/giddy. So there really is something there. Definitely not placebo.
  9. Hey, @Mindtrip! Welcome to the boards! I have Bipolar 2 and ADHD as well. Bipolar disorder and ADHD do occur together with a fair amount of frequency. I was diagnosed with Bipolar 2 first, and it wasn't for another 1-2 years after that until I was diagnosed with ADHD and prescribed stimulants. When you're bipolar, and especially when you're a rapid-cycler (like I am), you need to remember not to chase hypomania or motivation. Stimulants do motivate you for the first 1-3 weeks but after that the motivation goes away. The focus and concentration usually stick around unless you need to go up on dose, but the motivation is transient. It's important not to start on stimulants and just keep increasing to keep getting more motivated. Eventually you'll max out and just be over-stimulated. What I had to learn was first separate my mood cycles from the attention/cognitive problems. What I find is that during the "up-end" of my mood, I hardly ever have trouble with attention/cognition, and when I'm depressed, I have a significant amount of trouble. However, once I got my mood swings under control, I would still have significant problems with attention/cognition during a normal/euthymic mood (neither hypomanic nor depressed). Once I was able to actually "put a finger on this", I spoke with my pdoc about it. It's harder in adults because normally, ADHD is diagnosed when you're in elementary school, and the pdoc can come observe. Not so easy when you're an adult lol. We had to determine what dose of stimulants would be enough for me to be productive, but not too much to make me hypomanic. So he prescribed me Adderall 5mg immediate release. His instructions were to take 1 tablet, wait an hour, then try to do something that requires my undivided attention. Sometimes I need to do tedious audits at work that require me to review large spreadsheets. So I chose this as my task. The idea being, how many sittings does it take me to complete this task? How often do I get up for breaks? Etc. The next day, take two tablets this time, and try to do another productive task. The purpose to determine how much is too much, and how much is JUST ENOUGH. We ended up converting to Adderall XR 20mg. But issues with feeling like a zombie in the afternoon and just having it poop out starting at like 2PM prompted me to switch to Vyvanse. I've been up and down between 40mg and 30mg since. 40mg more so in the winters and 30mg in the summer. It is possible for people with bipolar disorder to take stimulants, it just may require a little more tuning and attention. It will also require a lot of personal insight on your part to make sure that you aren't chasing hypomania. That took a while for me to learn. Trintellix causes dopamine release, and I think Vyvanse, being as it does the same, works synergistically with Trintellix to increase that dopamine release. I also think the Vyvanse mixes well with the Rexulti. When I added the Rexulti, I felt more calm but at the same time slightly more stimulated. I also think Depakote has allowed me to take Vyvanse and stick at a dose longer without adjusting. Most importantly, make sure your mood swings are under control FIRST before adding a stimulant.
  10. You may have to get up to 200mg on trazodone for full sedative effect. But it's not really an ideal medication, because ideally you would be using medications that don't alter sleep architecture at all. Yeah it might be another few days yet before that really settles. It's only been 3 days so far. More than likely it'll be at least a week until that decrease "calms down". Like I said, up it to 200mg or switch to something else. Trazodone doesn't work for everyone when it comes to sleep, but it does work for most people lol Your signature says 1mg x2. So do you take 1mg twice a day or 2mg all at night?
  11. This is actually a tricky one to describe. It is a side effect, but it's not listed as a common side effect because the rate of occurrence was similar to placebo Placebo (N= 584) = 11% 1.5 - 3 mg/day (N=539) = 12% 4.5 - 6 mg/day (N=575) = 13% 9 - 12 mg/day (N=203) = 11% So basically insomnia occurred with almost equal frequency in all groups including placebo except for the 9-12mg group which is much smaller and still maintained 11% of patients reporting insomnia. So it you can do the math there and kind of see the steady growth and separation from placebo, but with it occurring so frequently, it's difficult to determine for sure. Stick with the trazodone. Maybe reserve 0.5mg of Klonopin for one of those times when you wake up in the middle of the night. But it won't help you feeling groggy during the day that's for sure. My mother-in-law's psychiatrist actually recommended something for her because she has sleep issues: take the Klonopin at night as prescribed and if you wake up at 2AM-4AM take a Xanax. She has both. Not a lot of pdocs are fans of using two different benzos that way but for refractive sleep issues it can be pretty effective. Try and stick it out though. The lower dose of Seroquel is likely still setting in. How many days now have you been at 100mg?
  12. YMMV is right. Bupropion is really hit or miss based on my experience and what I've read of other people's experiences. But when it works, it can work really well.
  13. Makes sense to start. If not, try 100mg. I think you can go up to 200mg on trazodone though so you have room.
  14. Yeah trazodone will be more effective for that. What dose were you prescribed for trazodone?
  15. Because Cogentin is "covering up" a side effect that has the potential to become permanent. EPS including or excluding akathisia/restlessness if its let go can turn into tardive dyskinesia which is a permanent movement issue that won't go away when you stop taking APs. For an AAP, Vraylar has one of the higher rates of EPS and akathisia. The hope is that as you adjust to it, this will go away. And that's a good thing. And it happens for plenty of people. But if it doesn't, then you might have to consider a different medication, because while Cogentin does temporarily make the symptoms of restlessness go away, it does not prevent you from developing TD. I'm not sure what dose your pdoc prescribed. Mine prescribed 1mg up to twice a day as needed. I took a 1mg tablet ONCE. I found it to be very sedating and intoxicating. It was VERY effective at treating the restlessness. But I felt downright STUPID. Definitely something I would only use if the restlessness was actually negatively impacting my day but I didn't have to go anywhere.