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JustNuts

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  1. Fetzima

    I'm still taking it to this day. It's been 1.44 years since I first started it (1 year 5 months 11 days // 17 months 11 days // 75 weeks 2 days). I think that may be a personal record, as I can't think of any other antidepressant that I've stayed on for anywhere near this long of a period of time. It's still working pretty well for me, although I have noticed that the issues mikl_pls had experienced and warned me about do appear to be present to some extent (they're quite inconsistent & variable though, and I don't seem to experience them as strongly as he did). I don't typically get tired during the day on this med unless I haven't had enough sleep/water/food (although I used to be constantly tired back when I was taking cariprazine (Vraylar) to augment the Fetzima -- are you possibly on any other meds that could be causing the tiredness?). I'm probably not the best judge of this though given that I'm on a high dose of Adderall as well.
  2. @Iceberg To my surprise I ended up getting billed a mere $33 for the ECG interpretation, which my insurer knocked down to $13.24, making this entire mess just $238.59. So it turned out quite a bit better than I was expecting in the end (I was thinking it'd be at least $300 at absolute minimum)... Not quite sure why they gouged me so ridiculously hard on the actual test, but whatever, it's basically over and done with at this point except for paying the bills... Of course now a new and much nastier crisis has reared its ugly head to replace the EKG one (which technically isn't even fully finished as neither the hospital nor the cardiologist have bothered sending me their finalized bills yet even though both claims have been finalized) and now I've got to go figure out how to deal with this new bullshit (if I even can — this one might actually be bad enough to finally call endex on life for good, which is quite a pity given how things had been improving recently).
  3. Well I was finally able to confirm that the EKG interpretation & report was completed and that my psych received it over a week ago. The results were pretty much exactly what I expected: Sinus Tachycardia, otherwise normal EKG. Seeing as my psychiatrist hasn't contacted me despite having gotten the report over a week ago, I'm assuming that he isn't overreacting to the sinus tachycardia, so no med changes, no worries, everything worked out fine in the end...except for the cost, which is going to be quite high (I'm guessing it'll ultimately be up to $400 once the bills from the in-network cardiologist who did the report and possibly also their in-network electrophysiologist (I think his name was also on the report?) are added to the outrageous $225.35 that my insurer apparently thinks is a fair price for a outpatient EKG test without interpretation or a report (I'm still wondering how the hell they justify charging so much money when the machine setup cost them no more than $15–$20k at the absolute most (assuming a very high end model/manufacturer — the lowest-end machines cost as little as $1000), the test uses well under $5 of consumables, it's done by a technician that makes a bit less than a RN, and takes maybe 5 minutes to do...not to mention that Medicaid/Medicare would have only reimbursed them <$10 for this and if I was in Ontario OHIP would have reimbursed them even less! It's just bloody ridiculous all around...)). Oh and I still didn't get a copy of the report as originally promised, only a brief look at a scan of it thanks to my therapist — I'm probably going to have to formally request a copy either from the practice where my therapist & psychiatrist are based at, or from the medical group that did the testing/interpretation/report...
  4. Hi Brand New, Need Stim Opinions

    The conversion between lisdexamfetamine and dextroamphetamine dosages with IV use is approximately 33–36% going by dose-adjusted AUC0–24 ratios in IV PK research comparing LDX and dextroamphetamine sulphate ((319.5/25)/(355.8/10) => 35.92%, (562.7/50)/(681.4/20) => 33.03%, ref). However, 40 mg of dextroamphetamine is supposedly an equimolar dose to 100 mg of lisdexamfetamine, suggesting a 40% conversion (apparently 40.3 mg of dextroamphetamine sulfate salts is equal to 100 mg of lisdexamfetamine dimesylate salts, with both being equal to 29.6 mg of dextroamphetamine base). The same study suggests a conversion of approximately 42% going by the dose-adjusted AUC∞ ratios with oral doses of LDX and dextroamphetamine sulfate ((1817/100)/(1727/40) => 42.08%, ref). Now it's clear that IV and oral use are quite utterly incomparable, especially so given the major differences between how d-amp and LDX operate and are absorbed, so the calculated 33–36% figures from the IV study isn't anywhere near an accurate estimate for oral use comparisons. The main reason for this is likely due to LDX having a consistently very high oral bioavailability with essentially all of the conversion from LDX to d-amp happening after absorption, while d-amp in comparison has a significantly lower oral bioavailability that is dependent on a number of factors. Therefore 40–42% seems to be the most accurate rough lower estimate for conversion between LDX and d-amp, and is in line with the literature I have previously reviewed on estimated equipotent doses of LDX and MAS/d-amp (generally in the range of 40–50%). However it is still useful to know where the incorrect lower estimates came from (the prior IV research). Note that the second cited ref (comparing oral dosing) has a much larger sample size than the first ref (23/24 vs 3/3 + 9/9). You cannot really truly directly convert d-amp and MAS because MAS is a mixture of multiple different salts and MAS is approximately 25% l-amp, which is not exactly pharmacologically equivalent to d-amp (although the exact magnitude and effects of the difference between l-amp and d-amp are still under debate). However it's fair enough to say that MAS is roughly equivalent to the same dose (by weight) of d-amp. Thus 90 mg d-amp ≈ 90 mg MAS. In theory if you go by amphetamine base content (ignoring the differential effects of l-amp base and d-amp base entirely), a given dose of MAS is supposedly equal to roughly ~85.5% of that dose in d-amp (e.g. 30 mg MAS ≈ 25.65 mg d-amp), or a given dose of d-amp is equal to roughly ~117% of that dose in MAS (e.g. 30 mg d-amp ≈ 35.1 mg MAS), but I honestly don't put that much stock in this conversion methodology given how it's seen very limited use in peer-reviewed literature and how it has obvious flaws. If you use this method, 90 mg d-amp ≈ 105.3 mg MAS. 90 mg of d-amp is equivalent to ~90–105.3 mg MAS. 90 mg of d-amp is also equivalent to ~180–225 mg (214.29 mg @ 42% LDX/d-amp conv) LDX (oral). Your numbers are wildly off. 300 mg LDX (oral) = ~120–150 mg d-amp (126 mg @ 42% LDX/d-amp conv). You'll never see 35% conversion outside of IV use.
  5. Jesus fucking christ, the claim for the EKG just popped up in my insurer's claims portal and it's an adjusted amount of $225.35 (and because my deductible hasn't been met, I pay the full post-adjustment amount). That's...extremely painful... Apparently the previous info I was given by the hospital's billings department was mostly bullshit... To make matters (much) worse, the billing code being shown here is 93005 only, not 93000 or 93005+93010, so presumably I'm going to get another separate fucking bill under code 93010 from whoever they use for the interpretation and report (which will cost god knows how much more — probably somewhere around $100 if it's similar to the past, although 93010 has always been on the same bill as 93005 in the past, just as a different line item, so that's a bit confusing to say the least). Fucking brilliant. I still haven't gotten any info whatsoever on the test results, but since I'm only seeing 93005 on this claim, that means it's entirely possible that whoever they use for the interpretation and report hasn't even done the fucking interpretation and report yet, and I have no info from my psych to confirm or deny this...although odds are that the interpretation and report have already been done and sent to my psych and the claim for that will pop up in a few more days.
  6. I just finished an exhausting ~10 hour work day on approximately 3 hours of sleep (oops), so bear with me here, this response might be a little incoherent despite the (currently quickly wearing off as I type this) caffeine & Adderall (I work in software development and am currently solely focused on a major cleanup/overhaul of the bloated and messed up codebase for the company's main product with a broad scope of action and not much support from the rest of the team (and while our >50k SLOC is still technically a "small" project in the big picture of things, it's still nowhere near a simple one, it's absolutely massive compared to codebases I've worked on in the past, it has very significant technical debt, there's extremely poor/minimal documentation available, it has been maintained haphazardly for years, it's fragmented to the point that the core devs & our team leader/director don't have enough knowledge to answer many important questions, and it's primarily written in C# (which is one of the software languages that I'm less comfortable with and have less experience with)), which is all rather mentally exhausting, especially so when I get too little sleep). So please tell me if I missed anything important or didn't answer anything in enough detail — hopefully my writing isn't too disjointed and/or riddled with errors to comprehend. If the interpreting cardiologist and my psychiatrist deem the results to be normal (assuming that the interpreting cardiologist finds nothing more of concern beyond the appropriate sinus tachycardia that appears to be present and that there is no overreaction to said appropriate sinus tachycardia (some doctors prefer to respond to any form of tachyarrhythmia aggressively irregardless of the rest of the clinical picture, but this relatively mild level of tachycardia present with the medication cocktail I'm on (the high doses of Fetzima and Adderall rather aggressively elevate norepinephrine levels, while the high dose of Adderall aggressively elevates dopamine levels as well, which both clinical data and structural mechanisms agree that this would generally cause a significant elevation in HR) and my history of anxiety (as well as my physical and family history) would generally/typically not be considered an issue requiring any response beyond continuing normal clinical monitoring and a repetition of the usual standard advice about best practices for exercise/managing stress/maintaining cardiac health), the medications will stay exactly the same as they are now. If the results are normal but an aggressive response to the results is preferred for whatever reason, my psychiatrist would likely want to reduce the dose of the Adderall and/or the Fetzima and may refer me to a cardiologist for treatment (either in combination with or in lieu of reducing the medication dosages). If the results are abnormal (i.e. if they find evidence of something genuinely concerning, such as atrial fibrillation, Wolff-Parkinson-White syndrome, atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, etc), my psychiatrist would most likely have me immediately stop taking the Adderall (and possibly the Fetzima as well) then follow up ASAP with a cardiologist for further testing. EKGs (technically I should really be using the term ECG or just electrocardiogram, but I'm stubbornly used to using the term EKG instead, which is still technically correct, and anyways I digress) have a relatively high rate of both false positive and false negative results (although it's highly variable), and the first step following most abnormal EKGs is to get more detailed/extensive testing done, with typically something like a holter monitor as the first step. If follow-up testing does not reproduce the initial results and does not result in any further abnormal observations, no further action would be required and I would most likely be returned to the previous regimen of medication. If follow-up testing does reproduce the initial results and/or results in any further abnormal observations, further testing may or may not be required, treatment is likely necessary, and depending on the ultimate diagnosis I may not be able to safely take certain medication (particularly psychostimulants) at all, or could only take them with extreme caution, ongoing monitoring and treatment, etc etc. But that's rather unlikely — if I had a genuinely concerning heart condition, one of the 3+ prior EKGs I've had would have already caught it unless it only developed recently or it was unusually excabarated by the current medication cocktail (rather unlikely given that I've been on cocktails in the past with far nastier observable cardiac effects (both in terms of HR and BP increases as well as physical symptoms) without anyone becoming concerned (and one of those prior EKGs was done while I was on a particularly nasty combination of high-dose methylphenidate, bupropion XL, and fluoxetine and was actively having a severe panic attack at the time). The psychostimulant (Adderall) probably causes the greatest elevation in heart rate, followed by the Fetzima (obviously the combination of the two results in greater effects than either one individually, and the fact that I'm on the maximum dosage of Fetzima plus a technically above maximum dose of Adderall (although dosing guidelines for Adderall are vague, poorly defined, and not based on empirical evidence — an issue also seen with essentially all of the other psychostimulant formulations used for the treatment of ADHD, and one that has seen limited but persistent & significant discussion in the scientific literature, in official evidence + consensus based treatment guidelines, in medical textbooks, and in other sources) is going to make matters worse — the literature certainly shows a pretty consistent (although rather broadly variable, i.e. with a high standard deviation in results) dose-response relationship between increased HR/BP/side effects and increased amphetamine/methylphenidate dosage, and while the literature on levomilnacipran is considerably more limited, it shows similar trends (actually levomilnacipran is technically associated with substantially larger average changes in heart rate than amphetamine/methylphenidate, even at high doses, although I'm not sure how high the variability is for levomilnacipran). But the most important part is what your baseline heart rate off of meds is — if that's already persistently elevated (which mine was), it's generally only going to increase further on these kinds of medication, especially at higher doses — and it doesn't take much of an increase to go from a "high normal" reading to a "low abnormal" reading! An EKG is a reasonably good initial cardiac screening tool, but for healthy adults (and children) with low cardiac risks, routine or screening EKGs are not recommended. This is why I said earlier "they could be a dick and reject it for being technically somewhat medically unnecessary if they wanted to", because professional guidelines for the treatment of ADHD don't really support the use of an EKG as a screening tool in cases like this, although I guess the complex polypharmacy in my case combined with the elevated heart rate, high dosages, and some other weaker semi-bullshit arguments would probably be enough to make a reasonably strong case to support the medical necessity of this EKG (however if the complex polypharmacy didn't exist the case would be relatively weak). If you're concerned enough about the episodic palpitations/tachycardia that you've mentioned, you can talk to your GP about it and see what they think. They'll have a much better idea of your detailed medical history than I would, and would be best qualified to determine if some sort of cardiac testing (EKG, holter monitor, cardiac event recorder, etc) would be appropriate or not in your case. However keep in mind that testing is expensive and the kind of episodic palpitations/tachycardia you've mentioned are usually entirely benign unless they're unusually severe, persistent, and/or present with other concerning symptoms potentially attributable to a cardiac abnormality. I'm just not able to function off of meds. No antidepressant = depressed & suicidal, while no ADHD meds = severe ADHD, depressed, and suicidal. No benzodiazepines = anxiety out of control. No HRT = gender dysphoria comes back with a vengeance. No PPI (pantoprazole) = gastritis symptoms return with a vengeance. Migraine meds (sumatriptan) drastically reduce the level and duration of decreased functionality due to migraines, and ibuprofen (which is what I relied upon before my current GP found out about my migraines, immediately wrote a RX for sumatriptan, and persuaded me that it was worth trying (I apparently had an extremely skewed perception about the point at which the severity, frequency, and controllability with OTC meds of migraines justified taking any kind of prescription-only medication for migraines, plus I was already rather overwhelmed with the number of meds I was on for other stuff)) is severely inferior to sumatriptan (alone and/or with ibuprofen) in efficacy. And without the temazepam my sleep is even more messed up. My therapist actually recently brought up the topic of potentially reducing the number of medications I was taking in the future, and I had to point out that I was already on essentially the bare minimum number already — the only thing I could potentially see being maybe able to eliminate under near-ideal circumstances was the antidepressant (and I guess I could dump the bicalutamide if I ever somehow managed to afford SRS (with the way things are going, it'll be fucking decades before that can happen), but that's literally it unless something miraculously and inexplicably drastically improved to the point where one of the other meds could be eliminated (ridiculously unlikely))... My criteria are complex, but I'll try to describe some of them. If the side effects are consistently far too much to bear at any point and there are either no medications capable of practically alleviating/controlling the side effects (e.g. 30 mg escitalopram was intolerable) or if the medication to alleviate/control the side effects is ineffective or insufficiently effective, I dump the med (or reduce dosage if the effect came from an increased dosage (e.g. 30 mg escitalopram)). If the side effects are ridiculously extreme (e.g. when sertraline was added to existing methylphenidate (my first experience with any form of antidepressant), where I ended up with full-blown goddamn serotonin syndrome for a few days until I figured out what was happening and stopped the med (it was an astoundingly horrible and bizarre experience); the very nasty and thankfully short trials of AAPs olanzapine IR/quetiapine IR/ziprasidone IR), I stop the med as soon as possible. During the first 1–3 weeks on a medication (and for a similar or sometimes shorter time following dose increases) I generally automatically expect significantly worse side effects than at steady state, and will do my best to tolerate any nasty side effects during this period. If the side effects are still nasty after this period has passed and there isn't a major enough benefit to offset them, I drop the med (note that for medications with an extremely long half-life (e.g. fluoxetine) I will wait far longer than 1–3 weeks for the initial nasty side effects to reside and for effects to start to appear). If I don't notice any even vague positive effects from an antidepressant within a certain period of time that depends on the severity of side effects and how close the antidepressant theoretically is to being at steady state for the current dosage (a period of time that can be roughly calculated from the half-life of the drug and any relevant active metabolites, although with certain concomitant medications (especially any concomitant medication that inhibits any of the enzymes responsible for metabolizing the antidepressant) I will wait longer than this period), I'll generally either ask about increasing the dose (if the side effects are still tolerable and a higher dose is practical), or ask about switching to a different medication. If over the long term an antidepressant has only minor or vague positive effects, I'll eventually ask about augmentation and/or switching antidepressants. If an antidepressant's effects fade away to an impractically low level after a period of time and remain that way (e.g. vortioxetine), I'll ask about augmentation and/or switching meds once it's clear that the effects are poor enough and have remained that way for long enough (the exact duration is determined on a case-by-case basis, although a few days isn't long enough). Evaluating the efficacy of an antidepressant is very difficult, and I have a tendency to err on the side of caution if the side effects are tolerable and the depression isn't severe enough. I do feel similar about tending to increasingly question the efficacy in the longer term. IDK, I feel like for most ADs, there's a significant initial placebo effect that fairly quickly fades with time, and the efficacy of the medication itself (or at least the perceived efficacy, which is approximately the same thing) also tends to wane with time...although the rate at which it does so seem to vary at least depending on the med, once it's useless it's generally not useful again even after a short (a few days to a few weeks) break (I don't think I've revisited an antidepressant med after a long break yet except for technically bupropion, which was a special case anyways), and some antidepressants' efficacy only wanes a little bit with time (Fetzima for example). Changes in environment or in other meds in my cocktail can also have a huge impact on the perceived efficacy of an antidepressant... I've also wondered about meds possibly/potentially making my depression worse, but I generally resolve that conflict if possible by tolerating the med for as long as possible then eventually just switching meds, and with Fetzima at least it's pretty glaringly obvious that my depression is overall not worsened by the med (and if it's specifically worsened in some domain, I'm not very sure what that would potentially be). I could write quite a bit more about this topic but I've spent wayyy too much time typing up this reply already, I need to wrap this up and go to sleep... Okay, last set of points to reply to. Primary efficacy-related drug trials required for FDA approval of psychotropic meds (focusing on antidepressants here) generally run for at least 4–8 weeks (more typically 6–8 weeks) as large double-blind placebo-controlled trials. A number of these types of trials are required for approval, as well as a few much longer open-label trials (often operated as extension trials as well) in which longer-term efficacy, safety, and tolerability is assessed over a period of over 8 weeks, and usually at least roughly a year (sometimes multiple years) for the longest trials (you need at least one ~1 yr long open label trial for approval plus at least a few 4–8 week long double-blind placebo-controlled trials and a pile of other shorter-term or more basic research plus a whole bunch of documentation and applications and proposed labels and other stuff, as well as FDA approval, which happens only once they're fully satisfied with everything — not only do they do detailed internal reviews of all the research and information associated with the information, they are also able to require additional research with FDA-set specifications from applicants if the FDA deems it necessary for the applicant to produce further research of any type and on any topic that the FDA requires in each individual case). As implied above, there are also a bunch of shorter trials done as well to test basic efficacy, dose-response, dose optimization, safety, tolerability, pharmacokinetics, etc prior to running longer trials, and there's always very substantial preclinical research done to obtain a broad variety of information on non-human subjects and in vitro. The overwhelming majority of drug candidates fail to make it to market, with failure rates increasing markedly at each stage (or more properly phase, a concept I won't discuss in detail) in the process. Overall, the FDA approval process is pretty damn thorough. If anything they are too conservative and stringent in a number of ways and areas. And they do require extensive post-approval monitoring and further trials as well. But the process is not perfect, and the benchmark for proving efficacy is lower for antidepressants than it is for many other medications due to the relatively uniformly very low effect sizes seen with pretty much all antidepressant trials. It would be inaccurate to claim that efficacy is established based solely off of short-term trials due to the existence of (mandatory) long-term open-label trials. If you don't have at least one sufficiently well designed and run large open-label trial lasting at least ~1 year, it doesn't matter if you have 200 4–8 week trials, you're not going to obtain final approval from the FDA for your NDA. It is also relatively inaccurate to claim that post-marketing reports or bad side effects are omitted, as all properly-conducted post-marketing trials and all reports of adverse effects from sources such as FARES will be taken into account by the FDA when it comes to subsequent post-approval monitoring, label/monograph revisions (the FDA gets a lot of control over these), additional post-approval research requests (the FDA's ability to require trials fulfilling certain requirements to be conducted by the applicant does not end after the drug has been approved), etc etc. All side effects that can be properly demonstrated to occur at even marginally significantly higher rates in patients taking the drug during trials are reported in the labeling/monograph, and are taken into account by the FDA. And the FDA is generally pretty good about ensuring that drug monographs/labeling contain enough relevant up-to-date information on most topics, although unfortunately not all of the topics covered are kept up to date, and due to limitations on length and the standard of evidence required a drug's monograph/labeling is never anywhere near perfectly comprehensive. Yes, very-long-term research on antidepressants is a bit lacking, but because their effect sizes are so lackluster in the first place, it's rather hard to measure their efficacy in general, especially in less severely depressed populations. Most psych meds are still officially intended/approved for short-term/medium-term use only irregardless of what actual consensus-based or real-world recommended usage durations are, and they pretty much all quite explicitly say in their product monographs that they have not been sufficiently evaluated for long-term use, etc etc. That doesn't mean that they aren't viable long-term medications. I'd usually do some more research on what the current state of the science is on the evidence for long-term (as in decades to lifetime) use of antidepressants and discuss the results of that here at this point, but I've spent hours working on this and I really need to go to bed now in order to maybe get more than 3 hours of sleep before getting up to get ready for work tomorrow (at this point I'm unlikely to get more than 5 hours max :(...god I hope I get more than 3 hours tonight, I will be an utter wreck tomorrow if I don't). Hopefully this is a sufficient answer for your questions.
  7. Went in and got the EKG done today. In theory interpretation should be completed and the final report delivered to my psych within 24 hours, but it may be a bit longer. I should have access to the report through their online portal at that point, which is nice, assuming it works... I got to take a brief look at the EKG readout after it was printed, nothing was obviously abnormal outside of the 110 BPM HR (although the only specific measure that I could really interpret was the QTc value, which appeared to be within the normal range — I'm nowhere near qualified to interpret the rest of the EKG without access to references). In hindsight I regret not asking to take a quick picture of the printout before I left — I doubt I'll see the actual printout again and it was rather interesting (not to mention that it cost god knows how much money so I might as well get my money's worth out of it). Ah well, hindsight is 20:20. Yep. The eternal struggle. Good documentation and research can only help so much... And this is all incredibly cost and time intensive. Not to mention the lovely stigma. Such fun /s. Attributing actual discontinuation symptoms to depression recurrence? That's odd. They shouldn't be trying to pull that BS. I agree. I wish I had something more encouraging to say...but after four years, >60 medications, ~7 inpatient stays (with a total of ~5 months spent inpatient), 6 therapists (4 primary), 8 psychiatrists (4–5 primary), and ~$300,000 of healthcare bills during this period (out of pocket share was roughly ~$40k including all copays and premiums), well, I'm a bit overly jaded at this point. Am I better off than when I started? Indisputably. Am I satisfied with the ultimate outcome? Only somewhat. Am I happy? Not really, although at this point I do have a pretty good understanding of where a relatively considerable amount of my remaining dissatisfaction is coming from (unfortunately it's mostly not something I can fix easily or quickly, and although I can slowly work towards a resolution, it's unclear how well that'll work out or how long it'll take). The only advice I have is that well-informed strong self-advocacy is very important, you need to remain open to trying different things whenever it's practical to do so, and no matter how many setbacks you encounter (big or small), you have to keep moving forwards with your best effort or else you'll never improve.
  8. This stupid EKG is going to be a problem. I figured out where to go to get it done (apparently I can just walk into the local hospital's cardiology department with the requisition form from my doctor, no prior appointment necessary), but apparently the insurer-quoted $26–$95 price is an inaccurate estimate as when I contacted the local hospital to try to confirm what kind of price range I was looking at, I was informed that they bill my particular health insurer $234 for an EKG (in comparison, uninsured people are apparently billed $422), and they could not tell me how much of that billed amount my insurer would accept/reject (not even a ballpark figure). Then I dug up some old insurance claims from 2016 that had two previous EKGs on them (same health insurer, one EKG was done at the local inpatient psychiatric hospital as a screening EKG prior to initiating a trial of ziprasidone, the other was done at the local hospital's ER when I was in there after I attempted to kill myself by overdosing on my meds) and discovered that the accepted and paid-out total amount for each of them was approximately ~$320. Then I checked the Medicare Physician Fee Schedule and found out that they pay out <$20 for an EKG. Checking third-party national sources gave a wide range of price estimates. Alarmed at the massive disparities/variation I was seeing I tried contacting my health insurer to see if they could clarify things a little bit, and was told that they could give me no information whatsoever beyond the fact that apparently their own healthcare procedure cost estimate calculator's estimates should apparently not be considered to be reliable or anywhere near accurate. Sooo basically I'm looking at anywhere from $26–$234 to get this EKG done, assuming that I can trust that the hospital actually quoted me the price for either the CPT code 93000 or the CPT codes 93005+93010 (and not something weaselly like just quoting 93005). The insurer's healthcare procedure cost estimate calculator spat out $26–$95 for CPT code 93000 in my area on my current plan with my deductible unmet (although perhaps the calculator is erroneously calculating the cost as what it would be if my deductible was met despite claiming to take that into account? that would mostly explain the observed price disparities... hmm...). Both previous insurer-billed EKGs were 93005+93010 combos (with ~$320 being the total combined amount paid out to the hospital per instance — back in 2016 the local ER had originally tried billing $398 for 93005 and $172 for 93010 before the insurer adjusted the price downwards on both of those). I think I'm going to try to just go get it over with tomorrow morning and try to avoid worrying about the price any more until the bill turns up, since there's not exactly much I can do about the cost right now (I already checked to see if I have alternative options — but there were essentially no other viable options in my local area that are in-network) and I have to get this done irregardless of the cost anyways. I was tempted to just go today, but since this is only my first day back on the full dose I thought it'd probably be better to wait a day or two before getting it done to let things stabilize first... The lamotrigine could be contributing to the apathy. But it could just be inherent as well. It's rather hard to tell them apart with long-term depression, multiple comorbidities, and polypharmacy... I'd say that's a decent description of what Fetzima is like. It's definitely somewhat additive with stimulants in its effects, although unlike bupropion there's no CYP2D6 enzyme inhibition to worry about, and in my experience it's not as troublesome as bupropion when it comes to increased HR/BP, increased anxiety, or a few other side effects (but then again I may just not tolerate bupropion well to begin with — not really sure).
  9. I've been on it since late December 2016. Titrated from 20 mg -> 40 mg -> 80 mg -> 120 mg. Its unique 1:2 serotonin:norepinephrine ratio (compared to 30:1 for venlafaxine, 14:1 for desvenlafaxine, and 10:1 for duloxetine) makes it a rather interesting SNRI, but that ridiculously NE-heavy ratio leads to poor tolerability and significant side effects, especially when first starting the med. IIRC back when my old psychiatrist first proposed prescribing levomilnacipran she had said that most of her patients couldn't tolerate it, but the ones who did tolerate it generally did well on it. Anxiety and nausea were definitely the most significant side effects during initial titration, but as I had a generous supply of PRN meds for both of those issues at the time, the titration process wasn't too bad, and the side effects dampened down significantly once I was done titrating and had stabilized at a consistent dose for a little while. Compared to other ADs, the only thing that's topped this was vortioxetine, which I had a superb initial response to (but that didn't last very long). It's definitely my favorite SNRI (duloxetine wasn't too great, while both venlafaxine and desvenlafaxine were utter crap). I'd say my long term response to Fetzima is significantly better than all other ADs, but it's not ideal. Then again, nothing is ideal, and this is the best single-entity antidepressant I've found so far. It lessens the depression and suicidal thoughts, increases my energy levels, increases my motivation a bit, and probably a couple other minor things that I can't think of. Side effects are somewhat similar to what you'd see with something like bupropion (anxiety, appetite suppression, increased heart rate, sometimes some mild jitteriness, dry mouth, nausea, insomnia, etc). In terms of half-life, it's relatively short at just 12 hours, but there are no major withdrawal issues assuming you take it "daily" (doesn't have to be exactly every 24 hours — I've found it to be much more forgiving than the other SNRIs in that regard). I've inconsistently noticed some limited changes in effects late in the day, but that's minor. If you actually outright skip/miss a day, withdrawal effects are initially reasonably minor (mostly just tiredness and difficulty thinking — sometimes the depression worsens a bit), but if I skip/miss more than a single day (it's happened a few times) I notice the depression rapidly getting much worse and I also start to get antidepressant discontinuation symptoms (it's not as bad as the other SNRIs with these but it's still not pleasant at all). Going back on the med quickly resolves both of those issues. Yep, it's brand-name only right now. Their 5-year FDA exclusivity expires in late July this year, but they have several patents covering the drug, the earliest of which expires in early June 2023, and the latest of which expires in late May 2032. So generics are nowhere near being available. It's relatively pricy for an antidepressant (cash price of >$400, my insurer/PBM pays ~$325), and my insurer considers it to be a non-preferred brand-name drug ($100 copay), but Allergan has a pretty good savings card available that cuts my copay down to $30 (if your copay is above $30 they'll pay up to $105 towards reducing it to $30). Last year's savings card had reduced my copay ($80 at the time) down to just $20, but they changed it this year (they also increased the maximum they'll pay towards reducing copays from $80 to $105, so I guess increasing the patient's share of the costs from ≥$20 to ≥$30 isn't too bad of a tradeoff to make on a broader scale...but of course on a more personal scale I'm pretty fucking fed up with these damn copay increases (my generic drug copay went from $10 to $15 this year)). It's not the most expensive drug I've been on (that dubious honor goes to the atypical antipsychotics I've been on, the worst of which was Vraylar (which had my insurer/PBM paying a whopping ~$1085)), but it's still relatively pricy for an antidepressant.
  10. levomilnacipram (Fetzima) 120mg — depression Adderall IR 60mg (20mg TID) — ADHD finally changing back to Adderall IR 80mg (20mg QID) in the next half-week or so temazepam (Restoril) 30mg QHS — sleep issues diazepam (Valium) 10mg (5mg PRN BID) — anxiety bicalutamide (Casodex) 50mg — gender dysphoria/gender identity disorder estradiol transdermal system (Vivelle-Dot) 0.2mg/24h BIW — gender dysphoria/gender identity disorder pantoprazole (Protonix) 40mg — antral gastritis (idiopathic/chronic) sumatriptan (Imitrex) 50mg PRN — migraines So after three very miserable months on Adderall IR 20mg (10mg BID) thanks to a stupid incompetent fucktard of a psychiatrist who really needs to have his board certification revoked, I finally managed to flee to the only other psychiatric practice in the area, which luckily has a so far seemingly decent psychiatrist, although he's remote (it's via telepsychiatry, which is weird), he's less accessible, and it took me almost two full months to get in to see him. Still, he agreed to take me on as a patient, and he restored the ADHD meds to something more or less functional (Adderall IR 60mg (20mg TID)), although I still unsurprisingly couldn't seem to manage to get the intended 12 hours out of TID dosing without some nasty crash-like effects towards the tail end of doses, which is a bit of a major issue. Still, it was enough for me to return to my part-time software development job at a startup, which I'm glad about. Today after close to a month on Adderall IR 60mg (20mg TID), I had my first follow-up appointment with this new psychiatrist, and we discussed the remaining issues I was having with TID dosing and what to do about them. Switching to Vyvanse was discussed, but it just wasn't that good of an option in a number of ways, so we're keeping it as a reserve option instead for if I ever need to switch ADHD meds in the future. The psychiatrist agreed that going back to my full old dose of QID IR Adderall (I had previously been on QID 20mg from August 2016 to December 2017 before the stupid incompetent fucktard of a psychiatrist who really needs to have his board certification revoked decided to screw with the dose) was probably the best option available to resolve the remaining issues, but due to it technically being an "off-label" dose, he wants me to go get an EKG done once I'm back on the full "off-label" dose in order to rule out any arrhythmias despite having at least two negative past EKGs (although this is apparently because I wasn't on as high a dose of IR Adderall specifically for any of said past EKGs). So I've got to go get that EKG done next week — hopefully my insurer will cover that, their site says it should be between $26–$95 if the EKG is covered and in-network, but they could be a dick and reject it for being technically somewhat medically unnecessary if they wanted to. And hopefully nobody decides that my relatively high resting HR on meds (it's high off meds too, just less so) counts as an arrhythmia... I'm probably worrying too much over nothing again though. On the bright side, I've been hearing interesting rumors through the grapevine about my previous stupid incompetent fucktard of a psychiatrist who really needs to have his board certification revoked. Apparently his practice has been virtually unreachable for patients and providers recently (heard this from both my therapist and secondhand from someone else), and according to someone else (secondhand) he and his practice are apparently under investigation for Medicare & Medicaid fraud and overprescribing/misprescribing (although I'm not sure if these particular accusations are fully true because while they do fit the picture I saw almost perfectly, I can't find any independent proof yet beyond this single person's second-hand claims to corroborate these claims — however if he is currently actively under investigation there won't necessarily be any open public records of it until after the fact).
  11. A LOT better until I stopped the Adderall. Even the turmoil from resuming the hormones after the abrupt extended breaks was finally evening out. I was feeling good enough to actually finally go back to work and was somewhat looking forwards to continuing (which of course that had to happen literally right before the whole mess with my psych started! I must look like a total fucking idiot reappearing after being gone for so long, apologizing, being back to normal for a day, then suddenly vanished completely again. I am very lucky that this is a very loose part time job where they let me mostly set my own pace and that they were fine with me being gone for so long, but I feel like I'm pushing it way too far and, and it being totally out of my control right now and entirely thanks to this fucking psychiatrist casually fucking me over for no clear reason is really not helping and I feel super guilty even though there is really nothing I can do)... So yeah, it got rather shitty again, but purely because of stopping the Adderall due to the mess with the psych. I completely stopped taking the Vraylar at all though when I stopped the Adderall, I was too depressed to care about that even when I was super suicidal and should have taken it, on Adderall I was still rational/aware enough to stop myself and take the Vraylar when I saw the warning signs, apparently I'm not (at all) when I'm off of it (no big surprise considering my pathetically poor executive functioning and the fact that stimulants are known to range from good to great at improving executive functioning in general, among other things). One of the things that's become super clear is that the Saphris was never really tolerable and stopping it was an excellent move. I think maybe the very first few days I was on it in the hospital it helped pull me out of the depression (although my therapist is pretty confident that there's a strong positive temporary psychological effect just from being in the psych ward temporarily removed from the situation "outside" and in a supportive atmosphere, and I think that makes teasing out the actual sustained efficacy of most meds started in the psych ward wayy harder to estimate), but after that, it was just a shitload of unpleasant side effects with no clear continued benefits from taking it. I'm STILL trying to figure out WTF happened with the psych. The past fucking ~1.5 months have been such a weird mess. I thought things were finally stabilizing and starting to become okay again other than the lingering on-and-off depression and that the worst things I'd have to deal with would be telling my PNP that I had dumped Saphris, figuring out the long-term solution for mood stabilization, and dealing with the health insurance uncertainty. Then this whole mess with the Adderall comes out of left field. I'm trying to decide which combination of the following potential theories might help explain the situation: Dr. ["actual" psychiatrist] being mad at my PNP for resuming the benzos (specifically the diazepam) after I was discharged (since he had abruptly stopped them while I was in the hospital for idiotic reasons ("too many narcotics", "coping skills are better than pills", "time to practice those coping skills", "the benzos were never meant for long term use", etc)) — however that's entirely my PNP's decision to make and she strongly disagreed with his rationale Dr. ["actual" psychiatrist] being mad at my PNP for putting me back on 20mg QID of Adderall instead of keeping me at the 10mg BID he had chosen in the hospital for god knows what reason — however in the hospital he said explicitly that my PNP would handle the psychostimulants again once I was discharged, in the past he's been quite clear that he wants her to handle them fully and has even said to me in the past that he doesn't care how she's prescribing (he literally said "[she] has her own DEA license and can prescribe however she wants"), plus he should already be well aware that she immediately returned me to 20mg QID after previous hospital visits in 2016 (which he apparently never had a problem with) and has had me on this dose for over a year (which he also apparently never had a problem with as long as he wasn't prescribing it directly), so this doesn't fully make sense... My PNP saying something to Dr. ["actual" psychiatrist] about or related to the hospital stay or my case in some way that ticked him off for whatever fucking ridiculous reason (she was not very happy with him after hearing about the utter mess he had made of virtually all my meds while I was there, was particularly annoyed that he interfered with the hormones and was still entertaining his odd and persistent pet theory that taking estradiol is a major factor in my depression while utterly ignoring the fact that stopping estradiol or the T blocker abruptly is much more likely to cause depression than taking it is (she also thought taking me off the estradiol just made no sense whatsoever and was outright stupid), made it clear that she viewed him as at least somewhat sexist (a view shared by several people at this point — the same people also made it clear that they think he has some sort of weird issue with me being transgender, although my PNP thinks that's just his sexism and ignorance in this area), etc)... I have a feeling (which a few people strongly agree with and actually feel much more strongly about it than I do) that Dr. ["actual" psychiatrist] is rather egotistical, has more than a bit of a God complex going on, is quite hubristic, and has massively overstretched himself. He's a very successful doctor in a hard and somewhat unrewarding job, comes from an immigrant background (foreign medical degree with residency in the US), and he's seemingly pretty smart, but he seems very blind to his own flaws and I question the wisdom of him simultaneously having privileges at every hospital in the area, running his own practice & seeing patients directly, having two PAs, a FNP, and a PMHNP-BC (PNP) attached to him/his practice (all seeing patients), operating a busy ~30-bed inpatient psychiatric unit (with him and his sub-practitioners all seeing patients there as well — he is not only the sole psychiatrist at this inpatient psychiatric unit but is also its Medical Director to boot!), teaching residents, and somehow has a family too. I noticed a disturbing number of inconsistencies and weird issues while observing him during my recent psych ward visit — he's acting weird, not the same as he used to — he keeps forgetting everything, he made some absolutely bizarre decisions (most notably randomly changed the Adderall from 10mg IR BID to 5mg XR BID one day) that he didn't even seem to recall making when asked about them the next day (acting utterly confused about it and had absolutely no idea why he'd have even done that!), he tried changing my Fetzima from 120mg to 80mg despite it not being on the formulary at the hospital at all (like the bicalutamide) and thus I was only able to take it because it had been brought from home (unfortunately the bicalutamide couldn't make it) but he didn't seem to understand that this meant I only had the 120mg dosage, which is a single completely sealed XR/DR capsule that is obviously utterly impossible to split (let alone split into thirds!) — but he didn't seem to notice the issue at all even though I know he was repeatedly made aware of it by the nurse in charge of medications well before I finally brought it up to him directly when I realized that he hadn't stopped the Fetzima (which is what I had assumed when after a single day back on 120mg I wasn't given it for two days — since he had been randomly discontinuing pretty much everything at the time I assumed he had decided to discontinue that as well (did I mention that he was absolutely terrible about communicating med changes with patients, or even communicating with patients at all? he's always been bad about it but this time he was way worse than usual), I think it was on the third day that I finally learned that he had actually ordered it for 80mg and apparently nobody ever bothered doing anything about it beyond than the nurses notifying him repeatedly about the issue), at which point he muttered something about samples (which never happened — not sure why, he should have had sample packs of it, I know they definitely used to have some at their main office because I was given several sample packs when I first started Fetzima before we decided to stick with it (which required a prior auth that was delayed until I flat-out ran out of the sample meds during the worst possible time (a brief period where I had absolutely no way of getting to the psych's office to get more samples — after several days of being out of Fetzima and unable to get more unless the prior auth was approved so I could fill the RX, my case worker at the time from the insurer called for a scheduled follow-up, and when I mentioned the issue to her she managed to very speedily resolve the prior auth so I could fill the RX and get back on the med)), and I've been on non-formulary meds taken from sample packs while there previously, so IDK what happened) and after I told him the next day that I still didn't get it the prior day, he finally switched me back to 120mg. This is just the tip of the fucking iceburg. IMO he's bitten off wayyyy more than he can chew and it's finally catching up to him. Either that or he has early-onset alzheimer's/dementia. I am so fucking off topic now. Tl;dr: He's acting weird as fuck. Dr. ["actual" psychiatrist] being mad at my PNP for giving me a 10mg BID RX at the follow-up but instructing me to take it as 20mg QID (she claimed she just needed Dr. ["actual" psychiatrist] to approve physically changing the RX back to 20mg QID and verbally informed me that this 10mg BID RX was a "stopgap"/"temporary" prescription that I was to actually take as 20mg QID after filling, and that as soon as Dr. ["actual" psychiatrist] responded to her message to him requesting approval of the RX change she'd issue the normal RX and have them call me to pick it up. I then asked her specifically about potential issues with conflicts from the apparent early fill that this could cause (as I'd be filling the normal RX a mere week or two after filling the "stopgap"/"temporary" RX since 10mg BID for 30d would last only 7.5 days if taken as 20mg QID like I was told to), and she explicitly said "because it'll technically be a dose change, there won't be any issues at all with filling the 20mg QID RX soon after the 10mg BID RX". So it was made very clear that I was to disregard the original written instructions on the 10mg BID RX. Of course then I never got the promised call from the practice. I finally followed up on November 29th by phone since I was getting low on Adderall and wanted to figure out what was going on. I was told that there was actually a RX waiting for me there already (so of course I immediately assumed they just had never called like they said they were going to and otherwise everything had worked out like I had been told it would). The next day I go to the practice to pick it up and am extremely surprised to see that it's inapplicably another RX for 10mg BID instead of the 20mg QID RX that my PNP had told me it would be — so I explain the issue, they go into the back and talk with some of the other staff, eventually after having to repeat everything several times to other staff members and trying to explain that the 10mg BID RX was literally 100% useless due to my PNP's instructions w.r.t. the previous one and w.r.t. the dosage I'm supposed to take making it utterly impossible to fill anyways I finally find out that Dr. ["actual" psychiatrist] had never fucking responded to the message that my PNP had sent him on November 15th (two weeks with no response! utterly ridiculous!). I'm then told that they're going to message him again, they're putting in a priority request, the issue will be fixed ASAP. Great! I assumed the issue would be resolved within a few days. Monday morning they call me and tell me that "Dr. ["actual" psychiatrist] wants me to remain on 10mg BID". In addition to being half-asleep I'm now extremely confused. Dr. ["actual" psychiatrist] is not my outpatient psychiatrist and never has been. That is my PNP's job, and it's been that way since January 2016. The only time I ever see Dr. ["actual" psychiatrist] is if I'm in the psych ward, which I (thankfully) no longer am. So why is he issuing instructions instead of my actual provider? What happened to my provider's instructions? Why would I be instructed to suddenly and radically change my dose after being on this dose for over a year? Could they please talk to my PNP about this to get a clearer answer? Etc etc. I get no real answer whatsoever outside of the person calling repeatedly and blatantly reframing my questions in real time into a bizarre narrative of "me requesting for them to communicate my desire to increase my dosage to 20mg QID to Dr. ["actual" psychiatrist]", which was not at all what I was asking about (when did he become my psychiatrist again? last time I checked it was the PNP in charge of my psychiatric care, not him. why would you be talking to him about an issue that you should be talking to my PNP about, or at the absolute least, to both of them about? why do you keep reframing things as me requesting a dose increase when I am actually requesting information and confirmation regarding this abrupt and dramatic dose decrease relative to the dose that I was currently on, that my PNP had told me to take last time I saw her, and that I had been taking for the past year?). Eventually I gave up. Later in the day I decide I need to call back and clarify things properly since I'm no longer half-asleep and have had some time to digest what I was told that morning. I wrote up a very brief summary of events with dates as a reference tool, and started calling. Of course it's just my bloody luck that every time I called, the phone was busy or nobody picked up and I was shunted to voicemail. I'm not a fan of voicemail at all, especially when trying to get immediate results (I was after all going to run out of Adderall the next day — something clearly needed to be done about that), so I keep trying on and off throughout the day. I had a scheduled follow-up appointment with the case worker from my health insurer in the afternoon, and by the time that arrived I'd called my provider's practice a half-dozen times at least with absolutely no luck. I went over these odd developments with my case worker, who decided to call them after we were done talking. I wanted to try calling them as well so she gave me leeway for me to try first. I finally got through to someone on one of the first few attempts (a minor miracle) and communicated the situation along with my desire to clarify things further as I hadn't gotten much of an explanation in the morning at all and wanted actual answers this time. I am then told that "[my PNP] is no longer making treatment decisions with regards to stimulant treatment for adult patients and if you want to [pursue that] you will have to set up an appointment with Dr. ["actual" psychiatrist]". After that bizarre and troubling revelation, I decide to try to call my case worker again before she called them. I then relayed what I was told and we discussed the situation. It was not promising at all, but I was at least able to use her help to figure out the very rough bare bones of what I needed to do next. The case worker was more than a bit perplexed at the whole situation, and she decided to continue with her earlier plan of calling the practice directly to try to get more information. She then called me back and explained that she was given essentially the same bizarre explanation that I was, and I guess she asked a few more questions than I had thought of or was willing to ask because she also found out that: • Their immensely-simplified and pointedly skewed (not to mention inaccurate) view of the entire matter was that when I went to pick up the RX last week, I was then apparently "instructed" to take (or maybe switch to taking?) 10mg BID (inaccurate, nobody ever told me that at all when I was there, the only point where that was even hinted at was on the inaccurate RX they had, which was identical to the one I had been given by my provider on November 15th, who had explicitly told me that it was a one-time-only temporary RX and to completely ignore the instructions on it as I was supposed to resume taking 20mg QID immediately and would keep taking 20mg QID using the remaining Adderall from my prior RX, that RX, and a forthcoming proper RX for 20mg QID. I was absolutely unambiguously instructed that the next RX would be for 20mg QID due to the clear-cut conversation with my provider about my concerns about a possible early fill, which explicitly ruled out any chance whatsoever of the next RX ever being intended to be 10mg BID. Thus every bit of the evidence available to me overwhelmingly pointed towards the 10mg BID RX being a glaringly obvious mistake on someone's part.). I then refused the RX (technically accurate — but I had actually stated that the RX was "completely worthless to me due to it clashing [violently] with my provider's last set of instructions regarding the Adderall" and thus, there was absolutely no point in picking it up at all so "they might as well just go ahead and shred it because I certainly can't fill it!" (and the overwhelming weight of the evidence had already made it quite clear enough already that the whole thing was just a mistake on someone's part in the first place — a notion that absolutely nobody made even the slightest effort to disabuse me of, in fact, it was quite the opposite!)). • Since I refused the RX, they had nothing available for me. • No, they would not issue a different prescription. • They did not care that I was about to run out of Adderall — that was apparently entirely my problem to deal with, and not at all their responsibility. • If I wanted to do anything at all related to the stimulants, I would need to make an appointment with Dr. ["actual" psychiatrist] to discuss it with him. • Yes, I still had my scheduled & upcoming appointment with my regular provider (the PNP) — she was simply no longer allowed to handle any prescription for stimulants with her adult patients, but she was allowed to manage the rest of my meds. ---- Now it's worth noting that it's highly odd and curious to note that my PNP had been apparently specifically banned from managing stimulant treatment in adults only. She had told me before that she treated a lot of kids for ADHD and really liked working with children (as well as apparently hating any inpatient psychiatry work — unlike the other PAs/NPs associated with Dr. ["actual" psychiatrist] she only saw patients at the inpatient psychiatry hospital ran & managed by Dr. ["actual" psychiatrist] on one day per month, and that was more than enough of that for her), but it was also clear that she had plenty of adult patients. Were all of the adult patients previously being treated by her with stimulants for whatever reason also now being forced to see Dr. ["actual" psychiatrist] directly for management of that specific type of medication? It seems dubious. And why would she be banned from managing stimulant treatment for adults but not banned from managing it for kids? ----- At any rate, my case manager didn't know what to do or say at this point beyond suggesting that I look into what other psychiatrists in my area are in-network for my plan, and to schedule an appointment to see Dr. ["actual" psychiatrist]. She was clearly confused over the blanket refusal from them to do anything at all about me running out of medication (despite this mess being their own damn fault), but had no idea why they'd do that. My PNP misprescribing stimulants (and/or other meds?) for other patients (could be anything from Dr. ["actual" psychiatrist] judging her prescriptions to be slightly too far out of line with his prescribing philosophy for his comfort to an actual full-blown DEA investigation in progress, although the most likely reasons would all likely lean far closer to the former extreme than to the later extreme given that the available evidence does not suggest anything even remotely serious could have happened without her at the absolute least being barred from prescribing stimulants for kids too, and more likely suspended from prescribing far more than just stimulants). If this was the case though, there's really very very few possible rational explanations for allowing her to continue to prescribe stimulants to kids, so it still doesn't make much sense. Dr. ["actual" psychiatrist] greedily hatching a nefarious scheme to scam patients and insurers alike out of even more money while boosting his practice's revenue by requiring that all adults with stimulant RXs see him personally (as well as their normal psychiatric provider within his practice if they're on any other psychotropic meds) for an appointment that requires him to spend next to no effort (essentially getting away with "managing" just a single RX, and a relatively easy one to manage at that compared to other psych meds), allowing him to rake in an extra $50–$100/patient/month (or more) from a decent-sized pool of patients. However I'd think that Dr. ["actual" psychiatrist] is already making plenty of money already from having his fingers in virtually every psychiatric pie in the region (metaphorically speaking)... If he's actually pulling a Medical Director's salary and even a small part of a typical psychiatrist's salary, to say nothing of his earnings from his practice and other stuff...he's got to be making at least $300k+ even accounting for the typically lower salaries in rural areas. Could be as much as $500k+. So he's not really hurting for money. But who knows. Any fucking crazy idea I could guess at. Sorry for clogging up this thread with my bullshit. I'm just going nuts dealing with this situation and need to vent and organize my thoughts somehow, and this helps a bit.
  12. Still off of it... Appointment with Dr. ["actual” psychiatrist] is next week (not expecting it to go very well but at least maybe I can find out something about WTF happened and get back on some hopefully-reasonable amount of Adderall), then an appointment with my PNP (who can address the antipsychotic issue and hopefully further elaborate on WTF happened). This break has certainly illustrated how utterly miserable it is to be unmedicated. My doctor had to cancel the appointment to follow up about the hormones — gotta wait until mid-January for that now... Oh well. Interestingly, a bill was signed into law back in late September (and it becomes effective in Jan 2018) that expanded the scope of practice for APNs/APRNs (i.e. NPs) in my state. Now if they have 4000 hours of clinical experience and 250 hours of continuing education, they get "full practice authority", which means they can practice without a written collaborative agreement, although they must still be in a "consultation relationship" with a physician to prescribe Schedule II narcotics (this term apparently only refers to opiates) and benzodiazepines, and if they prescribe opiates or benzos they must discuss the case monthly with the physician that they have a "consultation relationship" with. In contrast, the current situation required a written collaborative agreement in all cases (irregardless of level of experience), and only allows prescription of specific Schedule II controlled substances that the collaborating physician explicitly delegated prescription for with limitations like only 30 day supplies can be dispensed, any continuation beyond 30 days must only happen with the prior approval of the collaborating physician, and the APN must discuss the condition of any patients for whom (any?!) controlled substance is prescribed with the delegating physician every month. Now this of course means that my PNP (an APN/NP/etc) could theoretically be able to get full practice authority next year, as she has at least 7 years of clinical experience and I am fairly sure she meets the continuing education requirements. While I certainly don't expect her to necessarily go and obtain full practice authority, it's still an intriguing possibility, as it'd neuter the influence of this annoying Dr. ["actual" psychiatrist] w.r.t. everything but benzos...but a solution that damn slick likely won't happen.
  13. Oh Jesus fuck. Today has been hell. My psychiatrist is a PNP (psych APN), which in this state means that she needs to work with an “actual” psychiatrist to prescribe certain medications, most notably schedule II medications, despite having her own DEA license. Essentially the psychiatrist she works with has to sign off on her schedule II RXs to some extent and they have to co-manage cases to a limited extent. Since August or September 2016 I’ve been on 20 mg Adderall QID. Whenever I’m in the psych ward the inpatient psychiatrist (who happens to be the “actual” psychiatrist that my PNP works with) temporarily drops my Adderall dose down severely. Whenever I exit the psych ward I’m instructed to have the PNP handle the Adderall, and she inevitably resets it to the same dosage. This has worked fine until now. After the last psych ward stay, I was as usual instructed to resume my normal 20mg QID Adderall dose by my PNP at our follow-up, and was given a “temporary stopgap” prescription for the 10mg BID that I had been on in the psych ward, with the instructions to fill it and take it as 20mg QID (not as the labeled 10mg BID dose) while she got me a regular RX for 20mg QID again (was told that this was simply waiting for the “actual” psychiatrist to confirm her request - entirely routine). The fact that filling a 10mg BID RX would only give me 7.5 days of medication at 20mg QID was not supposed to be an issue because I would be changing directly back to the old 20mg QID RX, so no early fill issues should have came into play. Last Thursday I inquired as to what was happening as I hadn’t heard from them in two weeks and was running out of Adderall soon (this Tuesday to be precise). I then discovered that the “actual” psychiatrist never bothered responding to my PNP's message (despite two weeks having passed). I was told that they would sort out the issue and have the RX ready ASAP. This morning I get a call from the office saying that I was supposed to remain on the 10mg BID by orders of the “actual” psychiatrist (not the psychiatrist I’m seeing). Remain? I wasn’t even actually on 10mg BID! I had been instructed by my psychiatrist when I last saw her not to take the 10mg BID script as labeled and instead to take it as 20mg QID! They were then uncertain if things were correct or if something got mixed up, so they said they’d contact both practitioners and try to sort it out. This afternoon I call again to try to clarify what the heck is actually going on, since the morning's call didn’t exactly yield any clear answers. I am then told “[my PNP] is no longer making treatment decisions with regards to stimulant treatment for adult patients and if you want to [pursue that] you will have to set up an appointment with Dr. ["actual" psychiatrist]". WTF?!? Keep in mind that Dr. ["actual" psychiatrist] is the same inpatient doctor who is overly fond of cutting my Adderall dosage for no good reason, has stated openly many times in the past that he does not want to prescribe these meds for me at all and that the PNP should exclusively manage them instead, and has made it clear that he is flat-out unwilling to prescribe the normal dosage that my PNP has had me on for well over a year at this point. He is also kinda a poor practitioner in general - far too fond of screwing with things that work, poor listening/comprehension, strong accent, inflexible opinions, etc. Soooo now I guess I’m just utterly fucked on every level? Thanks to this mess I’m guaranteed to be stuck off of Adderall entirely for at least two whole weeks, and will have to set up an appointment with Dr. ["actual” psychiatrist] (god knows when that’ll happen considering how overbooked/overstretched he typically is) to discover how exactly he plans for me to function effectively on essentially 25% of my normal & optimal dosage that was working perfectly fucking fine for over a year. I’m going to loose my fucking job at this rate, and even if I somehow don’t outright loose it I cannot afford not to be working right now, and this is all apparently thanks to Dr. ["actual” psychiatrist]'s bullshit, since he seems to be the sole factor behind things going pear-shaped so quickly and dramatically. I feel hideously terrible. In one fell swoop I’ve all but lost one of the most important medications I’m on, with next to no hope whatsoever of it getting restored. I’m hopeless and suicidal, as much so or more than when I was in the hospital last, but the psych ward certainly wouldn’t help me with this, especially given that it’s ran by the bloody fucking Dr. ["actual” psychiatrist] (who doubtlessly would love a chance to make even more money from further worsening my misery via random med changes).
  14. Unfortunately there's no intermediate doses between 120mg and 80mg for Fetzima. I don't think I want to reduce it anyways. That's quite interesting. Yeah, I get the feeling. I restarted the Vraylar this week due to the depression worsening, which improved things a bit. However I learned that we're likely switching insurance providers next year (a relatively unexpected last-minute decision), and the other insurer does not have Vraylar on their formulary. So much for the one and only tolerable antipsychotic I've ever found... Fuck!
  15. Hmm, that's possible, although I'm hesitant to assume any single factor is at fault without clear evidence. I took a break from the Adderall for several days, which reduced the irritability a little bit while I was off of it, but it definitely didn't eliminate it, and it significantly worsened the fatigue (duh!). I guess there's always the option of reducing the Fetzima to 80mg...which might have negative trade-offs involved... Saphris should be basically all the way gone from my system now, so only Vraylar can still be sticking around at this point. I'm not sure what to do med-wise. I feel better than I did a week ago, which is certainly good. One major stressor is now behind me and over with (although there are too many more left). I'm still pretty firm in my decision that Saphris is a horrible med for me. I suppose for now I'll stick with my plan of "no antipsychotics unless absolutely necessary, and if absolutely necessary, Vraylar first", wait to see what my follow-up blood testing reveals about my hormone levels when I have that done, and hope that my psychiatrist doesn't have an issue with me having decided to take myself off of the antipsychotics (I think she'll probably be fine with it, but you never know). I can't decide if I should try moving up my follow-up with the psychiatrist or not — it's not as if there's anything urgent to do or discuss, but I feel maybe I should move that up anyways so that she knows what the situation is and so that we can agree on the best way to move forwards (keep Vraylar as standby? resume Vraylar? switch antipsychotics? change other things (Fetzima for example)?).
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