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ECT vs. MAOIs


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i'm so frustrated.  i know it's protocol to push MAOIs (and all other treatments) before ECT, but i just have no confidence in the patch, for so many reasons.  and to try it would be hell.  i get severe 24/7 panic when i try to withdraw from lexapro, and as you know there's a washout period before you can start an MAOI. 

i know MAOIs are good for intractable depression, but i feel like my depression has unique features and there is no evidence that MAOIs are good at treating these features.  my depression is accompanied by a unique type of fatigue- not the type where you can't get out of bed, but the type where i have the will and desire to exercise, but simply cannot recover from the exercise.  my body is just totally physically exhausted- apart from my emotional fatigue.  and i seem to have developed an intense addiction to SSRIs.  i cannot withdraw- the withdrawal symptoms do not subside, even after months.  i get constant panic, something that was never a part of my mental illness before.  and other substances like zyprexa, and xanax do not stifle the panic.  only resuming the SSRI does- that is what my body and brain need now for stabilization. 

also unique to my depression- i can't even tolerate many meds, like wellbutrin XL, i need to take a few days off every week, just to get rest from it, b/c it is slightly stimulating.  that's how tired i am.  it's not a bipolar reaction to the meds; i've been checked and treated with BP meds, and it's clear i don't have it.

i took the neurotransmitter urine test, too, which i know is controversial, but it did match up exactly with my symptoms both times i took it.  that seems like more than a coincidence.  my serotonin is insanely low.  apparently, the selegiline patch doesn't even hit serotonin at the lowest dose.  why take it?

my docs don't listen to me.  i just want to try ECT and get some relief.  i don't want to go through the torture of getting off lexapro just to try a med that is part of the protocol.

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sunburnt,

this is apart from the ECT vs. MAOI question...

have you considered that perhaps your fatigue is not necessarily from the depression?  inability to recover from exercise is one of the hallmarks of chronic fatigue.  of course i'm not diagnosing you, just suggesting that you may want to look into it. 

Centers for Disease Control's Criteria for Chronic Fatigue Syndrome

Clinically evaluated, unexplained, persistent, or relapsing fatigue that is:

    * Of new or definite onset

    * Not a result of ongoing exertion

    * Not alleviated by rest

    * Results in a substantial reduction in previous levels of occupational, social, or personal activity

Four or more of the following symptoms that persist or recur during 6 or more consecutive months of illness and that do not predate the fatigue:

    * Self-reported impairment of short-term memory or concentration

    * Sore throat

    * Tender lymph nodes

    * Muscle pain

    * Multijoint pain without swelling or redness

    * Headaches of a new type, pattern, or severity

    * Unrefreshing and/or interrupted sleep

    * Postexertion malaise (a feeling of general discomfort or uneasiness) lasting more than 24 hours

the CFIDS Association of America website has some good information, if you want a starting place.  i've had cfs for a while now (it's inching towards remission) and am willing to answer any questions you may have/ discuss my treatment/ reccomend books/ etc. just PM me, and i'll check on this thread.

once again, i'm not dx'ing you, just suggesting that you may have more than depression going on. 

as for the MAOI vs ECT debate, i personally feel that we are patients and consumers when we go to doctors, and the ideal doctor-patient relationship is one in which the doctor uses all of his/her knowledge to help the patient get better while following as many of the patient's wishes as is possible.

take care

penny

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i took the neurotransmitter urine test, too, which i know is controversial, but it did match up exactly with my symptoms both times i took it.  that seems like more than a coincidence.  my serotonin is insanely low.  apparently, the selegiline patch doesn't even hit serotonin at the lowest dose.  why take it?

<{POST_SNAPBACK}>

If you are on an uptake inhibitor or an MAOI, your urine test is pretty much useless. The whole point of

an SSRI is that serotonin reuptake is inhibited and so serotonin breakdown is also inhibited.  Reduced

reuptake is going to translate into reduced excretion. Hence, low levels on your test.  That is why your

doctors aren't paying any attention to your test results - they are normal for someone on an SSRI.

(possibily the controversy as well)

Selegiline at lower doses is selective for MAO-B, which primarily breaks down dopamine and

phenethylamine. You shouldn't need a full two-week washout going from an SSRI to a MAO-B-selective

med. because they act on differing transmitters.  (To Nardil or Parnate from Prozac? Hell yeah).

Did your doctor tell you s/he was planning a two-week med washout?  Or did you assume that

there would be based on recommendations for the other irreversible MAOIs that affect MAO-A?

Wellbutrin is very much a NA reuptake inhibitor with some DA uptake inhibition. It's the noradrenaline

that usually is associated with anxiety and the physical effects of anxiety. Selegiline doesn't do much

for increasing noradrenaline until enough is used to inhibit MAO-A. That's why your doctors

"don't listen" when you raise WB-worsened anxiety as a reason to not try it.

As to why try it?  Aside from still having problems and your doctors, based on their training and

experience want to try something else before ECT ?  Content edit: Note that I am not saying

"instead of" ECT

Have you noticed that Lexapro doesn't make a dent in your problems with exhaustion and inability

to recover from exercise?  Or maybe that when the Lex is high enough to really hit the depression

the exhaustion is worse?  Serotonin is a dopamine release antagonist in some parts of the brain - like

the parts that allow you to move. By cutting down on dopamine breakdown, selegiline increases

dopamine levels in those parts of the brain. That's why it's used in Parkinson's Disease.  Also, low

dopamine is  one of the potential reasons for depressed mood (dopamine and phenethylamine

are the "feel good" chemicals after all)...

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I tend to agree with what Penny said -- it seems like it might be beneficial to explore something like cfs for the fatigue. My sister has a similar combination and it's really flattening her out.

As for the MAOI vs. ECT, it seems like a good idea to try the medication first. MAOIs have approximately the same success rate as ECT, although it's near impossible to say how any one person will react.

I can't speak for the washout between an SSRI and the selegiline patch, but you do have to put one in for both Parnate and Nardil. I've done it, and believe me it rates as probably the most awful two weeks of my life -- but the positive result I have with Parnate has been more than worth it. It's possible the once you have the MAOI going it will ease your SSRI symptoms.

Fiona

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sunburnt,

this is apart from the ECT vs. MAOI question...

have you considered that perhaps your fatigue is not necessarily from the depression?  inability to recover from exercise is one of the hallmarks of chronic fatigue.  of course i'm not diagnosing you, just suggesting that you may want to look into it. 

<{POST_SNAPBACK}>

hey, thanks for the response.  i have approached my fatigue from a CFS angle for years, but with no luck.  what treatments for CFS have you had luck with?

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i took the neurotransmitter urine test, too, which i know is controversial, but it did match up exactly with my symptoms both times i took it.  that seems like more than a coincidence.  my serotonin is insanely low.  apparently, the selegiline patch doesn't even hit serotonin at the lowest dose.  why take it?

<{POST_SNAPBACK}>

If you are on an uptake inhibitor or an MAOI, your urine test is pretty much useless. The whole point of

an SSRI is that serotonin reuptake is inhibited and so serotonin breakdown is also inhibited.  Reduced

reuptake is going to translate into reduced excretion. Hence, low levels on your test.  That is why your

doctors aren't paying any attention to your test results - they are normal for someone on an SSRI.

(possibily the controversy as well)

Selegiline at lower doses is selective for MAO-B, which primarily breaks down dopamine and

phenethylamine. You shouldn't need a full two-week washout going from an SSRI to a MAO-B-selective

med. because they act on differing transmitters.  (To Nardil or Parnate from Prozac? Hell yeah).

Did your doctor tell you s/he was planning a two-week med washout?  Or did you assume that

there would be based on recommendations for the other irreversible MAOIs that affect MAO-A?

Wellbutrin is very much a NA reuptake inhibitor with some DA uptake inhibition. It's the noradrenaline

that usually is associated with anxiety and the physical effects of anxiety. Selegiline doesn't do much

for increasing noradrenaline until enough is used to inhibit MAO-A. That's why your doctors

"don't listen" when you raise WB-worsened anxiety as a reason to not try it.

<{POST_SNAPBACK}>

i wasn't on any psychiatric meds when i first took the neurotransmitter test, and my serotonin tested at 1/6 normal.  as far as a washout period, i didn't get that info from my doc about what that would entail going from lexapro to selegeline- i'm curious.  the unique thing about wellbutrin is that it doesn't increase my anxiety, in fact it may curb it a little.  but since it is slightly stimulating, and i'm so exhausetd to begin with, it eventually just burns me out, and exhausts me even more.  please keep the advice coming.

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i wasn't on any psychiatric meds when i first took the neurotransmitter test, and my serotonin tested at 1/6 normal. 

<{POST_SNAPBACK}>

That wasn't clear from your first post - totally different interpretation needed then.  Usually serotonin

can screw you over going low, but sky-high (or just selected receptors being pegged into overload)

is a rotten way to live as well.

as far as a washout period, i didn't get that info from my doc about what that would entail going from lexapro to selegeline- i'm curious. 

<{POST_SNAPBACK}>

While my layman's opinion is that a washout might not be needed (Lexapro to Selegeline), I think

that if you can spare a few days between meds it might be easier on the body and easier to tell

what sort of difference is really being made.

the unique thing about wellbutrin is that it doesn't increase my anxiety, in fact it may curb it a little.  but since it is slightly stimulating, and i'm so exhausetd to begin with, it eventually just burns me out, and exhausts me even more.  please keep the advice coming.

<{POST_SNAPBACK}>

Then I misread your post. Not surprising, considering how tired I was.

As Penny and others have pointed out there are so many things that can wipe you out neurochemically

and otherwise.

If low dopamine levels are an issue (and this doesn't have to mean Parkinson's), selegiline will do a

lot of good for the exhaustion.

I'm assuming your thyroid levels have been thoroughly checked, and also adrenal/pituitary function? 

If those  are thoroughly normal and the selegiline doesn't work, your doctors may end up having

to look at CFS, lupus, MS, and other legitimately scary things.

If the selegiline does work for the exhaustion but not all/enough of the depression, tweaking

serotonin levels with an SSRI or shifting to one of the broader-acting MAOIs might be needed.

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hey, thanks for the response.  i have approached my fatigue from a CFS angle for years, but with no luck.  what treatments for CFS have you had luck with?

um.  *looks at three baskets of supplemets and meds by bed*  heh.  i just realized that it's hard to put all those tests and meds and such into a post (let alone the saga leading up to finding a doctor who wasn't an ass and didn't scare the crap out of me.  no, it's not ok to say to a woman "do you want kids?" immediatley followed by "i think you have lupus.")  if i hadn't had the fortune of having a close relative who was diagnosed before me and found a good doctor and was willing to listen to my endless complaining and questions and feed me with books and tea i think my head would have fallen off... so, what worked...

i think the acetly-l-carnitine/co-q 10/ alpha-lipolic-acid trio has helped a lot.  b-12 shots, DHEA and Pregnelone supplementation (blood levels were low), fixing my slightly wonky thyroid, amino acids, digestive enzymes and probiotics, lots and lots of vitamins... ooh, i love ENADAlert.

basically, i had/have a whole bunch of small things just a wee bit off, but you stick them all together and whamo i couldn't move.  (thyroid and adrenals are a must to get checked and any dietary deficiencies.)

my doctor uses a lot of the techniques in the book from fatigued to fantastic (ignore the cheese ball title) and all of the things i take on a daily basis are in my profile.  i know it looks kinda weird that i take that much stuff... but i can leave the bed now which i couldn't for months.  but damn i'm tired of swallowing pills!

what treatments did you try?

penny

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  • 9 months later...

I had the ECT treatments followed by the MAOI (Selegeline transdermal patch). Since the pdoc wanted to wash out all the meds that raised the seizure threshold before doing the ECT, I was already off my lexapro, wellbutrin, and 3/4 of my lamictal before starting. They also reduced my klonopin which made me a little bit anxious, but didn't eliminate it entirely. I'm on the patch now; just finishing my first 30 days, and feel pretty good.

Tommy

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CFS could be likely. Couldn't hurt to get maybe a physical and bloodwork, if you haven't recently done so.

I'm going to go the ECT route, as soon as my Medicaid kicks in. I've tried everything and nothing so far works. I take Nardil, a low dose. i'll probably continue with it after ECT.

Ironically, my Pdoc is the director of ECT services at the university hospital. He would be the one to do it.

Also, some articles I've read say you can go to the patch from an SSRI without a wash out period.

Good luck

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From what I understand, there are three different strengths of patches. On the most commonly used one (6 mg./24 hrs.) you might get by without an SSRI washout and don't need to worry much about dietary restrictions. On the 9 mg./24 hr. and 12 mg./24 hr., the washout is a bit more critical and you need to observe the dietary restrictions.

Tommy

(pretending that the PI sheets are written in English)

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  • 1 year later...

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