What to Do?

[celestia]

So, back story. 49 y.o., female. Major Depressive Disorder going waaaaaaaay back.

RX history: TCAs, Prozac, Effexor, Prozac, Cymbalta, Lexapro, Lexapro/Wellbutrin combo.

I have a new pdoc appt. in 2 weeks. It's with the same practice, so my file will go with me. But I'm undecided about whether I want to go in there and just explain my symptoms (It's a full 80 minute session, since it's a new doc, so I have time to talk) and let him evaluate; OR, go in there with some specific recommendation or request for medication.

The only thing I would suggest to him is Effexor or Pristiq. Though I was on Effexor for about 8 years and it tanked, well, actually I tanked, but that's a long story. I think maybe if my life had not been wildly out of control, Effexor might have been fine and it was just me--drinking, drugging, etc.--that was contributing to the suicidality. Anyway, I have mixed feelings about asking for a med I've already been on. Then I think maybe Pristiq?

I did so well on Effexor, and also Cymbalta, but Cymbalta tanked like within months.

I also wonder if I should try a mood stabilizer. My dx of MDD has been affirmed many times, but I still have nagging thoughts about the moodiness being more BPII than anything else. Like, the soft signs, or whatever.

So, should I go in with a plan? I'm kind of leaning toward just laying it all out to him, symptoms wise, and let him decide. In my experience, if I say, "well, I would like to try ______", they usually give it to me, and I don't know that what I want to try; e.g., Pristiq, is really the best thing for what's going on.

I'm sick of being depressed more than stable, that's for sure.

[wondernut]

Honestly while I always over think every single one of my medical appts and go in with a plan each and every time ..I know for a fact if you have a good provider they are like a good detective you lay out the facts on the table they put them together objectively ...

imput is good but we pay them to do their piece you know? and you know I am a nurse and really do want to have control over each and every single thing on the planet ...

I find my best most productive visits come from laying it out as logically as i can and letting them do the putting together

they may even have a better alternative plan ..if they start going where you do not want to go you can redirect but usually they do know what they are doing and can be more objective than we can about ourselves

another point is ..if you come in with a plan for yourself they figure you want what you want and will either lean that way or against it depending on their nature ..so it is an ego thing as well

can you let go and let them choose for you? I do better when I do just that

good luck Celestia

[The Emperor]

If Effexor worked for you, Pristiq might be good. Also, it's been a while since you took the Effexor, I don't see any problem with saying "Hey, _____ really worked for me years ago for a long time, then stopped working, maybe I could try that out again?" Then you hear that shit about an AD not being any good the second time around, I don't know if that applies to Effexor.

If you don't want Pristiq, ask what a mood stabilzer could do for you. You certainly have a few options to talk about with p-doc, maybe tell him/her all your thoughts and see what they think is the best option for you?

Sorry, I think I just repeated everything you said without giving any real advice. I just don't see a problem with asking for a med you've already been on that WORKED. I could see that being weird if you were on it for six weeks and flipped the fuck out THEN asking for it again, but you were on Effexor for a while and it helped.

Good luck.

[tryp]

Generally I like to go in and lay it out and let the doc propose what they want to propose without my interference, but after they've proposed it, I like to have a few options of my own in mind to discuss as well. Sorta the best of both worlds approach.

Here are some things that spring to mind, if you want suggestions. If not, ignore :

1) You could jump on the possible lamictal-boat with me.

2) If serotonin and norepinephrine seem to be your answer, you could consider Remeron, though it's more sedating than activating, so maybe not. Then again, Remeron + Effexor isn't called California Rocket Fuel for nothing. If Effexor worked before, Effexor + Remeron might be worth a shot. Or start Effexor or Pristiq (which seems to be your plan anyway) with the idea of adding Remeron in the case of a partial response. Remeron didn't do jack for my depression but some people really do like it -shrug-

3) You could also consider the AAPs - there are activating and sedating ones, and if you think your MDD has a BpAD twist, they might be useful. I like Seroquel a lot on the sedating end of the spectrum, and Abilify is also supposed to be good.

I'm dubious about Pristiq myself. It's basically pre-digested Effexor. But I guess nobody really knows what's up with headmeds, so it could work somehow differently from Effexor. But I am dubious

[celestia]

You know...I keep reading about Remeron and always forget to talk about it to the docs. It's also good for sleep, no? I don't sleep well--at all.

[isis]

I usually do a bit of both. I say these are my symptoms and history, this is what ive taken before, this is what the outcome was, and my goals are to improve such and such and because i did well on this drug i thought it might be worth another try... and then they talk about their opinion. you won't really know until you start what the doc is like, but you need to explain your history and symptoms current and past, because if you just ask for the drug they'll want to know all that anyway so that they know that you need the medication. Better to build your case slowly then have to prove yourself if they are doubtful at the beginning... kwim?

[tryp]

Remeron is really good for sleep. I was originally put on it because of my severe insomnia and PTSD symptoms and I've got to say, it worked like a charm for those.

[lachesis]

Talk it out. Say you want to ask for x, but are unsure about asking. kwim?

[Indigo 'n dye]

Celestia, >>deep sigh<<, I know, I know I spend hours debating this issue over and over with myself prior to every appointment. It can be, and is, exhausting. As I too am looking at an appointment with a new pdoc--waiting for a call-back for a firm appointment--I empathize.

Best wishes for a productive and progressive first visit.

Indigo

[Catnapper]

New pdoc visits are always a combination of being fraught and a relief for me. Fraught because I don't know who I will see in the office, will we get along, will the meds work, does the pdoc know their stuff, and on and on. A relief because having an appointment means I'm taking care of myself, which I'm not always good at.

On my first visit with my current pdoc I gave him my history and suggested a med, and he suggested something I hadn't thought of (Lamictal), which has turned out to work very well for me. He's also the first pdoc I had to suggest BP II instead of MDD recurrent, and I think he's right, even though I've never been hypomanic. But I do have atypical depressions when I depressed, sleep all the time, eat too much, etc., so that in combination with the number of episodes is what made the pdoc conclude that I probably have BP II.

At this point, although it's nice to have a dx, the main thing is that I feel better. I highly recommend a mood stabilizer if you've had multiple episodes of depression. Good luck to you.

[Sam_I_Am]

Hi Celestia, I'm sorry to you hear your current regime isn't working anymore. From what I last recall, I thought you had liked the Lex/WB combo (but I haven't been around these parts for awhile.) For me personally, I usually go into a new pdoc's office having a general idea of a couple meds that I think could be helpful as well as an open mind. I will usually explain my symptoms (I come with lists in tote, I'm anal like that), let them make suggestions, ask them what they think of my ideas, and have a dialogue about the options. The only times that I ever went in there w/o a some sort of "plan" was with first two pdocs b/c I was new at it, but then I became more knowledgeable about meds and became better at self-advocacy. However, there's been many times when I went in with a particular idea, but then the doc will have something else in mind and explains it in a way that makes sense, so I leave with something totally different. But that's just my experience.

I don't see anything wrong with asking for Effexor/Pristiq even though you already took it. You know that you did do well on it to some capacity, and your first trial of it was not really a "controlled" experiment because of the alcohol and drugs. Now that you are sober, you could have a totally different experience with it. If you do tend toward very cyclical depressive episodes and generally moodiness, I think a mood stabilizer, particularly Lamictal, could be great, even in the absence of a true bipolar disorder. It is great for treatment resistant depression, has shown some efficacy in treating the mood reactivity of BPD (not saying you have that, but that shows that it helps with mood swings that aren't bipolar in nature.) I was prescribed it for the latter reason, and it worked great for me. The only reason it's in the rx graveyard for me is because it fucked with my hormones really badly, but that is NOT a usual response to it. I also like Tryp's idea of Remeron as an add-on, particularly if you are having sleep issues.

Are you looking to get rid of both the Lex and WB or just one or the other?

Sorry not to throw out any brand new ideas, but I hope this was helpful in some way.

[celestia]

Sam,

I'm not looking to get rid of Lex or WB. I've spent the past 10 weeks or so actually coming to grips with the fact that something was failing. Only this week did I stop believing it was ME and started accepting that it was the meds.

I have thought on and off about Lamictal. I *just* stopped having migraines all the damn time, and I think maybe the headache thing is scaring me off. Whether it's menopause, or MI, or both, I'm definitely more moody. I've always been moody, just never manic. My moods swing like crazy.

sigh.

You guys have given me some things to think about. I'm going to be really interested to just see what he suggests. Like Catnapper said, I don't know yet that I will even click with him. I hope so, but who knows? I agree with her though that now that the appt. is made, I'm feeling some hope that maybe all is not lost. And taking care of myself has it's own rewards. I took a shower, colored my hair, took my son out to lunch, went for a walk. I'm still anxious and depressed but not as bad as it's been for weeks now.