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Thinking of making the jump to an MAOI


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Hi there! I'm coming out of the shadows of lurkdom because I feel like I'm making a significant decision w/r/t my course of treatment and I wanted some input.

So here's a basic rundown of my medication history:

(was going to say brief but I can already tell this isn't going to be brief. I hope I'm not veering too far into blogland; I just want to give a full picture here.)

 

Lexapro: started in high school after I went to see my GP for insomnia/oversleeping and "unexplained" weight loss. (Really, I was in a severe binge/restrict cycle, but I was too in denial about it to admit it to anyone.) I was on it for about four months at 40 mg. Honestly, this was a while ago, and I've purposefully blocked a lot of this out of my memory, but I know that I HATED it. The GI side effects were really intense and I lost even more weight, but the worst part were the anger/anxiety issues. I was flying off the handle at everyone, daily bursting into tears in my car, and lying on the floor screaming when no one was around because of how completely overwhelmed I felt. I can't remember whether I felt any less depressed or not, because a. I wasn't ready to admit to myself that I was depressed, and b. any feelings I had got completely eclipsed by how totally bonkers I felt. I went back to my GP to complain, so she took me down to 20 mg. After a couple of weeks I decided I was fed up and quit cold turkey.

 

I spent my college years unmedicated, making dumb decisions, self-medicating with just about everything you can think of, losing my scholarship because I couldn't get out of bed to go to class (let alone do anything unstructured like, say, my homework) and barely graduating, spending multiple days in a row in my apartment with the shades drawn, and desperately looking in all the wrong places for connections trying to fend off the abysmal emptiness I felt whenever I was alone.

 

After six months of sinking further and further into the pit of post-graduation unemployment, I went home for a little bit to try to sort things out. I went and saw my mom's GP (a different one) complaining again of insomnia/fatigue. After a few questions, she told me she'd run some tests to make sure everything was alright with my thyroid, etc. but that I sounded like I was depressed. Everything came back normal, so after I vehemently protested her initial suggestion of Lexapro ("you didn't tell me you had already been on an antidepressant!" she clucked), she put me on a shiny new medication called...

 

Viibryd: ...which was a total disaster. Was on it for about three months at 40mg. I moved back to New York shortly afterwards so there wasn't really any follow-up between me and my doctor. It was rough titrating up--I had to take it at exactly the same time every day or I started getting brain zaps. One time I missed a dose by about 12 hours, had horrific, grotesque nightmares, and woke up the next day convinced that my brain was poisoned and I'd never be the same again. It only got worse; it exacerbated every single symptom I had. I was cutting more and deeper, I would go days without eating, crying fits were lasting for hours, and I was actively suicidal. Nearly took myself to the hospital more than once. It also made me hallucinate a little bit; not intensely, but in a "oh look, the walls are breathing" or a "hey, the woodgrain in the floor is dancing!"kind of way. But some days were okay! Some days I really didn't have a problem! But eventually I neared the end of my rope (would have quit cold-turkey again if the withdrawal symptoms weren't so awful.), and I just knew that if I went on any longer like this I was in serious danger of hurting myself.

 

So I finally reached out to a friend and through a system of referrals got hooked up with a pdoc and a tdoc, both of whom are really amazing. I really lucked out in that regard. Pdoc diagnosed me with MDD and GAD, with "borderline features" (impulsivity, self-injury, identity diffusion, mood lability). She immediately started titrating me down on the Viibryd and titrating up on the...

 

Lamictal: Titration was rough (flu-like symptoms, rashes [not THE rash], intense dizziness) but I stuck with it. It definitely helped keep my mood more stable, but it didn't really seem to touch the depression and it made me SO, SO tired. Like, I was pounding 3-4 double espressos a day and still getting sent home from work because of how awful I looked. So we started playing around with augmentation. I'm still on it (it's been a year), but I'm not sure it's doing too much anymore? Hard to say.

 

Celexa: was on a baby dose (I think 10mg?) for about a month. It was supposed to help with anxiety, but I felt noticeably snappier and irritable, so we stopped.

 

Abilify: Have been on and off of this twice. At lower doses it immediately lifted that leaden weight in my limbs and stomach, which was amazing! I didn't realize how much extra weight I was carrying around. At lower doses it helped my mood a little bit? So we pushed the dosage to see if that would help. It didn't. We got up to 10mg and I think it was making me more depressed. So we came off to see if we could find something that would take care of it better.

 

Wellbutrin: Was amazing! For three months. Didn't fix everything, and my anxiety definitely wasn't in check, but it was the closest I'd felt to normal in so long. I crashed pretty hard when it pooped out.

 

Vyvanse: Was initially prescribed to combat the extreme fatigue caused by the Lamictal, but oddly enough, I feel like this is maybe the best antidepressant I've been on? The problem being, of course, that it wears off; having a pill that gets you motivated isn't much help if you can't even get motivated enough to roll over in bed and take your meds. Currently on 70mg.

 

At this point, we had a discussion about where to go next. She wanted me to try Pristiq; I was really reluctant given my (admittedly, and comparatively, kind of limited) track record with SSRIs--I was reluctant to try anything with significant serotonin action. So we agreed to try a TCA, maybe one that doesn't hit serotonin too hard. So! On to...

 

Pamelor: Spent a month at 50mg. Seemed okay, nothing really special, maybe felt a little edgy, but it felt okay. So then we upped it to 75 mg for a week, and then up to 100mg. A couple days after that increase I was borderline catatonic. Didn't get out of bed for three days.

 

So I went back in to see my pdoc and we discussed a few more options. She suggested maybe switching mood stabilizers to Depakote or Lithium, or maybe trying an MAOI. We talked about the dietary restrictions and the OTC interactions and all that, and I'm more than willing to deal with that if this is what will do it for me. I'm med-compliant and not actively suicidal anymore, so she trusts me I think when I say that. She doesn't seem to think much of the Emsam patch so it was down to Nardil and Parnate, and she decided that Nardil might be the better fit for me. I'm titrating down on the Pamelor now, and it's honestly pretty shitty (I tend to crash pretty hard), but I've been managing with some liberal benzo use. We're also talking about maybe coming off the Lamictal as well, but that we're taking on a more wait-and-see basis. And obviously I'll have to come off the stims. So I'm due to start the Nardil in a couple of weeks once my washout is over.

 

In summation (because I know that was a little tl;dr):

Lexapro: Horrible

Viibryd: Even horribler

Lamictal: Curbs mood swings, may not be doing much anymore. Still on this one.

Celexa: Made me edgy and irritable, even at a low dose.

Abilify: Helped a lot with the physical symptoms, maybe not so much with the mood.

Wellbutrin: Worked great, until it didn't.

Vyvanse: Terrific! Still on this, until I start the Nardil anyway.

Pamelor: Not so great. Getting off this now.

 

So, I have two questions.

 

1. Am I wrong to be dismissing SSRIs and SNRIs completely out of hand? It's just that my couple of encounters with SSRIs have been so, so disastrous, and I'm scared of that it would just be more of the same. Plus I'd have to potentially deal with SNRI discontinuation syndrome, which I don't want to do. But I know some SSRIs/SNRIs work for some people when others don't? Has anyone reacted this violently to a couple SSRIs/SNRIs but done well on another?

 

2. Am I jumping the gun jumping to an MAOI? I know a lot of people view them as a last-resort kind of thing, and there's plenty I haven't tried: other TCAs, Remeron, other AAPs, other mood stabilizers, etc. But I really want a sledgehammer to maybe finally kick this thing and I think I'm responsible enough to deal with all the crap that comes with it. But should I be trying some of these other things first? I mean, it's not like lithium isn't its own different kind of pain in the ass.

 

Any input?

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IMO I wouldn't jump to an MAOI yet.  Like you said, it is like a last resort med and there are lots of other meds out there and in different combos/doses that you can try.  It could take awhile for you to get the right cocktail, but it is somewhere out there.  It took me at least 6 years if not longer to find the right cocktail.  I'm thinking more like 8 years actually but either way is was a long time.

 

I was on one of the MAOIs briefly and it sucked.  I dont' remember all of the details except only that I wished I'd never been on it at all.  And when I went off of it, I had to wait 2 weeks afterwards to do anything, ie get rid of the diet restrictions.

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I don't have an opinion on whether it's too soon. There are an enormous number of options out there. When you take the possibility of cocktails into account, the options are almost infinite. So you could try an MAOI, or not. You could try it, and if it doesn't work you could try something else.

 

Nardil reliably makes me hypomanic. I've taken innumerable other meds, and Nardil (and to a lesser extent Parnate) are the only ones that do that to me - so I don't consider myself bipolar spectrum or anything. I felt great but did become very disinhibited and flighty and overenergized to a destructive extent, so it's good I stopped. But I always consider it the nuclear option - if I ran out of options I'd be willing to take it again - or maybe something milder like the Emsam patch - or maybe with a mood stabilizer.

 

I didn't find the dietary restrictions that much of a hardship (although I love cheese). I did get paranoid about my blood pressure spiking though, especially when I had a headache. As far as I know it never did. Restaurants are definitely tougher, since it's like having a food allergy and all of the sudden having to wonder just what exactly is in your dinner.

 

The other thing was Nardil had a lot of side effects. None were a deal-breaker, but there were a lot of them. It's definitely a high-maintenance med.

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Unless weight gain(and its no guarantee you will gain alot or any at all) and possible daytime sedation(again might not be big a deal depending on dosage) are just no no's have you considered remeron? It's got a great rep for being a very effective AD but is not real popular due to the big possibility of Weight gain and the heavy sedation.

Cymbalta? I did alright on a combo of cymbalta and lamictal for awhile.

Edited by quiet storm
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Unless weight gain(and its no guarantee you will gain alot or any at all) and possible daytime sedation(again might not be big a deal depending on dosage) are just no no's have you considered remeron? It's got a great rep for being a very effective AD but is not real popular due to the big possibility of Weight gain and the heavy sedation.

Cymbalta? I did alright on a combo of cymbalta and lamictal for awhile.

 

I have thought about Remeron. The good thing is I tend tolerate medications well as far as side effects go--never had a problem with weight gain, SSI, etc. But those two in particular... Sedation is the reason my pdoc is making a lot of noise about getting me off the Lamictal, especially because my job requires that I be on my feet eight hours a day. There's always the Vyvanse, I guess. Weight gain: theoretically, I'd like to say that it's not an issue inasmuch as I feel like I'd put up with a lot in order to feel like a human. In reality, though, I've only very recently begun to unlearn disordered eating as a coping mechanism, and I (and my pdoc, I sense) worry that excessive weight gain could be reeeaaal triggering.

 

Then again, who knows? Nardil could make me gain weight! ARGH!

 

As for Cymbalta, my pdoc brought that up when we talked about Pristiq, and that gets back to my first question: am I crazy (ha) for not wanting to touch SSRIs/SNRIs with a ten-foot pole, given my experiences with Lexapro/Viibryd/Celexa? I mean, it was hell. Hell hell hell hell screaming hell. I know, I haven't exactly run the gamut there. And I know none of those are SNRIs, but I'm really afraid of the same thing happening and then getting stuck with discontinuation syndrome on top of it. I'd rather subsist entirely on white rice for the rest of my life and faint every time I stand up than go back on Lexapro. I was bonkers.

 

I'm really of two minds about this. Two, or three, or twelve.

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I don't think MAOIs are last-ditch. They are not first- or second-line mainly because of the dietary restrictions. They are good for treatment-resistant depression. And if it doesn't work out you move on. I'd go for it. But that is just the opinion of some random woman on the internet. :)

 

PS I was on Effexor about a decade and never had a discontinuation syndrome when I went off. Not a given. Nor from Cymbalta or any of the SSRIs I've been on over the years.

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there are other TCA's that are good for those who seem treatment resistant.  I am just a month in on a small dose of Tofranil-Imiprimine.  I take at night and I take the Prozac-fluoxitine in the a.m.  I have been on many meds. I haven't even listed them all in my signature, after all, I started with my mental shit around 1973! when the anxiety gets bad I do a bit of Clonazepam.  There are many options in each class, good luck.  IT sucks the worst with SSRI's that take 4-8 weeks before you even know if the side effects will lesson and the benefits kick in.  The TCA's are a bit faster in response. 

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When the Wellbutrn failed had you tried different doses?  Or the 24 vrs standard tablet?  I use that along with Buspar (for Anxiety) and Valium (As needed) when the others aren't enough.   The cocktail idea might be worth more exploration.  And in my opinion you have to try different doses to be sure about your drug being a dud.

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