Jump to content
CrazyBoards.org

Recommended Posts

Just having a really shitty day and keep thinking I'd rather just blow my head off then continue to suffer this bullshit depression. I won't though, because I know it would cause family to much hurt. Anyway, I'm on Nardil 45 mg because every other drug combination has failed, and MAO was a last pill resort. In the past, some of the SSRI drugs worked good for a couple of weeks, then I dropped back into the hole of depression only to have meds increased or changed. Same now with Nardil, worked good for a while but now like I said, I can't stand the depression that has returned. I know my pdoc will say lets go to 60mg, and I suspect it will work for a while (and I'll gain 10 more pounds), but I don't want to up it just for it to work a short period and then stop. Debating what to do; wondering if others have found increases in the right med to work for good, just confused and bitter.

Link to comment
Share on other sites

Well, there is always Rexulti to try. I've read that people find it superior to Abilify. But before I'd go off the Nardil, I'd give it a fair chance all the way up in dose. No guarantee that it will work or work for a longer period of time, but there is no way to know without trying.

Have you ever tried taking a mood stabilizer with your antidepressants? (I don't really count risperidone as a mood stabilizer.)

The combination which has worked well for me is: antidepressant + atypical antipsychotic + mood stabilizer (anticonvulsant).

Link to comment
Share on other sites

Jt07, I haven't tried  Rexulti, is it an atypical antipsychotic like risperidol? As far as mood stabilizers, I thought they were for Bipolar patients. Do they help the ups and downs of depression too? I do have decent days and certainly bad days, so maybe this could help. BTW, you always have the best ideas and give great advice!

 

Link to comment
Share on other sites

Thank you. Yes, Rexulti is an atypical antipsychotic like Risperdal so it might be a major change for you if the Risperdal is working. Although I personally found that Risperdal worked ok for my depression, Rexulti is supposed to be much, much better. It was designed with depression in mind.

Adding a mood stabilizer to antidepressants is a tried an true method of augmentation for unipolar depression. They used to use  lithium a lot, but now there are several anticonvulsants that also act as mood stabilizers. Like antidepressants sometimes it takes time to find the right mood stabilizer. For me it's Tegretol (carbamazepine). Others have success with lithium or trileptal or Lamictal, etc. 

Link to comment
Share on other sites

Usually, Nardil is titrated up to 60-90 mg "rapidly," continued until clinical response, then decreased slowly over several weeks to the lowest effective dose, which can be as low as 15 mg every other day. Maybe you could ask your pdoc to let you titrate up to 90 mg on your own, under his supervision (like increase 15 mg every 1-2 weeks until you get to 90 mg or until you feel a therapeutic response, which could be at 60 mg or 75 mg). The official maximum is 90 mg, but there are people who need more than 90 mg of Nardil.

If Nardil doesn't work for you, in the end, there's always Emsam, Parnate, and Marplan. Emsam is the safest MAOI to take, but it's annoying (to me anyway) to have to worry about the skin patches, plus I had allergic skin reactions to the patches. Emsam is weight neutral, or might cause slight weight loss. I gained weight on it though for some stupid reason. Parnate is more prone to hypertensive crises, but it isn't prone to weight gain; in fact, it's likely that you'll lose weight on Parnate. It's said that Marplan is weight neutral, but it belongs to the hydrazines just as Nardil does, the hydrazines being associated with substantial weight gain that never plateaus, so I don't know who to trust regarding Marplan's weight gain/loss propensities.

An old technique they used to do a lot more back when TCAs and MAOIs were the only antidepressants around was to combine an MAOI with a TCA, specifically a secondary amine TCA (because they don't cause much serotonin reuptake inhibition and therefore won't cause serotonin syndrome/toxicity), with the exception of amitriptyline, which can safely be used with MAOIs, along with amoxapine (actually a tetracyclic), desipramine, maprotiline (tetracyclic), nortriptyline, protriptyline, and trimipramine. (Prescriber's Guide: Stahl's Essential Psychopharmacology, Stephen M. Stahl, pp. 45, 53, 187, 411, 497, 585, 725) Imipramine and clomipramine are contraindicated with concomitant use of MAOIs due to how serotonergic they are. 

From "Advances in Psychopharmacology" by Mark S. Gold, John S. Carman, R. Bruce Lydiard, p. 168

Quote

The consensus of experienced clinicians is that combination treatment is safest if the following protocol is adhered to. The patient should be free from either medication for 2 weeks. Both medications are then started simultaneously, at a low dose. For example, the TCA would be started at an equivalent of 25 mg amitriptyline h.s. (at bedtime) and the MAOI started the next morning at 15 mg for phenelzine (10 mg for tranylcypromine or isocarboxazid). Every week the dose of each would be raised by an additional tablet; thus on day eight, 50 mg TCA would be given at h.s. and on day nine, 15 mg phenelzine at a.m. and noon. The total dose of TCA can be given h.s.; the dose of MAOI should be split during the morning (to avoid insomnia). Dosage can be raised weekly in this fashion to three pills MAOI, three pills TCA at which time 2 weeks should be permitted to elapse, to observe the patient for beneficial response. (Frequently, lower dosages are effective in combination treatment.)

If the patient has still not responded, the TCA could be increased by one additional tablet per week. Currently, dose equivalents of 45 mg phenelzine and 75 to 150 mg TCA (amitriptyline) have been recommended as therapeutic doses. If the patient still has not responded, consideration should be given to further increases. In particular, one might seek to attain 85% platelet MAO inhibition while avoiding severe suppression of the enzyme (greater than 95%) and the use of the laboratory would be particularly helpful in this case.

 

This could also be applied to Emsam, it'd just be different. The way my pdoc did it with me was we tried Emsam 6 mg with nortriptyline 50 mg, eventually switched to protriptyline 10 mg 3 times per day, then went up to Emsam 9 mg.

Lithium is also a good augmenter for MAOIs. Stimulants are also good augmenters for MAOIs. Thyroid hormone is another good augmenter, but that's usually used with TCAs. If your pdoc is liberal enough, s/he might let you do what mine did and do a MAOI + TCA + stimulant + thyroid supplement combo. I was on Emsam 9 mg, protriptyline 30 mg/day, dextroamphetamine 30 mg/day, and liothyronine 25 µg.

Hang in there, things can't suck forever! You'll find something(s) that will help you.

  • Like 2
Link to comment
Share on other sites

Mikrw33; thanks so much for the wealth of information! I am certain you know more about MAOI's and Tricyclics than my pdoc does. He just pats himself on the back because he has the "guts" to prescribe Nardil, which he claims most "younger" pdoc's don't won't because they don't know enough about it. I'll print your response and bring it to him and see what he wants to do. As far as Parnate goes, I would rather be on it if it doesn't cause weight gain. But is it as effective as Nardil? I thought Nardil was the gold standard for efficacy of MAOI's?

Velvet Elvis: I didn't know what ketamine therapy was so of course I went to Wikipedia, which didn't give it a good review: "Ketamine has been tested in treatment-resistant bipolar disorder, major depressive disorder, and people in a suicidal crisis in emergency rooms.[30] Benefit is often of a short duration.[31] The quality of the evidence supporting benefit is generally low." As far as ECT, I really fear the memory loss for a number of reasons of course, but especially since I work and need an intact memory to perform my job. If things get bad enough, however, I would consider this. As far as VLN, I don't know a lot about it other than it involves surgery. Having surgery means I would have to go off Nardil for two weeks in order to use anesthesia, this scares the hell  out of me. Thanks for your ideas!

Link to comment
Share on other sites

On 9/8/2016 at 6:54 AM, Twidder said:

As far as Parnate goes, I would rather be on it if it doesn't cause weight gain. But is it as effective as Nardil? I thought Nardil was the gold standard for efficacy of MAOI's?

Not sure. I can't attest the efficacy of any MAOI but Emsam. I didn't realize Nardil was regarded as the gold standard for efficacy of MAOIs. I have heard, though, that people who take Parnate, usually have to take a large dose to work.

On 9/8/2016 at 6:54 AM, Twidder said:

As far as ECT, I really fear the memory loss for a number of reasons of course, but especially since I work and need an intact memory to perform my job.

There's a study about using the Alzheimer's med donepezil (Aricept) in ECT patients to prevent memory loss and cognitive dysfunction. Maybe if it came down to you having ECT, you could take it during the course it.

Link to study: http://www.ncbi.nlm.nih.gov/pubmed/16957530

  • Like 1
Link to comment
Share on other sites

In my own experience I have often observed that an AD dose that is too low will often work for a little while then fizzle out. I had that happen with Cymbalta but once I reached the max dose the efficiency lasted. Also, I always aim to try an AD up to the highest dose I can tolerate if pdoc agrees. I think if one doesn't they may discard a treatment that could have helped. It isn't always worth doing that but if there is some response at the lower dose..

  • Like 1
Link to comment
Share on other sites

Join the conversation

You can post now and register later. If you have an account, sign in now to post with your account.

Guest
Reply to this topic...

×   Pasted as rich text.   Paste as plain text instead

  Only 75 emoji are allowed.

×   Your link has been automatically embedded.   Display as a link instead

×   Your previous content has been restored.   Clear editor

×   You cannot paste images directly. Upload or insert images from URL.

 Share

×
×
  • Create New...