Jump to content
CrazyBoards.org

Recommended Posts

Hey,

So about 5pm every day of late, my mood just turns black. I can't buy a neutral (forget positive) cognition or emotion, I start to feel and think very negatively no matter what I do. Of course, I'm feeling and thinking badly beforehand, but it just sinks to another level, or depth if you will. 

So I'm wondering if it's a med (or meds) that I'm taking that's losing effect around 5pm. I take the following meds - yes, it's a crazy-looking brew I know, but it allows me to function somewhat - at 6am (in milligrams):

  • 200 Provigil,
  • 2.5 Abilify,
  • 40 Fetzima,
  • 30 Lexapro, 15 BuSpar,
  • 150 Lyrica, 10 Percocet

and these at 2pm:

  • 150 Lyrica, 15 BuSpar

and these 4 times a day, where the last dose is typically 2pm:

  • 15 Adderall
  • 10 Percocet (for chronic pain)

and these at 7pm for sleep:

  • 150 Trazodone, 50 Benedryl

It's impossible to confidently predict a "culprit" but if anyone has any hunches, I'd love to hear them.

For example, today I'm splitting (some of) the 6am batch into two and  taking the second half at 2pm as an experiment. I feel that empirical experimentation might be the way to go because the theory is too complex with this many psychotropic medications in play. 

Cheers , Pete

Share this post


Link to post
Share on other sites
2 hours ago, sming said:

It's impossible to confidently predict a "culprit" but if anyone has any hunches, I'd love to hear them.

Maybe moving up the 2 pm dose of Adderall to 3 or even 4pm might help?..........Just a thought.....What time do you usually go to bed?

Share this post


Link to post
Share on other sites
3 minutes ago, CrazyRedhead said:

Maybe moving up the 2 pm dose of Adderall to 3 or even 4pm might help?..........Just a thought.....What time do you usually go to bed?

Thanks for the idea - I've tried that previously and the Adderall at 4-5pm had very little effect and I remained slightly-less, but still very depressed. Then someone mentioned that Ritalin can reduce Adderall's effectiveness so since then I've grouped the 4 Adderall doses together in the a.m./early p.m. and then started the Ritalin. It's hard to say if it's helped but it certainly doesn't help the 5pm mood crash 😕 

Edited by sming
typo

Share this post


Link to post
Share on other sites

Other ideas : ( like you said I know this could all be a theoretical exercise so just thinking out loud)

could you bump provigil?

Ever tried adderall XR? not for the whole dose but maybe one portion to last longer?

i know some here swear that they’ve had good luck switching from adderall to Dexedrine 

 

Share this post


Link to post
Share on other sites
1 minute ago, Iceberg said:

How is your pain controlled? That can tank things late in the day too

Good question. So I actually use the Percocet as an antidepressant. I take it concurrently with the 4 Adderall doses and this combo frequently lifts both my depression and anhedonia, which no other med or treatment can. Naturally I never tell my pain doctor or PDoc hat I use it for this reason, I'd be blacklisted for life in the current hysterical climate over opioid ab/use. I've been on the same dose for 2+ years now and I've also come completely off of it twice for a period of months each time, so I'm fairly OK with my usage of it*.

To answer your question, the main thing I use for pain relief is a series of cognitive "exercises" (?) from the book Explain Pain, which is my pain treatment bible. I also employ mindfulness for my anxiety, depression and pain to a lesser degree.

*If anyone's considering preaching to me about my opioid ab/use, save your fingers because I simply am not going to listen, unless you are in a very similar boat to me and have something constructive to add.

Share this post


Link to post
Share on other sites
9 minutes ago, Iceberg said:

could you bump provigil?

Hah! It's funny you mention that... 2 weeks ago over New Years I bumped it to 400mg and got 6-7 hours of relief from my depression (!!!). This lasted for 5-6 days and began to poop-out severely so I quit it cold turkey, since Provigil does not cause withdrawal (this is documented). However, I went through a very severe withdrawal (I was literally catatonically depressed) until I realised what was going on and took 200mg and sprung out of the catatonia. It turns out there are 2-3 cases reported (like, ever) of it causing withdrawal, if you look for them. I guess I make number 4 :( 

Quote

Ever tried adderall XR? not for the whole dose but maybe one portion to last longer?

Is that like Vyvanse? I tried Vyvanse to great effect when I first "discovered" that stims helped my depression. It lasted 6-7 hours initially and slowly the period of effectiveness shrunk down and down to like 2 hours. Hence I moved to multiple doses of Adderall as it gives me more coverage. Ditto for Concerta and Ritalin.

Quote

i know some here swear that they’ve had good luck switching from adderall to Dexedrine

Yeah I heard that too and tried it and hated it. It made me feel really just, horrible and icky and pissy and depressed. I am highly, highly refractory/atypical/TR/just plain weird ¯\_(ツ)_/¯ 

Edited by sming

Share this post


Link to post
Share on other sites
20 minutes ago, sming said:

Hah! It's funny you mention that... 2 weeks ago over New Years I bumped it to 400mg and got 6-7 hours of relief from my depression (!!!). This lasted for 5-6 days and began to poop-out severely so I quit it cold turkey, since Provigil does not cause withdrawal (this is documented). However, I went through a very severe withdrawal (I was literally catatonically depressed) until I realised what was going on and took 200mg and sprung out of the catatonia. It turns out there are 2-3 cases reported (like, ever) of it causing withdrawal, if you look for them. I guess I make number 4 :( 

Is that like Vyvanse? I tried Vyvanse to great effect when I first "discovered" that stims helped my depression. It lasted 6-7 hours initially and slowly the period of effectiveness shrunk down and down to like 2 hours. Hence I moved to multiple doses of Adderall as it gives me more coverage. Ditto for Concerta and Ritalin.

Yeah I heard that too and tried it and hated it. It made me feel really just, horrible and icky and pissy and depressed. I am highly, highly refractory/atypical/TR/just plain weird ¯\_(ツ)_/¯ 

The adderall XR, while more mild than the IR, can be more punchy than vyvanse. If your total day is 60mg(?) you could try making one of the later doses of 15 mg as extended release, like maybe at noon-ish, and leave the rest as ir. The XR supposedly lasts eight hours but often is more like 6, so the noon-ish timing could carry you at least a little past the 5 pm mark of doom. The XR does have ir capsules in it, so in theory it shouldn’t throw you off much, but I’ve found that it takes longer to feel an effect

Share this post


Link to post
Share on other sites

@sming My first thought is the Adderall wearing off also and you have the crash. Do you take breaks from it? A few here that claim it has never loses effectiveness for them, but I think that is unusual. Do certain foods/drinks make it weaker? I seem to have less punch when I eat food/coffee with ritalin.

I've read that over time, Percocet can make you depressed (even for people without any depression before), but you mention it helps you with depression though (which I assume it would if you're in chronic pain!) so that may not be the culprit... Do you know what causes the chronic pain?

Share this post


Link to post
Share on other sites

Is it the Skol? Awful shit but I'm amazed you know about it in NYC. Haven't seen the stuff for about 10 years or more. But anyway, more pertinently, most people seem to suffer from depression more in the mornings while a few, like me, feel it more later in the day. Maybe talk to your doc and shift the timings of you taking your meds, because maybe you're set for getting over the early morning depression when you feel it worse in the evening. Just a thought. Might be completely useless but hope you feel better soon. 

Share this post


Link to post
Share on other sites

If talking to your pdoc about the way you take specific meds is problematic, perhaps you could shift the nature of the conversation a bit and talk about what the overall strategy is in your case. For instance, I'm prescribed Adderall along with my Effexor XR not because Adderall is gernerall a stimulant, but specifically because Adderall is a dopamine release agent. That pairs along with the Effexor at my dosage being a dopamine reuptake inhibitor. Together, they're targeting what we believe to be a dopamine deficiency caused by a failure of my system to produce enough and keep it long enough. You might be able to get your pdoc to respond in terms of targeted therapeutic dosing along the lines where you're finding relief, if you're able to share the fact that it's happening. (Adderall, incidentally, is not an opiate, but an amphetamine.)

Share this post


Link to post
Share on other sites
On 1/12/2020 at 5:05 PM, Fluent In Silence said:

Is it the Skol? Awful shit but I'm amazed you know about it in NYC. Haven't seen the stuff for about 10 years or more. But anyway, more pertinently, most people seem to suffer from depression more in the mornings while a few, like me, feel it more later in the day. Maybe talk to your doc and shift the timings of you taking your meds, because maybe you're set for getting over the early morning depression when you feel it worse in the evening. Just a thought. Might be completely useless but hope you feel better soon. 

Ha ha ha, a fellow shit lager aficionado. I'm actually from Wales originally and came to NYC via London. 

Yeah that's entirely possible. I think it's also a mental blow when I take my last Adderall+Percocet because experience shows that that's the last time that day that I'm going to feel anything approaching human. It's very hard not to let this fact (and it is a fact - it's the only thing that lets me feel alive) affect your outlook for the rest of the day.

Thanks for the suggestion.

  • Like 1

Share this post


Link to post
Share on other sites
23 hours ago, Cerberus said:

If talking to your pdoc about the way you take specific meds is problematic, perhaps you could shift the nature of the conversation a bit and talk about what the overall strategy is in your case. For instance, I'm prescribed Adderall along with my Effexor XR not because Adderall is gernerall a stimulant, but specifically because Adderall is a dopamine release agent. That pairs along with the Effexor at my dosage being a dopamine reuptake inhibitor. Together, they're targeting what we believe to be a dopamine deficiency caused by a failure of my system to produce enough and keep it long enough. You might be able to get your pdoc to respond in terms of targeted therapeutic dosing along the lines where you're finding relief, if you're able to share the fact that it's happening. (Adderall, incidentally, is not an opiate, but an amphetamine.)

Thanks, yeah it's tricky because I'm using the Opioid for its anti-depressant properties and like I said, that's an immediate no-no in America right now. I have told him to drill down on the dopamine because it's dopaminergic meds that actually have some positive (and sometimes negative) psychotropic effect on me. Most other meds just give me horrific side-effects.

Yeah I know Adderall's not an opioid I was referring to the Percocet when I said "opioid" previously  :)

Share this post


Link to post
Share on other sites

Thanks to all who have posted and suggested stuff.

I think I've found a/the main culprit of this 5pm crash: I'd forgotten that my pure OCD (about spontaneously committing suicide) and the self-loathing it prompts kick-in at dusk in Winter :( 

For your efforts, here's a sneak-peek into my "special", TR-OCD, twisted brain that's causing most of this daily suffering:

1. I notice that it's getting dark early (as it's wont to do in Winter)
2. my OCD Spike "short, Wintery days are depressing" triggers, followed instantly by: I won't be able to bear this depression!  I will spontaneously commit suicide!!!
==> This causes latent, stealth, paralysing feelings of pure skin-crawling terror :( 
3. then my OCD's over-self-preservation function kicks in: I must avoid all avenues of depression. I will achieve this by blaming and punishing myself horrifically for jeopardizing my life: "I am a very bad person for jeopardizing my life" (i.e. for allowing myself to experience a "depressing" Wintery dusk).
==> An endless stealth mantra of telling myself this makes me feel worse than soggy dog poop; the very worst human on the planet. I feel utterly crushed from the self-loathing.

And hence the majority of 4/5/6pm crash ¯\_(- -)_/¯ 

I am a fucking nutjob.

Share this post


Link to post
Share on other sites
9 hours ago, sming said:

Thanks to all who have posted and suggested stuff.

I think I've found a/the main culprit of this 5pm crash: I'd forgotten that my pure OCD (about spontaneously committing suicide) and the self-loathing it prompts kick-in at dusk in Winter :( 

For your efforts, here's a sneak-peek into my "special", TR-OCD, twisted brain that's causing most of this daily suffering:

1. I notice that it's getting dark early (as it's wont to do in Winter)
2. my OCD Spike "short, Wintery days are depressing" triggers, followed instantly by: I won't be able to bear this depression!  I will spontaneously commit suicide!!!
==> This causes latent, stealth, paralysing feelings of pure skin-crawling terror :( 
3. then my OCD's over-self-preservation function kicks in: I must avoid all avenues of depression. I will achieve this by blaming and punishing myself horrifically for jeopardizing my life: "I am a very bad person for jeopardizing my life" (i.e. for allowing myself to experience a "depressing" Wintery dusk).
==> An endless stealth mantra of telling myself this makes me feel worse than soggy dog poop; the very worst human on the planet. I feel utterly crushed from the self-loathing.

And hence the majority of 4/5/6pm crash ¯\_(- -)_/¯ 

I am a fucking nutjob.

You sound exactly like me in this regard.

I have the OCD thing about the days being shorter, not feeling like I'm going to make it through the winter, 5 PM crash, everything...

On 1/12/2020 at 5:54 AM, sming said:

Hey,

So about 5pm every day of late, my mood just turns black. I can't buy a neutral (forget positive) cognition or emotion, I start to feel and think very negatively no matter what I do. Of course, I'm feeling and thinking badly beforehand, but it just sinks to another level, or depth if you will. 

So I'm wondering if it's a med (or meds) that I'm taking that's losing effect around 5pm. I take the following meds - yes, it's a crazy-looking brew I know, but it allows me to function somewhat - at 6am (in milligrams):

  • 200 Provigil,
  • 2.5 Abilify,
  • 40 Fetzima,
  • 30 Lexapro, 15 BuSpar,
  • 150 Lyrica, 10 Percocet

and these at 2pm:

  • 150 Lyrica, 15 BuSpar

and these 4 times a day, where the last dose is typically 2pm:

  • 15 Adderall
  • 10 Percocet (for chronic pain)

and these at 7pm for sleep:

  • 150 Trazodone, 50 Benedryl

It's impossible to confidently predict a "culprit" but if anyone has any hunches, I'd love to hear them.

For example, today I'm splitting (some of) the 6am batch into two and  taking the second half at 2pm as an experiment. I feel that empirical experimentation might be the way to go because the theory is too complex with this many psychotropic medications in play. 

Cheers , Pete

When are you taking your first doses of the every four hour meds?

I thought I'd mention with Adderall, it's "intended" to be taken every 4-6 hours (instant release), but since you have four doses, perhaps you could take them every 3-4 hours like with Ritalin?

I take my Dexedrine in three doses every 4 hours, and if I don't take it on the dot, my mood completely tanks into oblivion. I think my stimulant dominates my regimen for sure and has the most effect (positive if taken, negative if forgotten).

Also, FWIW, I had a horrible experience with Fetzima where I started feeling very weepy, dysphoric, and started having withdrawal symptoms by about 4-5 PM.

  • Thanks 2

Share this post


Link to post
Share on other sites
4 hours ago, mikl_pls said:

Hey @mikl_pls, good to hear from you.

4 hours ago, mikl_pls said:

You sound exactly like me in this regard.

Huh. I hadn't really appreciated we were similar in this regard. You've written about so many trials and tribulations about meds it's hard to know what does and doesn't help you!

4 hours ago, mikl_pls said:

I have the OCD thing about the days being shorter, not feeling like I'm going to make it through the winter, 5 PM crash, everything...

Wow, I've never heard of anyone having that before. I thought it was SAD and bought 3 different "Natural" lights, all to no avail - obviously.

4 hours ago, mikl_pls said:

When are you taking your first doses of the every four hour meds?

6am typically.

4 hours ago, mikl_pls said:

I thought I'd mention with Adderall, it's "intended" to be taken every 4-6 hours (instant release), but since you have four doses, perhaps you could take them every 3-4 hours like with Ritalin?

And my problem is that the anti-depressant effect of both Adderall and Ritalin is less than 2 hours :( Hence I have to take them every 2-3 hours or I regress into horrific feelings of emptiness and worthlessness and can't do a thing. Hence I tend to run out by 3-4 pm and the rest of the day I'm just suffering, basically. I frontload my day's work for this reason. I've not been on a night out in... years?

4 hours ago, mikl_pls said:

I take my Dexedrine in three doses every 4 hours, and if I don't take it on the dot, my mood completely tanks into oblivion. I think my stimulant dominates my regimen for sure and has the most effect (positive if taken, negative if forgotten).

Wow, that's super-similar. I wish mine lasted that long. They used to but my brain has up/down-regulated presumably. The stims are absolutely the key to my regimen. Without them I'd be staring at the wall literally all day long. At least they allow me to focus. Stim+Percocet allows me to actually want to do things, to be interested in things.

4 hours ago, mikl_pls said:

Also, FWIW, I had a horrible experience with Fetzima where I started feeling very weepy, dysphoric, and started having withdrawal symptoms by about 4-5 PM.

Interesting. I am thinking of cutting it from my regimen as I don't think it's doing anything. It's a bugger that you can't easily split the dose. I suppose I could empty the capsule into water and take 1/2 in the a.m. and 1/2 in the p.m.?

Out of interest, since we're similar in this regard, what was/is your most successful regimen and what is your current regimen?

Share this post


Link to post
Share on other sites
12 hours ago, sming said:

Huh. I hadn't really appreciated we were similar in this regard. You've written about so many trials and tribulations about meds it's hard to know what does and doesn't help you!

I think I've just been reaching in the dark hoping something would help me... lol.

12 hours ago, sming said:

Wow, I've never heard of anyone having that before. I thought it was SAD and bought 3 different "Natural" lights, all to no avail - obviously.

Yeah, mood lamps don't work for me either. They brighten up the room quite nicely though! Someone on here suggested a dawn simulator (forgive me for not being able to remember who), and my lights in my room are automated to be controlled by a Goodge Home, so I just set all my lights to come on at 1% brightness at sunrise and fade to 100% over an hour's time, and that seemed to work, except now my circadian rhythm is turned around and it just gets on my nerves when they come on at 1% brightness by themselves. (I have a CRSD, not sure which one, but probably delayed sleep phase disorder or non-24 hour).

There's definitely a seasonal element to my mood swings. I have very rapid "micro-swings" and rapid "macro-swings" (micro-swings being my mood shifting from day to day, week to week, etc.; macro-swings being the dominant mood of about a four month period, being depressed from about October through February-March-ish as well as June through July-August-ish and the rest of the time being quite chipper and "up"). I really hope that made sense, it makes sense to me in my head but doesn't to my pdoc or anyone else lol.

12 hours ago, sming said:

6am typically.

I don't know about the Percocet, but perhaps ask your pdoc about trying the Adderall being dosed every 4-6 hours. I take Dexedrine every 4 hours, 8 AM, 12 PM, and 4 PM, and it seems to do me well. If I could have four doses then I would take them every three or so hours and I think it would be really helpful.

12 hours ago, sming said:

And my problem is that the anti-depressant effect of both Adderall and Ritalin is less than 2 hours :( Hence I have to take them every 2-3 hours or I regress into horrific feelings of emptiness and worthlessness and can't do a thing. Hence I tend to run out by 3-4 pm and the rest of the day I'm just suffering, basically. I frontload my day's work for this reason. I've not been on a night out in... years?

One thing to consider is that Ritalin cancels out the effects of amphetamines by means of its mechanism of action. Ritalin acts as a NDRI, while amphetamine is both a releasing agent and reuptake inhibitor of norepinephrine and dopamine. Ritalin's mechanism of action in the4 release of dopamine and norepinephrine is fundamentally different from most other phenethylamine derivatives, as methylphenidate is thought to increase neuronal firing rate, whereas amphetamine reduces firing rate, but causes monoamine release by reversing the flow of the monoamines through monoamine transporters (NET, DAT, SERT) via a diverse set of mechanisms, including TAAR1 activation and modulation of VMAT2 function, among other mechanisms. The difference in mechanism of action between Ritalin and amphetamines results in Ritalin inhibiting amphetamine's effects on monoamine transporters when they are administered concomitantly. So it would be probably a good idea for both you and your pdoc to chose one or the other and build and synergize upon that stimulant class. 

For example, increasing the dose of either stimulant and just taking that stimulant (I know you're already at max Adderall dose) or ask your pdoc about staggering the dosing of Adderall and Ritalin (like Adderall at 6 AM, then 2 hours later Ritalin, then another 2 hours later Ritalin, then 2 hours later Adderall... etc. etc.) if you don't want to give up both stimulants might be something to think about (with your pdoc, don't want to tell you how to take your meds!)

Going back to synergizing one particular stimulant, you could also maybe have your pdoc add an Adderall XR dose or two throughout the day on top of your Adderall IR, which would also drive your Adderall dose over the max, but that's okay because a lot of people do it. (E.g., 10-20 mg XR twice a day every 4-6 hours or so + your current regimen). You could also do Vyvanse 50-70 mg once or twice a day, but definitely keep the Adderall IR because Vyvanse takes about 2-3 hours to start working. I don't know what your Ritalin and Concerta doses are, but I assume they're also max dose. You could probably try adding Metadate CD or some other extended release methylphenidate to keep it pure methylphenidate or probably add Focalin/Focalin XR (dexmethylphenidate) to the mix, which is supposed to be twice as potent as Ritalin. Concerta dose can also go from the FDA official max dose of 72 mg up to the "unofficial adult" max dose of 108 mg (54 mg twice daily), and Ritalin can be taken as high as 120 mg or more depending on your pdoc's prescribing liberalness and willing to duke it out with your insurance company. Also, increasing the Adderall IR dose or adding more doses throughout the day (same with Ritalin too) may be something else to consider. A way to get around the quantity limit is for your pdoc to prescribe a different strength alongside your current 15 mg and have you take however much s/he wants you to take in addition. Say you need 90 mg Adderall: 15 mg qid + 10 mg tid, or 120 mg Ritalin: 10 mg 2 tid + 20 mg tid. The possibilities are still pretty broad if taking even one class of stimulant, but it all depends on your pdoc's liberalness with prescribing stimulants. My pdoc won't even prescribe above 20 mg Adderall or Ritalin anymore after her husband's passing from sudden cardiac death—I think she is trying to be overly cautious with them honestly, but that's just my opinion. But she'll prescribe the hell out of some antipsychotics, so long as they're second generation antipsychotics. That's why I have to go to my GP for my stimulant dose, but he won't go above the max dose. He was willing to try Nuvigil in addition, as well as amantadine. Nuvigil doesn't really do anything for me, and amantadine had a paradoxical sedating effect yet was stimulating in a way that I couldn't sleep when I laid down. Then I had to go to the ER with akathisia and they thought I was manic so they gave me IM Zyprexa and Ativan shots. Ugh. I was supposed to be prescribed a medicine called Wakix but my insurance won't cover it and there's a special form the doctor has to send to the specialty pharmacy since its distribution is regulated for some reason. (It's not scheduled...)

12 hours ago, sming said:

Wow, that's super-similar. I wish mine lasted that long. They used to but my brain has up/down-regulated presumably. The stims are absolutely the key to my regimen. Without them I'd be staring at the wall literally all day long. At least they allow me to focus. Stim+Percocet allows me to actually want to do things, to be interested in things.

Same for me, my stims are essential for me to function at all/be out of bed and do anything at all. I think it must be an ADHD and not bipolar thing I guess... *shrugs* 

So you're taking Percocet strictly for antidepressant effects? That's very intriguing. They make extended release and instant release straight up oxycodone that would be better on your liver without the acetaminophen. They make a 5 mg capsule, tablets in 5 mg, 10 mg, 15 mg, 20 mg, and 30 mg, ER tabs in 10 mg, 20 mg, 40 mg, 80 mg, and solutions in 5 mg per 5 mL and 100 mg per 5 mL. I don't know how quickly the antidepressant effect wears off for the Percocet, but you could try the 10 mg tablets qid or 40 mg ER tablets qd and hope the extended release mechanism works well. There are also brand-name, I think Xtampza ER, which has an abuse-deterrent formulation to reduce potential abuse or misuse. By the way, if you're not taking anything like Amitiza or something like that for opioid-induced constipation, this is a personal question I know, but are you having healthy bowel movements?

Have you thought about trying buprenorphine for its antidepressant effects? It's a µ-opiod partial agonist, δ-opioid antagonist, and a κ-opioid antagonist, and a nociceptin receptor partial agonist. The  κ-opioid antagonist property causes dopamine release, I believe, and has antidepressant effects. They were proposing a combination medicine of buprenorphine/samidorphan (ALKS-5461) but the FDA rejected it (of course). Just an idea to throw out there, not an obligation to talk about it with your pdoc. If it ain't broken, don't fix it. ;) 

12 hours ago, sming said:

Interesting. I am thinking of cutting it from my regimen as I don't think it's doing anything. It's a bugger that you can't easily split the dose. I suppose I could empty the capsule into water and take 1/2 in the a.m. and 1/2 in the p.m.?

Honestly, Fetzima just isn't worth that much trouble in my humble opinion, dude. It's just an all around terrible medicine. My pdoc loves it for some reason, but refuses to go past 80 mg. (Her conservative prescribing habits again...)

If you want to do an SNRI, I'd do Cymbalta or Effexor XR at high doses if you can tolerate them, or even "heroic doses" as Stahl calls them (beyond the max dose). Examples are Cymbalta up to 240 mg (with blood work monitoring liver function), Effexor XR up to 600 mg (with blood work measuring active metabolite levels), and Pristiq up to 400 mg, but personally Pristiq is another one of those useless meds for me.

12 hours ago, sming said:

Out of interest, since we're similar in this regard, what was/is your most successful regimen and what is your current regimen?

My most successful regimen was as follows:

  • Abilify 20-30 mg 1 PO qam
  • Zoloft 100-150 mg PO qam
  • Norpramin 50-100 mg 1 PO qam
  • Dexedrine 10 mg 2 PO tid
  • Trileptal 600 mg 1 PO bid

I'm honestly thinking about going back to it.

I've had good results when I'm on Cymbalta 120 mg, but my pdoc refuses to go that high. I just don't get why. I haven't told her yet, but one of these days I'm going to ask her if she'd rather the meds kill me or me kill me. That and she doesn't want me to have ECT. I may seek a second opinion on that.

I feel like if I could have more Dexedrine/dextroamphetamine somehow, I could feel a lot better. Just 20-30 mg more would help I feel. I could probably even do away with most or all of my antidepressants if I could somehow convince my doc to prescribe more dextroamphetamine. I think he's really scared to because he's a family practitioner. Maybe he could refer me to someone who would be willing to prescribe more than the max? A specialist of some type other than a pdoc? Like a sleep doc? (I do have idiopathic hypersomnia...) I asked for a referral to a sleep doctor a while back and haven't heard from them. I need to call them. Anyway, I hope my post was helpful, I feel I kinda babbled and was a bit too chatty. Also I wrote it over the course of the day because I had to go to the doc (upper respiratory infection) and see my tdoc. 

Share this post


Link to post
Share on other sites
On 1/12/2020 at 5:54 AM, sming said:

So I'm wondering if it's a med (or meds) that I'm taking that's losing effect around 5pm. I take the following meds - yes, it's a crazy-looking brew I know, but it allows me to function somewhat - at 6am (in milligrams):

  • 200 Provigil,
  • 2.5 Abilify,
  • 40 Fetzima,
  • 30 Lexapro, 15 BuSpar,
  • 150 Lyrica, 10 Percocet

and these at 2pm:

  • 150 Lyrica, 15 BuSpar

and these 4 times a day, where the last dose is typically 2pm:

  • 15 Adderall
  • 10 Percocet (for chronic pain)

and these at 7pm for sleep:

  • 150 Trazodone, 50 Benedryl

P.S.: I forgot you're on the Lexapro 30 mg and BuSpar 15 mg.

If Fetzima is giving you a fit like it gave me and is pooping out halfway through the day, I would recommend a secondary amine tricyclic antidepressant in addition to the Lexapro, like nortriptyline, desipramine, or protriptyline. That creates a "customizable SNRI"-like effect. That's what my Zoloft + desipramine combo was for. If I needed more or less serotonin, adjust the Zoloft (which gives a tad bit of dopamine too), and if I needed more or less norepinephrine, adjust the desipramine. Lexapro is a clean SSRI with no other mechanisms of action and would be a nice SSRI to pair with a secondary amine TCA. Nortriptyline has the least inhition of CYP2D6 I believe, and would logically be the best to pair with Lexapro (or Zoloft which also has a clean liver enzyme usage profile but not as clean as Lexapro), but for me, desipramine and protriptyline are better than notriptyline. Oh, I should probably mention this, this is probably TMI, but protriptyline has a strange side effect of ever so often inducing a spontaneous micro-orgasm randomly and unexpectedly. Sometimes it's very embarrassing (even though no one knows it's happening), sometimes it's kinda nice... lol. This is a side effect of TCAs in general, especially with imipramine I believe, which is a tertiary amine TCA so it not only works mostly on serotonin, but it has an active metabolite (desipramine) which works primarily on norepinephrine (and indirectly dopamine in the frontal cortex) which increases as the dose increases (and so becomes less sedating dose-dependently).

That's just my additional ¢2's for what it's worth. I really liked the Zoloft + desipramine combo especially when both were at 100 mg. I think next visit I will ask about going back to that regimen and staying on it for another year or so provided it still works. (I know I've been switching meds around a lot but when you asked me what my best regimen was, it made me rethink what I am taking).

Also, btw, Strattera works nice in substitution of a TCA if your pdoc doesn't like to prescribe those. It's not as selective an NRI as desipramine, but it's more selective than nortriptyline and probably protriptyline. Strattera also has an interesting sexual side effect, at least in males that I know of... I won't mention it unless y'all want me to because it's kinda... "detailed..."

As for going up on the Abilify, have you tried managing the agitation/irritability/anxiety/etc. induced by Abilify with benzos, beta-blockers, hydroxyzine, etc., or dropping the BuSpar which shares the mechanisms of action of 5-HT1A partial agonism and increasing dopaminergic neurotransmission (at least at the BuSpar dose you're taking)? I don't want to introduce too many ideas at once. Your combo is kinda like mine—very complex—and requires surgical intervention when being modified.

Anyway, I hope this also helps.

Share this post


Link to post
Share on other sites
On 1/14/2020 at 8:45 PM, mikl_pls said:

P.S.: I forgot you're on the Lexapro 30 mg and BuSpar 15 mg.

If Fetzima is giving you a fit like it gave me and is pooping out halfway through the day, I would recommend a secondary amine tricyclic antidepressant in addition to the Lexapro, like nortriptyline, desipramine, or protriptyline. That creates a "customizable SNRI"-like effect. That's what my Zoloft + desipramine combo was for. If I needed more or less serotonin, adjust the Zoloft (which gives a tad bit of dopamine too), and if I needed more or less norepinephrine, adjust the desipramine. Lexapro is a clean SSRI with no other mechanisms of action and would be a nice SSRI to pair with a secondary amine TCA.

Thank you @mikl_pls, this is a really good idea. Do these TCA's have longer half-lives or is it that they just don't exhibit this crash-like effect for you? I will suggest this to my PDoc. Do you happen to know if such TCA's would be hot-swappable with the Fetzima? I get really, really rough side-effects - like horrific - when titrating down and up on meds.

On 1/14/2020 at 8:45 PM, mikl_pls said:

Nortriptyline has the least inhibition of CYP2D6 I believe, and would logically be the best to pair with Lexapro (or Zoloft which also has a clean liver enzyme usage profile but not as clean as Lexapro), but for me, desipramine and protriptyline are better than nortriptyline.

How are they better for you? Are they more betterer such that I should choose those over Nortriptyline. 

On 1/14/2020 at 8:45 PM, mikl_pls said:

Oh, I should probably mention this, this is probably TMI, but protriptyline has a strange side effect of ever so often inducing a spontaneous micro-orgasm randomly and unexpectedly. Sometimes it's very embarrassing (even though no one knows it's happening), sometimes it's kinda nice... lol. This is a side effect of TCAs in general, especially with imipramine I believe, which is a tertiary amine TCA so it not only works mostly on serotonin, but it has an active metabolite (desipramine) which works primarily on norepinephrine (and indirectly dopamine in the frontal cortex) which increases as the dose increases (and so becomes less sedating dose-dependently).

Really? That would be nice cos my drive is at -100 right about now. Cheers for the info.

On 1/14/2020 at 8:45 PM, mikl_pls said:

That's just my additional ¢2's for what it's worth. I really liked the Zoloft + desipramine combo especially when both were at 100 mg. I think next visit I will ask about going back to that regimen and staying on it for another year or so provided it still works. (I know I've been switching meds around a lot but when you asked me what my best regimen was, it made me rethink what I am taking).

May I ask why you stopped it? Presumably it pooped-out? I've had precious little luck with meds I've tried already. My brain seems to "know" them and just ignores them.

On 1/14/2020 at 8:45 PM, mikl_pls said:

Also, btw, Strattera works nice in substitution of a TCA if your pdoc doesn't like to prescribe those. It's not as selective an NRI as desipramine, but it's more selective than nortriptyline and probably protriptyline. Strattera also has an interesting sexual side effect, at least in males that I know of... I won't mention it unless y'all want me to because it's kinda... "detailed...".

I've discussed Strattera (I think) with my PDoc. I think he'd be OK with TCA's, he's one of those rare PDocs: really-experienced (used to be a surgeon, is qualified to do TMS, has done tons of ECT...) and keeps on top of the latest developments. I can never catch him out knowledge-wise. w.r.t. NRA's, I LoL'd when I read "A meta analysis published in BMJ in 2011 concluded that the selective norepinephrine reuptake inhibitor reboxetine is indistinguishable from placebo in the treatment of depression" because reboxetine gave me unstoppable 24/7 suicidal ideation for 2 frikkin weeks before I quit it.

On 1/14/2020 at 8:45 PM, mikl_pls said:

As for going up on the Abilify, have you tried managing the agitation/irritability/anxiety/etc. induced by Abilify with benzos, beta-blockers, hydroxyzine, etc., or dropping the BuSpar which shares the mechanisms of action of 5-HT1A partial agonism and increasing dopaminergic neurotransmission (at least at the BuSpar dose you're taking)?

Yes, I have actually. It worked fairly well (benzos) but I felt like a balloon that's about to burst - loads of pent-up / masked irritability. I've been on 5mg for 4 days now and this time I'm tolerating it. I have absolutely no idea why this time that's the case...

On 1/14/2020 at 8:45 PM, mikl_pls said:

I don't want to introduce too many ideas at once. Your combo is kinda like mine—very complex—and requires surgical intervention when being modified.

Anyway, I hope this also helps.

Very helpful. Thanks again.

Share this post


Link to post
Share on other sites
On 1/18/2020 at 9:04 AM, sming said:

Thank you @mikl_pls, this is a really good idea. Do these TCA's have longer half-lives or is it that they just don't exhibit this crash-like effect for you? I will suggest this to my PDoc. Do you happen to know if such TCA's would be hot-swappable with the Fetzima? I get really, really rough side-effects - like horrific - when titrating down and up on meds.

They have longer half-lives and they also don't exhibit these crash-like side effects for be, so both. Just note that pdocs most often now are usually closed to the idea of prescribing TCAs. I personally wouldn't have any discomfort or concerns with hot-swapping a TCA with Fetzima. Fetzima has such a short half-life anyway it will clear out of the system in just a few days. However, if you're susceptible to side effects, you may wish to take 20 mg for a few days, then take 20 mg every other day for a week or so, then start a low dose of a TCA, like 10 mg or 25 mg at the very most, or if starting with protriptyline, 5 mg 2-3x/day.

On 1/18/2020 at 9:04 AM, sming said:

How are they better for you? Are they more betterer such that I should choose those over Nortriptyline.

For me, they are better insofar as they actually produce therapeutic effects, and they for most people have less side effects, except protriptyline, which for me the anticholinergic side effects can get nasty after a while sometimes (like urinary hesitation, constipation, dry mouth/throat, blurry vision, unable to focus close up, etc.) Nortriptyline is sedating slightly in lower doses and at first because of its affinity to the histamine H1 receptor. But after a while and especially at higher doses, it becomes stimulating because it is a relatively selective NRI (more of a SNRI though with much more emphasis on NE). Nortriptyline just so happens to be the "cleanest" and "safest" TCA, I use quotes because no TCA is actually 100% "clean" or "safe." IOW, they all are slightly dirty in their mechanism of action (targeting many receptors and transporters) and can have dangerous side effects (like cardiovascular in particular, some are worse than others, but nortriptyline is the safest supposedly).

Desipramine is actually cleaner mechanism of action wise because it is essentially just a selective NRI (most selective NRI and most potent NRI), with mininmum antihistaminergic, anticholinergic, antiadrenergic, etc., side effects. It's not necessarily safer than nortriptyline, but it's safe enough to be used in the geriatric and pediatric population somewhat commonly. It's used in the pediatric population for ADHD and geriatric population for depression not responsive to first-line agents. It's safe for use in geriatric population from the TCA agents because of its lack of anticholinergic and antiadrenergic side effects, causing less delirium, cognitive side effects, and orthostatic hypotension (leading to less falls) than other TCAs. It's also probably the least sedating, and for most, stimulating even in low doses.

Protriptyline is an entirely different animal. Instead of being taken at night (except for desipramine which can be taken day or night), it is taken along 3-4 divided doses throughout the day. It comes only in 5 mg and 10 mg tablets, much like a stimulant (and it is rather stimulating from my experience, probably the most stimulating TCA... even more stimulating than desipramine for me). It also tends to respond to depression quicker than most antidepressants and the rest of the TCAs, sometimes taking just two weeks to respond to depresssion. So it has a good therapeutic mechanism of action. But this is offset by its rather dirty side effect profile. It's highly anticholinergic, almost as much as Elavil (amitriptyline). It has some affinity for the H1 receptor, so there is some potential for sedation despite the stimulant-like properties. It also is known for cardiotoxic side effects, like almost all TCAs... Might not be a good choice for a geriatric patient unless used in low doses, same for pediatric patients. But if you aren't taking too much meds already and can tolerate some potential side effects for a very good antidepressant with a good therapeutic profile, protriptyline is a good one.

If I had to summarize them, I would say this (these are my personal assessments about their effects on me):

  1. nortriptyline: "safest," (least side effects across dose span), probably most sedating of the three but goes away after a while, moderately anticholinergic but not noticeable, only "feel" the medicines effects in high doses (100-150 mg), somewhat stimulating in high doses (usually at max dose of 150 mg)
  2. desipramine: probably second "safest," cleanest side effect profile, effective as an adjunct but not monotherapy personally (even up to 200 mg, max 300 mg for most), least side effects aside from those caused by therapeutic effects, somewhat stimulating rather than sedating even in low-ish doses (~50 mg), high doses probably not necessary (150+ mg, 50-100 mg probably all that is needed), low doses can help with sleep yet help with depression a little (10-25 mg)
  3. protriptyline: probably the most stimulating of the three (usually at 30 mg/day or 10 mg 3x/day), probably most cardiotoxic of the three but not as bad as clomipramine for example, anticholinergic side effects can be troublesome and are dose-related, hardly sedating at any dose, 30 mg is probably the best dose for balancing therapeutic effects and side effects, 40 mg is slightly more effective yet with much more side effects (mostly anticholinergic), max is 60 mg but I personally couldn't imagine taking that much
On 1/18/2020 at 9:04 AM, sming said:

Really? That would be nice cos my drive is at -100 right about now. Cheers for the info.

It won't really do much good in the way for drive, but does have strange, random sexual side effects, that one happening in a minority of patients. I guess I was "lucky..." (???)

On 1/18/2020 at 9:04 AM, sming said:

May I ask why you stopped it? Presumably it pooped-out? I've had precious little luck with meds I've tried already. My brain seems to "know" them and just ignores them.

I stopped because the combo pooped out. I too have meds that don't work if I try them again, but some my brain seems to just "like," and no matter how many times I swap out for other meds and come back to them, they always work at least a little and for a longer period of time than other meds. Zoloft + desipramine has been the most consistently-working combo for me ever. It has worked the most consistently, the longest, and has been the best-working, with least amount of side effects. Zoloft can cause sexual side effects in the higher dose range for me (150 mg and up), but I'm usually able to keep the Zoloft at 100 mg and the desipramine at 50 mg, only occasionally needing more of one or both agents. The temporary need of increased doses makes the side effects they cause more tolerable. If you need 200 mg Zoloft though, the side effects will eventually go away mostly, but will have some remaining side effects).

On 1/18/2020 at 9:04 AM, sming said:

I've discussed Strattera (I think) with my PDoc. I think he'd be OK with TCA's, he's one of those rare PDocs: really-experienced (used to be a surgeon, is qualified to do TMS, has done tons of ECT...) and keeps on top of the latest developments. I can never catch him out knowledge-wise. w.r.t. NRA's, I LoL'd when I read "A meta analysis published in BMJ in 2011 concluded that the selective norepinephrine reuptake inhibitor reboxetine is indistinguishable from placebo in the treatment of depression" because reboxetine gave me unstoppable 24/7 suicidal ideation for 2 frikkin weeks before I quit it.

I don't get it, my pdoc has a lot of qualifications similar to your pdoc, but her prescribing habits are so much more conservative and guarded... I dunno lol.

I've not heard good things about reboxetine. I think I read that same article... Reboxetine is very similar to atomoxetine (Strattera) if I'm not mistaken. Strattera can help me but sometimes has this dysphoriant ettect on me, causing profound dysphoria and suicidality. I think one of its metabolites works a certain way on the opioid receptors that can be prone to cause dysphoria and suicidality. It's not working on the µ-opioid receptor, it's one of the other ones...

Desipramine, being the most potent and selective NRI (at least in the US), strangely enough, while helping immensely at moderate doses (±50 mg, like 50-75 mg, but my pdoc won't prescribe over 50 mg anymore for some reason), at higher doses like 150-200 mg, it doesn't help any more than it did at lower doses, produces a little more side effects, and may sometimes make me feel a little flat (the one time she did let me take 200 mg a few years ago when I was severely depressed. I was taking desipramine alone without the Zoloft at this dose, so I think I need both serotonin and norepinephrine reuptake inhibition for it to be therapeutic at all).

On 1/18/2020 at 9:04 AM, sming said:

Yes, I have actually. It worked fairly well (benzos) but I felt like a balloon that's about to burst - loads of pent-up / masked irritability. I've been on 5mg for 4 days now and this time I'm tolerating it. I have absolutely no idea why this time that's the case...

I don't know man... Abilify was great for me at first the first time I tried it, but then caused me to sink into what was theretofore the most dysphoric a depressive episode I had yet to experience. I am still in that depressive episode and haven't remitted from it, and that was about 5 years ago. I have not been able to shake this episode except for a few weeks or so at a time. Any subsequent time I tried Abilify, I would get very angry, irritable, and aggressive at low doses (2-5 mg).

So I tried starting it at 10 mg with my pdoc's permission and I did fine, but needed to keep increasing it until I was up to 30 mg. That was awful because of the compuslivity reaction, which for me exhibited itself as compulsive spending/shopping. I still haven't recovered completely from that either. I tell ya, Abilify was great while it lasted (the first month the first time I took it, and for about a year and a half a few more times after that), but it has permanently altered the way my brain works. I have no imagination, no positive emotions (flattened affect), no creativity (haven't written a song in 5 years, not a single one... started on a handful only, and not finished any of them...), etc., am always depressed, suicidal, dysphoric, etc., can't shake obsessive thoughts especially when they're related to suicide... Ugh.

I have a very profound love/hate relationship with Abilify. I was so glad to get off of it last spring, but now I'm hating Vraylar and wanting back on Abilify despite the side effects it causes... I'm going to look for an alternative, but unless I can find one, it'll be Abilify for me all over again, and I'll be an happy yet empty shell of a person again without any personality. It's a very strong, potent antipsychotic compared to the others... IMO... It works in a different way that is not nearly as well studied IMO. I think these dopamine partial agonists need more trials and studies to be done before more of them come out. The dopamine antagonists are far more well studied simply because they've been around longer. 

I'd recommend a trial of Abilify to anyone, but only after certain other trials have been done... That's how I feel about it. Most people don't consider it a "big gun" or a "sledgehammer," but personally because of my experience with it, I consider it a pretty heavy hitter.

I wish you the best of results and the least negative side effects with it!

 

Share this post


Link to post
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.


  • Similar Content

    • By Michelle1
      I hate being on adderall.  I can't seem to work when i'm not on it.  I'm on 15 mg now.  It's working, but I feel speedy & have a hard time sleeping.  I'm wondering If i go down to 5 mg, if I can still get some work done.  
      Does anyone just take 5mg of adderall?  
    • By Blahblah
      I'm struggling to adjust my Ritalin dosage. It really helps with cognition/focus (and even mood balance), pdoc recently increased my dose. I take 30mg (LA) morning, and now 10mg (LA) in late afternoon. I'm OK on morning dose until about 2pm after I eat lunch...then energy really tapers off, I start to get more distracted, then I take afternoon dose by 4pm.
      The afternoon dose makes me immediately sleepy. This effect seems really paradoxical! Is there something I can do to reduce this? Caffeine??  IR form only lasts like 2 hours & I crash, so I want to avoid that. Where I live, its tough to get anything other than Ritalin...
      I read that some stimulants (such as Ritalin & Adderall) are better for reducing Hyperactivity - which may be why I feel so sleepy/dazed when taking it in afternoons? I've never been hyperactive....
      Would Vyvanse be better in this regard (helping with both focus + causing less sleepiness)?
    • By Blahblah
      I'm sorry if this question is redundant....
      @notloki I know you're knowledgeable here.
      I've been getting very inconsistent effects from Ritalin. I recently increased my dosage, because I was experiencing more fatigue afternoons and having to nap. I take 20mg (extended in morning, before I get up), then I take 10mg (extended) after lunch. Pdoc said I could take 10mgIR no later than 3pm if needed.
      I'm compliant with this routine. Dose 40 minutes before getting up, same exact breakfast every morning: oatmeal, fruit, yogurt, nuts, coffee. Yesterday, I felt pretty good and energetic in the morning (both mentally and physically). Then today, I feel focused..yet, (sort of zombie-dazed staring at screen), incredibly drowsy/tired and apathetic, like I really need to nap. I get plenty of sleep every night.
      Is there a reason this is happening? Seems doses effect me differently all the time. I prefer extended because the IR (while it hits more noticeably) I feel more intense energy crash and can become moody...Note: Pdoc will not let me change until I hit the max (60mg), and other stimulants (even Adderall) are either extremely hard or impossible to get prescribed here.
×
×
  • Create New...