Archive for the ‘Depression’ Category

We Will Remember Siggie – 2000-2013 RIP!

Pets play a major and significant role in our lives.

Many studies have indicated that having a pet in the home is particularly good for elderly people that live alone.  They become a part of our family.  Our Bassett Hound, named of course, Sigmund (but we called him Siggie,) died June 15th.  He was 13 years old.  Needless to say, our whole family, especially our daughter that raised him, miss him and have gone through a true grieving process over his loss.  Some people don’t think that their grief over a pet is appropriate, and/or embarrassing.  The truth of the matter is that grief helps us heal after losing a beloved pet, and we should all allow that process to happen.  Most of us will outlive our pets, so losing them at some point in time is usually inevitable.

Dr. Jones has always been amazed at how many pet owners do not think they should be devastated over the loss of a pet.  It is perfectly normal to grieve and to miss them, just like any family member that is lost!  He always assures them that it is okay and normal to be upset over their loss!

I am attaching our tribute video to Siggie.  I hope you enjoy it!      RIP Siggie, we love you!

http://video214.com/play/nUjXSEF4KERjetBHXgVG0w/s/dark[spider_facebook id=”- Select Form -“]<div class=”fb-like”” data<href=”http://developers,facebook.com/docs/reference/plugins/like”

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Pristiq vs Effexor

Question: Now that Pristiq has been out for awhile, what has been the clinical response with your patients compared with the Effexor XR formulation? Rumors have said it is more tolerable and less sexual side effects, although I have tried some samples, and it doesn’t seem to be as calming as Effexor, and I am unsure what the Pristiq 50mg dose is compare to a similar Effexor XR dosage?

Also what SSRI/SNRI tends to have the fewest sexual side effects?

Thanks


Answer:

Pristiq and Cymbalta seem to have less sexual side-effects than Effexor
and if Pristiq at 50mg is an adequate dose it should have the least
sexual effects. 90% of the first 570,000 treated with Pristiq have
stayed with a 50mg dose. This dose has the same efficacy in control
studies as 75-150 of Effexor with better tolerability. The drop out
rate due to side-effects is essentially the same as placebo.

When most people (normal metabolizers) take Effexor – 70% of the benefit
comes from Effexor being metabolized so the effects are very similar.
Pristiq does have a slightly higher ratio of norepinephrine effect
relative to serotonin than Effexor and this could account for your
impression that it’s not as calming – that is most likely a temporary
effect.

Because Pristiq doesn’t require the same liver metabolism as Effexor
there are less issues with drug drug interactions and tolerability for
those people (7-10% of Caucasians) who are poor metabolizers. Poor
metabolizers don’t usually do as well on Effexor and don’t usually
tolerate doses above 75mg. Some people do better on 100mg of Pristiq.

Pristiq is also more cost-effective, especially at 100mg dose – since
there is a 100mg tablet – whereas Effexor frequently requires 225mg or
more necessitating multiple capsules.

Wyeth is also getting ready to launch a program where they will pay 1/2
of your cost (copay or cash) as long as you take it on a continual
basis for life if necessary.

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Best Medications Revisited

In December 2006 I participated in a survey of psychiatrists by a pharmaceutical company.  They asked me if I could have only five medications to prescribe which ones would I choose?  Since I have a cash only practice I have to go with the most effective medications long term.

Most medication studies are to meet FDA requirements, which means short studies (6-8 weeks), and they only have to show 50% improvement in symptoms and be statistically better than placebo (that may be associated with only 30-40% improvement).  These studies do not represent real world treatment – patients can’t be given any counseling and can only be on one medication. 

It is only through extensive clinical experience that we can learn which medications are best.

I think of the best medications as the ones that patients come back and say are great….that they have changed their life – side effects are minimal, and the highest standard is that they are still saying it after 6 months, 1 year, 5 years, etc.  If the medication starts working on day one that is a bonus. 

Great medications help you feel better, function better, be less stressed and help protect your overall health.  Great medications also enable you to focus on your life – career, relationships, hobbies, and not be constantly preoccupied by symptoms and survival.  You think – I wish I had this medication a long time ago. 

The main problem with the best meds is cost – especially if you don’t have good insurance – but usually there’s a way to get the medications you need or at least to find generics that are close to the best branded meds.

In my experience stimulants as a group have the highest batting average (the highest percent of the time a particular med works great).  I have patients that have taken them for over three decades.  I haven’t seen any long term problems from taking them.

I was initially trained in the 60’s.  One of the most helpful things I was taught – “if what you are doing isn’t working, do something else.  Even if it is wrong it will get you unstuck.”  This led me to trial and error and eventually to appreciate the value and relative safety of stimulants.

Amphetamines have been available for over 70 years and methylphenidate over 50 years so we have more experience with them than any other medication that we currently use in psychiatry.  Ironically, stimulants aren’t included in the top 10 most often prescribed meds by psychiatrists in the first quarter of 2008.  Despite the fact we have much safer delivery systems the FDA still regulates all the stimulants at a higher level – requiring a written prescription and maintaining a record of each prescription. This creates practical problems, inconvenience, etc.,  not to mention a certain intimidation is felt by doctors.  By contrast, the most abused prescription medications – pain meds – such as Hydrocodone – are much less regulated.

My top 5 list has changed some since 12/06 and hopefully will keep changing as we get even better medications.  For now it consists of the following:

#1     Stimulants – Vyvanse (preferred by 3/4’s of my patients who prefer amphetamines) and Adderall XR (preferred by 1/4 of my patients who prefer amphetamines).  15% of patients prefer one of the methylphenidates such as Concerta, Focalin XR, or Daytrana.

#2     Benzodiazepines – Alprazolam (Xanax and Niravam are my first choice).  Clonazepam, especially Klonopin wafers are a  close second.  

Alprazolam, in a recent study was the #1 med prescribed for stress symptoms by primary care physicians.  Psychiatrists in 2008 used Clonazepam #1, then Seroquel #2, and Alprazolam #3 for stress symptoms.   

#3     Sleeping medication – Ambien CR/Lunesta (I rated Ambien CR first in 06 only because 15-20% of patients have a bad taste the next day from Lunesta – but using a mouthwash with whitener morning and night usually prevents significant taste problems).  Both of these meds work great for most people.  They are both approved for long term use and provide normal sleep.  Short acting Ambien is still preferred by some patients and some take it because it is in generic and they can’t afford CR or Lunesta.  Short acting may not keep you asleep more than 5 hours and has some risk of side effect issues.

No sleep medications were in the top 10 meds prescribed by doctors in 2008.

#4     Antidepressants – Pristiq/Effexor XR – I don’t have enough experience with Pristiq (son of Effexor) to be confident that the majority of patients will end up preferring it to Effexor XR, but in theory it’s better, safer to use, easier to dose, easier to combine with other meds, especially Wellbutrin.  Wellbutrin is the only antidepressant that almost never has weight gain or sexual side effect issues (except for infrequent uses of MAOI’s like Emsam patch).  But Wellbutrin doesn’t have efficacy for the whole range of anxiety and depression symptoms so it would not be the preferred med if you could only use one antidepressant.

Cymbalta is the other antidepressant in this category.  It has more FDA approved uses including fibromyalgia, and generalized anxiety disorder and is very similar to Pristiq in its ratio of effect on serotonin and norepinephrine.  I rank Pristiq first because it has much lower protein binding and therefore gets into the brain faster and works faster.  Prestiq has essentially no drug drug interactions whereas Cymbalta inhibits metabolism of certain medications that can either result in unexpected side-effects or interfere with the activation of pain medications like codeine or hydrocodone. 

#5     Mood stabilizers – Abilify/Seroquel.  There is no perfect choice in this category.  I use these two the most but I also use a lot of Lamictal, Zyprexa (Symbyax) and Lithium.

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How can I prevent recurrence of depression and what do I do if the depression does come back?

Depression runs in my family and I’ve been on the same medicine for a while with no episodes of depression.  About two weeks ago I woke up feeling not myself and contributed it to getting my period on top of coming down with a respiratory infection.  Still not feeling well after two weeks I think it might be depression because I feel tired, confused thinking, can’t focus, etc.  I’ve called my doctor and he told me to up my medicine 100mgs.  My question:  

Since I have not had an episode of depression in quite some time could it have been brought on by me not feeling well?

 


 

Dr. Jones’ reply:

I’m not sure what antidepressant you are on – but it was possibly Zoloft or Luvox since they can be increased by 100mg increments, but not SNRI’s (Effexor, Cymbalta) or other SSRI’s (Prozac, Celexa, Lexapro, Paxil).

Women with a family history and or prior history of depression who respond to an SSRI or SNRI can have return of symptoms if their serotonin level is reduced (as it is premenstrually, post partum, or during perimenopause).  Being ill can also contribute to relapse by disrupting sleep or normal thyroid function.

Previous studies have shown that:  "the dose that gets you well keeps you well", but even then the relapse rates are:  20% of patients have recurrence within 3 years,  50% relapse if the dose is lowered, or 80% relapse if medication is stopped.

Recurrent depression not only causes distress and possible short term impairment, it can also increase your vulnerability to future episodes and decrease your responsiveness to treatment.

There are several things that can help prevent recurrence:

  1. Good sleep – 7-8 hours every night (Lunesta, Ambien provide normal sleep)
  2. Physical activity – daily vigorous activity for at least 30 minutes (a 2 mile walk or equivalent)
  3. Omega 3 fatty acids – take twice daily.  (I trust Cooper brand the most)
  4. Bright light daily 
  5. Thyroid – make sure thyroid levels are good  test.askdrjones.com/ 
  6. Cognitive behavioral therapy – if needed
  7. Other medications – other medications may help such as alprazolam, atypicals, stimulants
  8.  L Methylfolate – (Deplin,  Cerefolin, or Cerefolin NAC)  – these contain a form of folic acid that gets into the brain cells.  Deplin was recently approved by the FDA as an add-on treatment for depression.  Cerefolin also contains B12 and Cerefolin NAC has a third ingredient that increases glutathione (a powerful brain cell antioxidant).  These medications not only can improve mood, but improve cognition and energy.  Caution:  taking Deplin if your B12 level is low can be harmful.  It is safer to either check your B12 levels or take Cerefolin. 
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When my mother died my doctor prescribed Meridia and I like it very much but recently it has not worked. Is there anything similar to Meridia?

Meridia (sibutramine) is FDA approved for weight loss.  It combines the effects of antidepressants like Effexor (at doses of 225mg or higher) or Cymbalta with dopamine effects like stimulants.  One possible side effect is increased blood pressure.

Years ago I tried Meridia for several patients and most of them didn’t like it enough to stay on it.  If you are looking for a medication that helps with depression and weight loss then I would recommend Wellbutrin.  test.askdrjones.com/2005/12/29/how-to-take-wellbutrin/  If you are mostly interested in the mood/anxiety effects I would recommend Effexor XL at least 225mg per day possibly in combination with Wellbutrin.  This would closely duplicate the effects of Meridia.  An alternative that might even be better would be Effexor and Vyvanse.

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Say Goodbye To The Pill Ladies

I am now completely against birth control pills. I’m also against hormone replacement with oral estradiol. Estradiol (in every birth control pill) taken by mouth goes through the liver and causes problems with thyroid, testosterone, and the most effective form of estrogen.

In anyone with a history of depression and/or stress reactivity, this can be a major contributing factor to their functioning and quality of life.

For premenopausal women the NuvaRing seems to be the best option. This is because the hormone blood levels are about 1/3 of what they are with the weakest birth control pill.

Controversy continues regarding hormone replacement in postmenopausal women. However, for most women, the benefits outweigh the risks – especially for brain function (mood & memory). Using the right types of hormones and the right dose is essential. The best options are Premarin or Cenestin tablets and/or estradiol by patch or gel.

Remember, estrogen x thyroid x brain transmitters = mood in women.

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Treatment Resistant Depression

The following question addresses specific aspects of this patients case. However, the underlying principle is an important aspect of effective medication management. What are treatment options when a single medication, even at high doses, is not adequate?
Question: Hello, I am mostly looking for a second opinion, and this website is coming up on pretty much all search engines. I moved to Dallas about 1 yr. ago.
I was taking 300 mg Effexor XR and 45 mg Dexedrine (2 in am, 1 @ noon). I had to stop the dexedrine because I became pregnant. Now that’s over, and I chose a doctor in TX mostly based on proximity to my job, and that they took my insurance. However, now they have kept me on 300 mg Effexor, added 200 mg Provigil, 2 mg Lunesta, and Zoloft. I was told at the beginning that I was to take 150 mg Zoloft (I feel that Effexor is not working like it used to) and once I felt better, I would be weaned off Effexor, and only take the Zoloft. I did this for a couple weeks, but when I still didn’t feel better, they upped the Zoloft to 200 mg. A couple weeks after that I still do not feel better. I told the new Dr. that I do not want to become dependent on 2 antidepressants (I have tried to wean off Effexor 3 times now–with horrible withdrawal symptoms-enough to make me keep taking the medicine, even though I don’t feel it’s working).
The Dr. now wants to double my Zoloft to 400 mg. I am VERY hesitant to do this. (700 mg of antidepressants?) He did ask if there was any time I could remember feeling better and I told him about my previous Dr recommending 300 mg Eff w/45 mg of Dexedrine (I came to him on 75 mg Effexor, he tried methylphenidate 1st, but it gave me awful headaches, so switched to dex).
The new doc seems to really not like stimulant type drugs (emph. added), so they put me on Provigil. It was great at first (after giving birth and being off med. for about a year) but I think i have quickly built up a tolerance, because it is no longer as effective as it was. I am hoping that my intuition is correct, and that I do not require 700 mg of antidepressants, but that it is only the Dexedrine that is missing, and this new Dr. is wrong. I am absolutely terrified of becoming “hooked” on 2 antidepressants vs. 1, and have refused the 400 mg of Zoloft for now.
I am very hesitant to continue w/this Dr’s advice, when I have told him what worked for me in the past, and he has not told me anything regarding why that is not the appropriate treatment, or why he does not prescribe the Dexedrine, and continue to monitor my progress to make sure it is the right treatment option. (emph. added) Help!!
Answer: “If it ain’t broke, don’t fix it”. When a medication combination works well we don’t usually change it. If we have to stop, especially during pregnancy, we go back to it.
We sometimes have to combine antidepressants but it’s better if possible to take only one.
Provigil is totally different than stimulants like Dexedrine. It does have a tendency to develop tolerance because it induces the enzymes that break it down.
Going above approved doses of antidepressants is usually reserved for when all else fails.
Bottom line, I agree with you.


This article originally appeared in the Q&A section10/26/2005.

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Best Medications for Premenstrual Dysphoric Disorder (PMDD)

Premenstrual Dysphoric Disorder responds to medications that enhance serotonin levels. It can be inferred that the cause relates to dropping serotonin levels as estrogen levels fall (since estrogen increases serotonin). Lowering serotonin levels only causes mood symptoms in women who have a genetic predisposition or previous history of depression.
Unlike depression, symptoms of PMDD respond fairly quickly to medication. Typical mood symptoms of PMDD are sad, tearful, feeling overwhelmed, irritability and being overly emotional.
Before deciding whether to use medication every day or just in the last 1-2 weeks of the cycle it is recommended that mood charts be kept for 2-3 cycles. This is primarily to evaluate mood in the first half of the cycle. It is believed that many women have mood symptoms all the time but they are worse during the premenstrual phase. It may be that the lesser degree of depression in the early cycle is normal (by comparison). PME or premenstrual exacerbation of mood symptoms is best treated with daily medication – though sometimes increasing the dose in the last 7-10 days is helpful.

For true PMDD there are several reasons that limiting medication to a few days is helpful. The biggest reason is avoidance of potential long term side effects, especially sexual side effects, possible weight gain and blunting of emotion and motivation. Other reasons include the cost, stigma, and the hassle.
When using medication just during the late luteal phase (last few days of cycle) my first choice is Effexor. Because Effexor is the quickest to cross the blood brain barrier (due to low protein binding) it can be taken for the shortest number of days. It frequently starts working the first day (usually 37.5mg is adequate but sometimes 75mg is needed). Once Effexor is discontinued – usually once menses starts – the Effexor is totally out of the system in 3 days. Most medications take one week to be out of the system. Prozac (fluoxetine) aka Sarafem takes six weeks to clear – i.e., it can’t be taken just during the PMS phase. My 2nd choice and the second fastest to work is Lexapro 5-10mg. Ironically it’s Prozac (Sarafem) and Zoloft (slowest to work) that pursued and received FDA indications.
Although Effexor and Lexapro may work the first day it’s usually better to start them 2-3 days before symptoms usually start – this of course requires using a calendar and keeping track of due dates. If you can tell when you ovulate it’s easy – 14 days later you will start your period.

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How To Take Wellbutrin (Bupropion)

WELLBUTRIN SR and XL (Bupropion)

Wellbutrin SR comes in two strengths: 100mg blue tablets and 150mg purple tablets. Wellbutrin XL comes in 150mg and 300mg tablets.

Wellbutrin enhances the brain’s natural stimulants, dopamine and norepinephrine. These help increase mental energy and motivation/interest. Wellbutrin also helps to control addictions, increase sexual functioning (especially libido and orgasm), and aids in weight reduction.  Wellbutrin works just as effectively as the Serotonin Reuptake Inhibitors (SSRI’S) for anxiety symptoms associated with depression. 

HOW TO TAKE FOR DEPRESSION

WELLBUTRIN XL

Do not break tablets.


Starting dose
150mg in the morning for one week
After one week Increase dose to 300 mg in morning.
Sometimes dose needs to be increased to 450mg, and rarely to 600mg.

WELLBUTRIN SR

Starting dose One 150 mg tablet in the morning. 

If any significant side effects, decrease dose by cutting the tablet in half or switch to 100mg tablet. (Only about 10% of the slow release action is lost when the tablet is cut.)


After 3 – 7 days
Add a 2nd tablet at lunch

After 1 week on 2 tablets per day
Take both tablets in the morning if tolerated
After 3 – 4 weeks of 2 tablets per day If dose is not strong enough, add a 3rd tablet per day and take in divided doses of 2 in the morning and 1 at lunch.
(A total of four tablets per day can be used in divided doses but this is rarely needed by most people.)

OTHER TREATMENTS

SMOKING

300mg of Wellbutrin SR is usually the most effective dose to help quit or decrease smoking. It’s is even more effective when combined with nicotine replacement. (Nicotrol inhaler is best-tolerated form) 

A smoker does not have to be motivated to decrease or discontinue smoking. They just need to try the drug along with the smoking. Most people find that after taking the medication they no longer crave nicotine, and the need to smoke decreases.

SEXUAL DYSFUNCTION

Wellbutrin is effective for treatment of low sexual interest. It can also help primary orgasmic dysfunction or secondary orgasmic problems caused by other medications, especially SSRI’s. Treatment success is usually 40-50% for orgasmic dysfunction on an “as needed” basis.

WEIGHT REDUCTION

Wellbutrin has recently been found in studies to improve weight loss in obese patients. It is also an effective treatment for sluggishness and weight gain secondary to medications.

ADD and BOREDOM

Often respond well to Wellbutrin.

ANTIDEPRESSANT AUGMENTATION

Wellbutrin works well as a complementary drug with other antidepressants to achieve a more effective response in some patients.

SIDE EFFECTS

Side effects are usually mild and controllable with a dose adjustment or by adding a second medication to control side effects until they subside.

Most common side effects are:

  • Insomnia
  • Dry Mouth
  • Nervousness
  • Irritability

For full information, see package insert or prescribing information.

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How To Take Effexor (Venlafaxine)

EFFEXOR XR (Venlafaxine)

EFFEXOR XR (Venlafaxine) is a slow release capsule and comes in 37.5, 75, and 150mg sizes.  It is a broad spectrum medication, which means it works by blocking reuptake of Serotonin (at 37.5 to 75mg) and norepinephrine (at 150mg+). Serotonin and norephinephrine are the two primary stress neuromodulators. Because Effexor XR works on both these neuromodulators, it is effective in treating anxiety and depression. When Effexor XR is taken, the brain levels of Serotonin and Norepinephrine are lowered if too high (as in anxiety), or raised if too low (as in depression).

Effexor XR has no significant drug/drug interactions and does not require dose decreases for the elderly.

HOW TO TAKE FOR ANXIETY/DEPRESSION

For mild to moderate symptoms
Week 1 37.5 mg in a.m. (after breakfast)
Week 2 75 mg in a.m.
Week 3+ 75 mg in a.m. if improving, if not, take 150 mg

For moderate to severe symptoms
Day 1 37.5mg in am
Day 2 & 3 37.5mg in am and at suppertime
Day 4+ 75mg in am and at suppertime

For severe symptoms
Day 1 37.5 mg in a.m. and at suppertime
Day 2 75 mg in a.m. and at suppertime
Day 3+ 150mg in a.m. and 75 mg at suppertime

PARTIAL DOSING

During transition, (if less than 37.5 or between 37.5 and 75mg is needed), capsules may be opened and used as a sprinkle form on any soft food. Sprinkled granules remain slow release unless bitten into.

PANIC PATIENTS NOTE: 

This step is especially important in panic disorder where initial doses as small as 9mg may be needed. It is essential to minimize side effects with panic patients because of extreme sensitivity to side effects. The dose can usually be gradually increased.

DO NOT abruptly stop the medication.  This can cause rebound symptoms such as muscle aches and nausea. When tapering the dose decrease by 37.5mg every 3 days. 

WHAT IS THE BEST DOSE TO TAKE FOR ME?

Take enough, not too much!  How much is that?  I don’t know.  Each person has to find the dose for him/her that achieves the goal of remission (completely back to normal functioning).

  • If you have some side effects but they are mild – remain on dose schedule
  • If side effects are bothering you – shift the dose time, split the dose or decrease the dose for 3-4 days, then try to go back up
  • If you have taken it for 1-2 weeks and not seeing significant benefit – increase the dose

SIDE EFFECTS

Possible side effects and suggestions for management.
Fatigue, Sluggishness First, shift the dose to evening meal. If still a problem, decrease the dose.
Delayed Orgasm Change dosing time to right after sex.
Nervousness Decrease or divide the dose, decrease caffeine intake.
Nausea Take with food, decrease dose or split dose for 3-4 days.
Sweating Take medication at suppertime, or decrease dose.  Adding Cardura (a mild blood pressure medication) may help.
Increased blood pressure This occurs occasionally in susceptible patients and is usually higher doses. Is easily managed by lowering dose, splitting dose, or adding Cardura. 

HOW DO I SWITCH FROM ANOTHER ANTIDEPRESSANT TO EFFEXOR XR?

Note: The most important rule of changeover is make only ONE change at a time. In other words don’t change the Effexor XR dose and SSRI dose both on the same day.

Use a “stagger” changeover schedule for 2½ weeks:
Days 1-4 37.5 mg Effexor XR in a.m. and current dose of SSRI in evening
Days 5-8 37.5 mg Effexor XR in a.m. and decrease SSRI by ¼ – ⅓
Days 9-12 75 mg Effexor XR in a.m. and SSRI dose not change
Days 13-16 75 mg Effexor XR in a.m. and decrease SSRI another ¼ – &frac13;
2½ weeks Re-evaluate – if all is going well, discontinue current SSRI and consider going up on the Effexor XR if needed for symptoms.
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