Is It All Trial And Error?

[ginsa]

I am wondering how an Psychaitrist knows what drug to prescribe for depression. From  my personal experience and from what I've been reading, it seems that whatever drug is currently popular is the one that gets prescribed. I have had Drs. shove SSRIs at me for 20+ years with no good results. I am so tired of being a "guinea pig". I'm not just tired, I'm scared. I have fallen into the most debilitating depression than I have ever experienced and it's not getting better. It's been going on 4 years now with no relief in sight. It seems I can't get through to my Psych. I had limited relief from Seroquel ( which was given to me by a different Psych. while I was hospitalized  this Jan.) but my regular Psych said that it couldn't have been helping  because the dose was too low and took me off it bc of the diabetes risk. I am exhausted and very hopeless in the face of what seems like ineptitude on the part of my Dr. I'm afraid that another SSRI will finally push me over the edge, they have made me feel THAT bad. I can't afford a different Psych, I get free care through the county. I just don't know what to do. I don't think he really does either. I have been so desperate looking for a solution that I quit taking opiate medication for pain thinking that might be aggrivating my depression. I quit taking Benzo's because they don't really help long term. I've suffered through the withdrawl from both these drugs and am now dealing with the additional anxitey and depression of withdrawl.

To add to already being depressed, now I feel like both the Psych and my Therapist have fixated on addiction as my problem. I don't understand this. It was my idea to quit pain meds and I have a good attitude about having quit.  I am not defensive about having used opiates but when I question their focus, I get some real attitude from them both. When I remind them that depression pre-dated the pain meds, their eyes practically glaze over.  I am so frustrated. I do not feel like I'm going to get the help I need from these "care givers". The Psych now wants to put me on 50mg Naltrexone for opiate addiction. I am just beside myself trying to understand his reasoning. I do not crave the pain meds, so I fail to see how naltrexone will help. I've read that fear of relapse sometimes creates anxiety, but I am not afraid of relapsing. I went through 4 months of horrible withdrawl while I was tapering off the opiates and didn't give up. When I question him about WHY,  he gives me a "pat" answer of  "some people feel better while on it",  or talks in circles. I did a lot of research on Naltrexone and it causes anxiety and depression and a significant number of suicides have been reported in conjunction with it. I didn't refuse to take it because if I do, it will get me nowhere. I don't want to be labeled as "belligerent", I just think he's on the wrong track and I don't feel like I have time to waste experimenting.  

Anybody have any thoughts about this? I wonder if I'm missing something.

[Hensley258]

My symptoms of depression are much like yours. It's as if I am wound up and agitated, yet at the same time I have no energy or desire to do anything. It's like every nerve is standing on end, yet I am Lathargic.

[ginsa]

Hensley-
You are the 2nd person who's mentioned suboxone as a treatment for depression. It may be just as well that it didn't work for you. It is extremely addictive. Naltrexone is a full opiate antagonist whereas Suboxone is a partial opiate agonist. Naltrexone does not produce euphoria. Low Dose Naltrexone (4.5mg ) taken at night before bed inhibits natural endorphin production during the time ( 2am-4am ) when the body is at it's peak for endorphin production. This somehow causes overcompensation during the rest of the day with an increase in production. I don't think there have been any trials which have tested LDN for depression. What I've read about it is all anecdotal. I believe all of the people who have posted their experience using it this way are from the UK, Maybe Drs. there are more open minded? Some people get relief taking it only every other night.  I learned about it on the addiction forum as respects PAWS and after researching it, concluded that it might help me. It seems a relatively innoculous drug in low dosages and is not addictive, so I thought it might be worth a try. I had hoped that my Psych would be willing to give it a try. I went to an appointment with several pages of notes about it and was surprised when he brought it up before I could. I was disappointed though when I realized that his focus was strictly on preventing relapse. To his credit, he did consult with a colleague at a large University Hospital about it before rejecting the Low Dose option. I just happen to be very concerned that 50mg will exacerbate depression and anxiety.

I found an excerpt from a book that explains the relationship between dopamine, norepinephrine, and serotonin in depression and the symptoms that each causes. I fit almost the entire profile across the board. I feel like I am wound up with no energy to do anything. This is mentally exhausting.


whodunnit-

I can understand how my history might influence the thinking of my Psych.. What bothers me is that he has only known me since I started to wean off opiate pain med.. I started to wean off thinking that I would not experience withdrawl this way. When I did start to have withdrawl it was in the form of severe anxiety. I had full blown panic from the time I woke up until I took Ambien to make myself sleep. This was very different from generalized anxiety. I endured this for 3 months without knowing what was causing it. During that time I was not myself. I could barely think. The stress was unbelievable. One night I tried to drink the pain away and when that didn't work I called to talk to a counselor out of desperation. I was so frightened by the way I was feeling that I agreed to go to the hospital. I was in a Psych ward for 4 days where I was given my previous dose of opiate. I felt better almost immediately. Duh. But I still didn't get it. I thought it was the Seroquel.

It later became apparent that it was opiate withdrawl when I got back down to a minimal dose and the cycle  began again.

What has destroyed my confidence in my Psych more than anything is his refusal to acknowledge that I could have been experiencing withdrawl for such a long time. I have tried to explain the physiology of withdrawl to him and it's fruitless. He hasn't actually called me a liar, but he is clearly sceptical.  This really is a problem, because it affects the way he approaches treatment.  My therapist seems a bit more willing to take me seriously now that I'm not using any addictive substances.  It was  her urging that convinced me to enter detox. She scored big points from me for that, but she admits that she wasn't really attributing my symptoms to withdrawl either. She was just agreeing with me about the pointlessness of continuing  to use them. At this facility psychaitrists are there strictly for prescribing medications, and visits are only about 15 minutes once a month. I don't think that's conducive to clear understanding of a clients needs.

I'm going to try the 50mg Naltrexone and see what it does. I can't imagine it would be worse than the SSRIs I've tried. I'm a little curious and the results should be immediate. I figure if nothing else I can take experimentation into my own hands and try taking it in low dose. If that makes me feel better I'll have made progress. Then it will just be a matter of convincing him of it's effiacy or finding a different Dr..  

Thanks to both of you for your input.

[whodunnit]

Hi,

I am more than concerned about your relationship with both your doc and counsellor/therapist.

Why do they conclude what they have? Is there history they base that on? Do you ever agree with them? If you don't then belligerence is their conslusion as they actually have the training to make decisions on prescriptions and so on.

Regardless though it is your treatment, your life and your decision on what meds you accept and what advice you take. Do not accept something if you disagree with it. But be aware that will cause many docs to say "Can't help you". Frankly if I disagreed with a doc and he said that I'd say back "You weren't helping anyway" and leave.

Getting on with your doc is critical to your chances but I'd suggest you examine your own attitude first and decide if you are compliant but careful or just reject whatever they say. A personality clash will destroy treatment so a change of docs is the best option if you believe you are innocent of anything they say.

If you accept meds you are worried about they will be a problem for you as you arte worried before you start. Don't take them until you decide they are what you need.

I'm also a little concerned about the advice you have been given on here as I see someone wanting a reason to tell the doc they are wrong rather than someone seeking the facts.

Investigate what you have been told here but please don't latch onto it as "the solution". It is just as bad as what's been happening unless it happens, by chance, to be the true problem.

Summary? Be honest with yourself and decide if you do what the docs say. Totally honest as anything else fools one person. You.

If you are totally honest and still disagree and don't trust them, change docs, regardless as they can't help you as things are.

Consider all advice and possibilities with care and thoroughness.

Look after you.

[Hensley258]

It's interesting that you mention "Endorphine defficiancy."
There is a cross section of people that have what is called Endorphan defficiancy in the brain. This often causes depression.

I have read a lot about endorphine defficiency as it relates to Major depression. Try a Google search for "Endorphine defficancy depression" and you will find a wealth of info related to the subject.

My depression is very treatment resistant and for awhile I thought it may be because I had an Endorphane Difficiancy in my brain. I actually found a doctor that was willing to try to treat my depression with low dosages of Suboxone which elevates endorphanes in the brain.

I gave it a 1 week trial, but found that while the Suboxone helped with my depression that it sent my anxiety thru the roof. Thus that little experiment failed.

Not to mention that my body has absolutly no resistance to Opioids like Suboxone and the Sub at just 1Mg made me high as a kite. When I say high I mean I was wasted stoned high. This effect agitated my anxiety. I later found out that Suboxone is 10 times more powerful than Morphine. No wonder I got so wasted.

Then when I came down from the Suboxone I felt irritable and itchy all over. I then backed it down to just 1/2 Mg a day and while I didn't get high I felt too energized and this again sent my anxiety thru the roof.

So my little Suboxone experiment failed. Probably because my depression is not related to Endorphine deficiancy. Then again I do know people that for years had tretment resistant depression that found Suboxone to be very effective.

If it were not for my anxiety dissorder then I think the Sub would have worked for me.

[ginsa]

I have been searching for info about the different causes of depression, and you summed it up pretty well. I am going to use the information you gave me to search further. I recently read an article that explained that the right questions and their answers can tell a Dr. what is causing Depression and that it isn't always serotonin related. But it didn't explain the other causes.

I have only been seeing my current Psych for 5 months.  I am hoping that as it becomes clear to him that my symptoms are not the result of opiate use, he will take me more seriously. This is one of the reasons I decided to quit taking the pain med.

At my last appointment I said that I have read that Low Dose Naltrexone administered properly can stimulate endogenous endorphin production. But I also told him that a 50mg dose blocks receptor cells from ALL endorphin uptake, not just exogenous opiates. I asked how I was supposed to feel good if all endorphins were blocked.  His reply was, " We are not really an addiction treatment center." to which I said. "And yet you are treating me as an addict."  I'm just stunned by what seems to be giddy arrogance.

I'm going to have to go to my next visit compliant on the Naltrexone in order to be taken seriously. He will order blood work to make sure I'm taking it. If I'm not and I try to get another Psych. assigned to my case I will meet with a lot of resistance.

Thanks for replying.

[Hensley258]

Bad doctors often tend to just prescribe the most common SSRI's and send you on your way. Part of the medication selection process is trail and error, but a good Psychiartist that actually listens to your exact symptoms can absolutly find meds that are better for your specific symptoms.

It is often nessasary for your Psychiatrist to augment your antidepressants with good effective mood stabilizers.

In some people depression stems more from lack of Serotonin, and in some it is simply from lack of Norephinepherine. In others it is both, or maybe even dopamine.

For example SSRI's do not address Norephinepherine depletion in the brain. Some Tri-cyclics do not address Serotonin. Many of these drugs can easily be catered to specific symptoms the patient is having.

For example my depression causes me to have severe Lathargy and sleepiness, this would indicate a depletion of Norephinepherine in my brain, thus my Psychiatrist gives me Protriptilyne which is a more energizing antidepressant.

Other symptoms one may have would be an indicator that perhaps a differnt drug would be better.

Any good Psychiatrist knows what drugs to prescribe for what types of symptoms your having. It also helps if your Psychiatrist has addictional up to date training in Psychopharmocology.

Prescribing Psychotropic drugs is an art, but this art gives clues to each Psychiatrist about which drugs are best for each patients symptoms.

I'm no doctor, but even I know which antidepressants and mood stabilizers work best for a persons exact symptoms.

[ILADVOCATE]

Best to find out about your treatment. SSRI's are helpful and potentially have less side effects than older anti-depressents for some people but as studies progress they have not found they are not more effective overall. There are other classes of anti-depressents. It depends on the particular medication and the side effect profile and how a person responds. There are studies all the time on how people respond to current medications as well as new classes of medications in development. You can google "Depression Central" for more information and speak to your psychiatrist about available options.