9 replies to this topic

[check]

Just thought to check for any possibilities for additions to an MAOI regimen.

Currently:
40-50 mg Parnate, perhaps an increase as orthostatic pressures level out.
600 mg Lithium

Quite a lot of long stories on this forum, so I'll keep it easy. Relatively typical refractory depression case- low appetite, low sleep, low energy, not really thinking, negative outlook in frame of understanding. No real connection to interests from before depression- "intelligent person/hard-working" background. Math/science, museums, music, history, technology, movies. (Whatever that means after many years of depression.) Evaluated for personality disorders and other problems, and came out clean. Working low level job, getting through. Don't really do anything outside of work. The interests are there inside of me, but I don't seem to be able to wade through the depression.

I'm getting better, just very slowly. Disorganized. Went through the ssri loop, many augmentation routes, and periods of being on nothing at all and doing exercise and diet changes. Lot of partial or stunted responses. Got close to a break in the depression with 80mg Prozac, 300mg Wellbutrin, and 1200mg Lithium (Psych went through a Bipolar II phase with me, but has since gone away from it. Never been hypomanic, but I can be a bit anxious.)


Any ideas or experience in this area? (I don't plan to go change anything without checking with my docs. )


Things that I have tried or may try, or general comments:

Might be put on a stimulant. Seeing how this dosing goes. I am tired on Parnate, one of those types.
Evaluated for Cardiac health. Quite good. (Checked when on Desipramine and lithium.)
Thyroid a-ok. Vitamin D has been very very low before, but should be okay now.

Tried intense exercise the previous med break. Really made me feel not well. I don't seem to get the same results out of exercise as others seem to. Still planning to return to some healthy level of it though. Certainly the only way to go healthily. I tend to really feel dumb around it.

Low-carb, Paleo, or caloric restriction were terrible for my mood and affect. Just went flat and negative. I tend to seem to do best with almost too much food and big meals. I just have trouble eating that much most of the time, and likely it just is a short-term measure. Trouble eating too many rich foods.

No problems diet/tyramine-wise with Parnate. Looking right now at some leftover Thai food, some chocolate. Regular pizza seems to be fine, and fresh mozerella is great anyways. The highest reading I've had with my pressure after eating was 135/75, which is high for me, but certainly not any sort of reaction. I do have an accurate blood-pressure machine. Typically 110/65, though with the orthostatic problems it sometimes drops to 88/44 (that area). Only at the start of dose change. Did have a 150/90 during an anxious/depressive state once, but I was in a pretty bad state.

Sleep is not too bad now. Not really hit by the insomnia typical of parnate. Fairly consistent sleep regimen, if somewhat marked by early morning awakenings.

Not a drinker or a drug-user. Well, I've certainly been on a lot of drugs, but not in an abusive or illegal fashion.

Music - I play some piano. Coming back to it as I feel better with the Parnate.

Trying some more with Meditation. I have a lot of difficulty with it, and I find it very hard to stay in whatever moment that I have to stay in. Monitoring my own body doesn't seem to help much. But I am interested in incorporating some measure. It just is an interesting mental state.

Therapy- currrently in combo cbt/dbt/act sort of deal. Slow progress for me, but certainly the right course of therapy. Straight cbt didn't do anything (or at least how I approached it, it didn't help me) for severe depressive episodes, and excerbated the negative evaluation cycle that seems to be a major component of my depression.

Choline- Alpha GPC, CDP Choline, etc...well, I have a good dose of depression. Not helpful for my flat mood or negative thoughts.

Ginkgo and Ginseng - didn't react well with the lithium, although that was on a much higher dose. I probably don't want to do anything that would lower my blood pressure too much more.

I don't personally care for the Lithium in regard to cognition and memory, and maybe energy, but it is certainly the best choice for anti-depressant augmentation and for helping with suicidal ideation and processing. Lithium Orotate was certainly nowhere near the same sort of drug. I could never suggest it as an alternate, "bioavailibility" or whatever. I am a particular case though. Depakote- slow. Just slow. Lamictal- had auto-immune rash in high school, so everyone has been very wary. Topamax- dope-a-max. I was just braindead. Without migraines though. Benzos- never been on any, though I have been given a few small doses from time to time. I just sort of shut down and sleep.

I tried Piracetam and Aniracetam, but it was during an increasing depressive episode, so I really didn't notice anything at all. Not really a fair evaluation. Alcar/ALA was during the same period as well. And l-theanine. Hard to judge.

Social anxiety and Isolation- were bigger symptoms a while ago, but I seem to work okay. Missing out on friendships. Hard to not get in that "drain on the people around you" state when you are going pretty slow.

Post-SSRI effects - never really noticed all that long of a period. Cold-stopped Zoloft due to an interaction, and Cymbalta as well. Tapered off Lexapro pretty quickly. Whatever periods of dullness and mood fluctuation seem pretty small compared to the rest of the depression.

Caffeine- been off of it for many long stretches, and never noticed a benefit. I enjoy my coffee too much as a drink anyways. Not a large effect.


But now it seems like I have a new slate with the MAOI. Just looking for any suggestions. The dangers are quite high, beyond even the typical interactions. I emphasize that danger again, just to make it clear I am not acting on anything too quickly, and that I know I don't have the knowledge and experience to really make the decisions. I'm not the impulsive or dramatic type. But it is good to throw ideas around. (I apologize if I am late to respond. Really pretty slow with this.)

[jadamgo]

Haha, this is the sort of thread I live to respond to. Plenty of relevant information, organized cleanly into individual paragraphs (with bolded headers) and the subject matter is right up my alley. You see, I too spent some time on the MAOI+Lithium combination.

What was helpful to combine with it?
Bright light therapy. Psychotherapy. (SInce I'm recovered and have been for quite a while, those two are the only mood treatments I still use. And when I say that I still use psychotherapy, I really mean "frequent meditation and the occasional CBT worksheet when I start freaking out." I haven't actually seen my therapist in over a year.)

Also, since I have ADHD, I had to continue methylphenidate. During the time I was on the MAOI, I had to lower my dose drastically. In fact, my dose has stayed low even though I haven't taken the MAOI since last April. Evidently, the dopamine receptors sensitize when under co-treatment with MAOI+stimulant, and they stay sensitive after you quit the MAOI. This has been very beneficial, because I enjoy far fewer side effects with this lower dose.

If you want to try methylphenidate, I recommend that you get 5mg pills and cut them in half. I DON'T recommend that you get any amphetamine products. They do not mix well with MAOIs. Just trust me. (And, ya know, the label on the prescription bottle.)

Other things that play nice with MAOIs and Lithium:
Racetams. All of them. IME, there's simply no interaction. No dose change, no new side effects, nothing.

Modafinil: It works, but cut the dose. Try 50mg.

Medium- to low-intensity exercise: I always got terrible headaches, exhaustion, and dissociation when doing any intense exercise on the MAOI, and after adding the lithium, I also found I lacked the energy to do much more than walk. But medium or easy exercise was great. 15-30 minutes has a beneficial effect on energy all day long. The technique is that you exercise long enough to feel your energy increase, and then quit before you use all that energy up. If you exhaust yourself when exercising, you either pushed too hard or did it for too long. (Or you dropped your blood sugar too low.)

Mucuna pruriens: this is a dirty little secret for the occasional energy and mood boost in MAOI users. Don't use it frequently or it'll quit working! Be sure and take it with a cup of strong green tea to help limit dopamine production outside of the central nervous system.

Meditation: As with physical exercise, mental exercise comes in many different forms. Everyone has some forms of meditation they hate, some that are okay but not that great, and some they really come to like. If you searched for and found a form of meditation that you actually enjoyed doing, and if you practiced it for several years (because it was fun, not because you were forcing yourself to do it), how do you think your mind might work differently?

Let me know any questions you have.

Edited by jadamgo, 27 January 2013 - 07:38 AM.

[gray.bot]

Mucuna pruriens: this is a dirty little secret for the occasional energy and mood boost in MAOI users. Don't use it frequently or it'll quit working! Be sure and take it with a cup of strong green tea to help limit dopamine production outside of the central nervous system.

HEE HEE HEE

I knew stalking you would pay off...

[penisbreath]

60mg of Parnate was great for my depression (in fact, only thing that's ever worked), and even helped ADD a little, but made more more agitated and anxious; I'm just about out of options, so was considering returning to the Parnate .. do you think there's a chance the Lithium might even out the side-effects? Otherwise, I've heard clonazepam mixes well.

[nupi]

Clonazepam would definitely do the job and if you have a shrink who gives you Parnate, arguably he will be open to stacking the two. Unless you are BP, I don't think I would bother with Lithium... Did you try any of the other MAOIs, BTW? Maybe Nardil, Moclobemide (that one is mainly MAOA-I in lower doses so should be easier on the agitation) or Selegiline would have a better side effect profile?

[jadamgo]

Actually, low-dose lithium is a great add-on to antidepressants in drug-resistant depression, even if you aren't bipolar. (But it's especially good if you have any bipolar family members. Having the genetics that underlie bipolar disorder seems to improve chances of responding to lithium, even if you've never had mania or hypomania.) It's particularly good to combine with MAOIs and the stronger TCAs. Personally, I did not experience agitation as a side effect of my MAOI, selegiline, but I did experience significant social and general anxiety from living and working in a very fucked up environment. The selegiline helped a bit with that, but the lithium really did a number on it.

Still, I do agree that you ought to consider trying nardil if you haven't already done so. It's one of the most anxiolytic antidepressants out there.

[penisbreath]

My anxiety is indescribable (OCD onset at 19, which has slowly morphed into a really distressing mix of agoraphobia, depersonalization etc. over the past 2 years). I've heard Nardil can be a miracle for anxiety, but that it has little effect on ADHD -- and can make it worse in some cases.

Parnate at 60mg was great for depression, as I say, and helped ADHD, but possibly exacerbated my anxiety (or at least didn't help it). I've heard higher doses can be paradoxically anxiolytic.

Anyway, I'm in Australia, which is super-conservative, so the chances of getting Nardil + a stimulant prescribed a probably next-to-zero. Hence considering returning to Parnate + anxiolytic.

My current shrink actually fired me recently; he was open to suggestions (I managed to convince him to prescribe 60mg of Parnate, when the recommended max here is 30mg) but he just didn't feel he could help me anymore. Next step is possibly inpatient at a private clinic; I'm hoping they're amenable to MAOIs. I refuse to touch another SSRI.

[check]

Lithium is a really interesting case- some people it solves the case and in others it is nothing or misery. Very much a personalized drug that your psych would have to carefully monitor. Clonazepam would be an easier case to start off with if you have had any experience with benzodiazepines. Really depends on the state of your anxiety and ocd. Coming from a place also with agoraphobia and depersonalization, perhaps more from depression, I have to say that lithium has been part of the structure that allows me to even be able to post online and start to pursue non-work-related interactions. Doesn't mean much to some, but it is a start for me. (Also, nothing idd the trick for dysphoric anxiety like lithium. Mainly at higher doses. Very blunting and not something I would see as a cognitive boost. Ahem.)

Also, there is clomipramine, depending on the state of ocd. Not with parnate though. And there is the possibility of low-dose quetiapine or risperidone. (I can't honestly suggest an atypical AP without mentioning having bad experiences with them. I essentially did nothing at all on even 25 of seroquel, and was hospitalized on Abilify. Desipramine/anticholinergics/benzos take me out. Then again, everyone is unique. I'm taking my parnate at night because I am quite fatigued with it during the day. And my blood pressure isn't that bad. So, a bit strange.)

Good luck with your treatment.

I actually have been looking back into getting a light box. Been meaning to for years, to be honest, but that's how depression goes sometimes. Strangely enough since the last posting I did also get vitamin D checked and was surprisingly low, considering I've been fairly careful in trying to get some sun and getting a decent diet.

Meditiation has been a tricky one. I appreciate it, and have great respect for those who really practice and get through it, but I haven't connected to it besides some verbal understanding. Just balancing breathing and relaxing tension seems to be quite tricky for me. Visualizations were a little tough when I was more depressed; I don't know quite how they will be now. They seem very choppy, like a stuttering and buffering video. Sometimes like one of those vibrating gifs. Or just jump about with thoughts. (My mental "stage" or "canvas" seems very small. But at least it is there. I don't think I'll be going back to rotating 3d shapes interacting very soon, which is kind of sad considering that was what I was good at.)

Therapy is key. CBT is still some of the best work for anxiety. Occasionally, it played into depression a little bit in focusing on the disruptive thinking. What I mean by that is that, at the time, I interpreted the CBT measures as the lists of all the ways I was thinking incorrectly, rather than on the improved thinking afterwards. Kept myself in a negative mindset in being caught up in my own thinking too much; a meta-negative mental filter of sorts. Which I then recognized...and continued to use as an example of how I wasn't doing things well or was really a waste of time. Lovely train of thought. But that was during a more negative period, and I think some of the acceptance and identification measures of DBT and ACT will help diffuse that line of thinking.

Thanks for the suggestions.

[penisbreath]

Thanks for your help. Clomipramine caused too much agitation and akathisia; like you, had bad experiences with APs (akathisia on Seroquel, even at 25mg; increased anxiety on Risperdone and Zyprexa).

I've heard there's differences between the US and Australian (GSK) formulations of Parnate. It certainly didn't fatigue me. If anything, I was far sharper and motivated on it, but that of course bled into more anxiety and agitation.

P.S. have you tried using Nicotine (lozenges, gum) to boost cognition while on Parnate? I know a guy with ADHD who did that because his doctor wouldn't prescribe stimulants with an MAOI.

[check]

The fatigue certainly wasn't because of the formulation. I just seem to have a weird response to some of these drugs. Most people do find Parnate fairly activating,

Akathisia is miserable. What about atarax (hydroxyzine) or an augment of pregabalin or gabapentin? Depending on how my course goes, I may be switching to lamotrigine, although it seems unlikely as my psych is heading away from a bipolar ii diagnosis. Oh, and low-dose naltrexone, although that doesn't have too much behind it to really sway conservative treatment. (I tried it and didn't really notice anything. Then again, I cold-stopped Cymbalta and didn't feel all that different either. So, probably not the best example.)

I actually did look into Nicotine for a bit when I wasn't on an MAOI. Although something like the gum or patch might not be addictive in the same way as cigarettes, MAOIs do seem to up that property. (And considering I was thinking of using some gum from around the house from family member's numerous failed attempts to quit smoking, addiction does worry me. I have the perfect background for alcohol and smoke abuse, except for the individual lack of an addictive personality.) Lot of mixed evidence. Might be worth a shot using a slow patch or something.