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Aswad -> RE: Bi-polar Mania on Mood Stablizers? (5/27/2007 1:21:33 AM)
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quote:
ORIGINAL: maybemaybenot
It is not uncommon to use a combination of SSRI's in the treatment of depression.
There's a number of different combinations that are common when treating depression.
Many of these have not been studied, some have been studied, and a few have been scientifically studied. SSRI+Wellbutrin has not been scientifically studied; i.e. there have been no placebo-controls.
Generally speaking, if there is negligible or no response to the SSRI, taper and discontinue; unfortunately, the docs often forget this, giving some occasionally "interesting" interactions.
There are exceptions, of course, but in general, if an SSRI isn't giving any response by the end of 2-4 weeks, the whole cycle of "increase-wait-increase-wait-swap-wait-lather-rinse-repeat" can be skipped, as the likelyhood of response, compared to the waste of time and the chance of spontaneous remission in the meantime, just doesn't justify it at a GP level. Unfortunately, the GP level is where this cycle is most common, arguably because of cost and low short-term toxicity, combined with limited information.
But, yes, there are plenty of combinations that work well, and some of them involve SSRIs.
Some of them are also, technically speaking, contraindicated in the literature. Mostly to keep anyone from trying it without having a solid idea of what they're doing. I've seen doctors advocate 1.3mg/kg/dy Parnate with 25mg BID dexamphetamine; should give a bit of an impression of just how far some will go to solve the problem, if needed.
Really, it depends on the patient, their medical history, the specific characteristics of their depression, what they've tried in the past, and so forth.
And, of course, the treating physician. My first pdoc, when he transferred me to another, said at the time, "You know the one about the wizard's apprentice and the crystal ball, right? I'm passing the buck to the wizard himself," or something to that effect. I love it when a doc is honest about their own limitations; makes it a no-brainer to trust them when they say they are on top of things.
The most complicated stack I've been on was 50mg QID tranylcypromine, 5mg BID dexamphetamine and 4mg QID buprenorphine, with 0.5-2mg flunitrazepam used on occasion until the insomnia subsided, and the equivalent of 200-400mg meprobamate used as required to control breakthrough episodes. I'm still here, and it did make it so I don't even have to think about that stack again.
No regrets, but I no longer need that, and to anyone who hasn't "been there" (i.e. that bad), the side-effects alone, in retrospect, would seem like a decent reason to go kill oneself; at the time, I didn't significantly notice them above the "background noise", though.
My GP wouldn't touch me with a ten foot pole at the time; between them, those drugs cover just about every liver enzyme there is, inhibiting some and inducing others. Me and the doc in charge of the treatment would sit with these binding affinity tables and work out anything that I needed to take, how we would adjust the dosages, etc... Even for OTC stuff.
Glad that bit is in the past.
Anyway... have done a bit of research over the years, and talked to more than a few pdocs, profs and so forth, and would be happy to pass on tips and advice to anyone who bears in mind that I'm not their doc, and that they need to run this stuff by their GP, pdoc or whatever. I need some details to do that, though, whether on the board or in a collar-mail/PM.
Bits like having recently been through heart surgery drastically affect the picture. That's both why I need more details than "would X + Y work?", and a big part of why my reply needs to be run by a doc who knows the patient.
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