Anyone ever tried Dexedrine/Ritalin augmentation for treatment-resistant depression?

In My Humble Opinion
1

I was recently (finally!) diagnosed bipolar II, after years of being diagnosed with unipolar depression, generalized anxiety disorder, a multitude of personality disorders, and whatever else, short of schizophrenia.

I started seeing a new shrink (since my old shrink left town a couple of years ago) because my GP just didn’t know what to do anymore. This new shrink - a very serene man (65 years old, and gay) - after taking down my psychiatric history, suggested a few things to me. One was the possibility of my being bipolar, and he encouraged me to research it on the web. I did, and I saw myself. I also read that many bipolars are in the psych system for an average of 12 years before being properly diagnosed, which also hit home.

I went back to see my shrink the next week, and told him what I had discovered, and that yes, I’d be willing to try a mood stabilizer (divalproex sodium). It took a long time to get the dosage and dosing times right, but I think we’ve got it now. No more mind filled with frantic thoughts. Fantastic.

But the depression… there’s always that part of the bipolar spectrum. And it’s hit me hard over the past month or so, and it’s not letting up. We’ve increased the Wellbutrin - once my magic bullet - to 400 mg a day, which is over the recommended daily dose. (People are still scared of the remote possibility of a seizure.) We brought the Celexa - which was doing nothing - down, because he was worried about too much Wellbutrin with too much of an SSRI. We pushed the trazodone before bed up to 200 mg.

Now, I’m thinking that it’s time to look to the “big guns,” as it were. We discussed augmentation with a psychostimulant a little over a month ago, but he said it was still too soon to tell. (This is when I went up to 400 mg Wellbutrin.) He did say that he had some patients on psychostimulants. Having read a lot about the subject, it seems that when all else fails - augmentation with a mood stabilizer (check), with another class of antidepressant (check, check), raising the dose to the max (check - we did that early on with the Celexa, with no result) - one of the final options is augmentation with a psychostimulant, usually Ritalin or Dexedrine. (I know there are others out there, but my drug plan only covers Ritalin/Ritalin SR or Dexedrine.)

If we were to go that route, I’m sure he’d lower the Wellbutrin, which is fine, because I need a new prescription for that anyway. He told me a while back not to be afraid of asking him to try something, that he was open to my suggestions, and that he knew I know a hell of a lot more about these drugs than most people.

As for the stimulant precipitating mania, it wouldn’t, he said, because that end of my spectrum is already well under control with the divalproex. (Besides, Wellbutrin has strong stimulant properties - “speed lite” I call it - and I haven’t gone hypomanic or manic at all since going up to 400 mg.)

I’m just going to say, “A while back you said it was too soon to tell, but given that I’m not getting better, I’d really like to try Ritalin or Dexedrine for two weeks or so just to see what it does for my depression.”

So, has anyone here had a treatment-resistant depression that required augmentation with a psychostimulant? I want to know if it helped you, how it felt, how it worked in tandem with whatever antidepressant(s) or other meds you were taking. I don’t want to be scolded for “wanting speed.” There is more than enough research out there that shows that this class of drug can have a significant, positive impact on a large percentage of people with treatment-resistant depression.

2

I’m on a combination of Effexor XR and Adderall and it’s been effective for me. The Effexor worked on my depression, got me to feel “normal” again, but I was still having problems with lack of energy and an inability to concentrate (or rather, to go back to concentrating if I was interrupted). We just upped my does of Adderall to get me over the last little bit of inertia, and even with the increase I haven’t felt any “speed” like affects. I take it in the morning to avoid any problems with sleep but I had no side effects.

Good luck.

3

What about the atypical anti-psychotics? Risperdal, zyprexa and the like? Have you done a trial of those?

From the reading I’ve done on bipolar, I’d be wary of mixing an SSRI and a stimulant med. I’m not familiar with using ritalin or dex for depression and I’m curious about the mechanism. I’ve heard that strattera or reboxetine has been effective for some people but they are expensive meds.

And lastly are you familiar with this site crazymeds.org? There’s a lot of interesting info there.

4

SSRIs can indeed push the mind into a manic state. However, as my shrink told me when we first increased the dose of Wellbutrin (not an SSRI but somewhat a stimulant), the mood stablizer is taking care my hypomanic (elevated) states.

Still, there’s the swing back down into depression (it’s called bipolar for a reason), and we’ve tried a lot of things.

As for Zyprexa or Riserdal, I haven’t found much evidence that they would improve my case, and besides, they’re some serious drugs.

Strattera, Adderal, and many other new stimulant drugs (or else new formulations of existing drugs) have yet to be approved for sale in Canada. For the time being, it’s Dexedrine or Ritalin.

Anyway, it’s up to my shink; he’s the doctor.

5

Yeah, we just got Strattera approved here a few weeks ago. It costs $5 a day because it’s not on the PBS. ::sigh::

I’ve reached the point where I’m less scared of heavy shit drugs than I am of cocktails. I’ve honestly found that it was easier to manage my kid on risperidone than on a cocktail of various meds although I nearly had a nervous breakdown when we finally decided to go with the risperidone.

I hope your doctor comes up with something that works and works soon.

6

scott I would seriously ask your psychopharm to consider replacing your Depakote with Lamictal. It’s superior in virtually every way. No side effects like weight gain or hair loss, and it seems to put in a much higher bottom in mood. IMO, the only MDs who are still prescribing Depakote are those that aren’t familiar enough with Lamictal. You also don’t need to monitor your blood levels. The only potential setback is that some small percent of people can develop a rash that will prove fatal if the drug isn’t discontinued. Of course you just start slowly, and if you get a rash you stop. In my long long history with psychopharmaceuticals, the biggest gain of all was switching from Depakote to Lamictal.

As far as Depakote inhibiting stimulant-induced mania: Ehhh. Depakote will stop a full blown mania but not a reasonably irritating hypomania. And your tolerance for Wellbutrin isn’t an indicator that you can withstand Adderall, Dex, Ritalin etc…

BTW I’d take Adderall over Ritalin or Dex. It’s a much less agitating mixture of a couple of different stimulants.

Now, if your if going to take a stimulant to “see” if you’ll feel better, I can answer that question for you now–You will. The only way you won’t is if your avoiding all productive activity and the stimulants make you more anxious about procrastinating (though you are admittedly less likely to procrastinate).

FWIW I still take Adderall once in a while to start the engine.

7

I’m doing well on Depakote in terms of complete elimination of mania/hypomania. No hair loss, and the weight gain has been minimal, probably since I’ve been too depressed to go to the gym. My shrink is more than familiar with the other drugs, but for him, divalproex was a good choice for a first-line mood stabilizer (ahead of lithium). And you don’t have to get your blood levels checked on divalproex, since dosing is based on weight and response, whereas lithium dosing is based on blood levels. So right now, I’m really trying to find something for the low end of the spectrum.

Possibly true, but we have yet to see.

Adderall is either not on my insurance formulary or not available in Canada. Not sure which. I do know that it would probably be better for me than Ritalin or Dexedrine. I can, however, get sustained-release formulations of both of these.

We’ve exhausted pretty much everything.

[ul][li] No real point in switching to another SSRI, as far as I’m concerned. The Celexa pooped out a long time ago, and even after we went up to the maximum, there was no discernable change. And I’m not going through the hell that is Paxil ever again (even though the generic is now available). I could ask about Effexor XR (an SNRI). People say it’s really hard to get off of, but it could work well while I’m on it, especially in tandem with the Wellbutrin and Desyrel and everything else I take.[/li][li] The use of newer antipsychotics as antidepressant augmentation is based on shaky research, as far as I’m concerned. I’ve read a lot about it, and the studies don’t make a good enough case for me, especially since even with the atypicals I’d still be risking tardive dyskinesia.[/li][li] We’d really be pushing it by going up to 450 mg or 500 mg of Wellbutrin a day.[/li][li] I’d really like to steer clear of the MAOIs. Not worth the necessary washout period. Moclobemide (Manerix/Aurorix) doesn’t have the dietary restrictions that the other MAOIs do, but you still have to take it directly after eating. So no MAOIs for me.[/li][li] If I were to go on a stimulant, I’m pretty sure my doc would reduce the Wellbutrin to at least 300 mg, if not even lower. [/li][li] We could always add something flaky like l-tryptophan, but I don’t see the point, because all it is is a precusor to serotonin.[/li][li] Finally, ECT does work for many treatment-resistant depressions. But I really, really, really don’t see my doc suggesting that. [/ul][/li]
And I really should take more B complex vitamins. Can’t hurt.

I’ll find out today. I have a tall order for the poor guy: both this, and my SO’s recent threats to leave me. ::sigh::

8

Well Depakote (divalproex sodium) really isn’t any longer the first line among psychopharmacologists in the know. Also, I’m sure that Depakote must be blood monitored even if the MD took a guess based on weight/ht. There is a very narrow band of efficacy in blood levels for Depakote and a guess isn’t nearly as good as a blood test. The good thing about Lamictal, besides the things described in my previous post, is that it acts as a mood elevator as well as a stabilizer. It puts a roof on mania and a floor on depression, unlike Depakote. I know many others, including myself, who made the switch from Depakote to Lamictal and most agreed it was lifechanging.

As far as anti-psychotics. No fricking way. Zyprexa is Thorazine’s bitch cousin and will just numb you. That are risperdal are more typically used as an anti-anxiety rather than a mood elevator. I’ve tried them both and they’re bad news.

The reason you’re probably not having convulsions on that amount of Wellbutrin is because you’re on Depakote, which is an anti-seizure drug (as is lamictal). 500 mg sounds like way too much and I sure as hell wouldn’t take more than 300mg without Lamictal or Depakote on board.

If you do decide to go with a stimulant (and I’m certainly not recommending against it), stay away from generic time-released Ritalin (methylphenidate). It has really poor binders and even MDs agree that its just not very good. Rather than go time-released, many people choose to take smaller doses throughout the day.
I do.

Are you seeing a psychiatrist or a psychopharmacologist. Most psychiatrists knowledge of meds can’t come close to a psychopharmacologists.

Good luck Scott. Do you live in NY? I can make some recommendations.

9

Heh, I should be so lucky…when I was on it, it cost me…hmm…about $350 a month. (This is why we complain about our health insurance system so much.)
:slight_smile:

10

I think we should leave this alone, because while I think you have a point, I mainly agree with my shrink.

Well… I’ll do some research before asking him.

I asked him about this, and he said the Wellbutrin type of seizure is different from the seizures for which anticonvulsants are used to control.

Noted. I won’t ask for an SR version of either Ritalin or Dexedrine. I can get Alertec, but a form has to be faxed to my insurance, because it’s an “exception medication” that they only cover if the doctor insists. But I read that Alertec is kind of wacky.

Well, all I can say is that he knows more about psych meds than my GP did… Which is why I see him; also because we get on well. And he’s also very open to my own medication suggestions (which usually means I can get what I want), because he knows I know about this stuff. Many doctors don’t like being “told” what to prescribe a patient, because they have huge egos. My shrink doesn’t, obviously. I think the way we interact during talk therapy is important, so as long as I feel he knows his meds to my satisfaction, then I’m fine with him.

No, I live in Montreal, Canada.

11

Re SR Methylphenidate

I disagree. My shrink switched me from three pills a day, to a single time release in the morning. The only changed I’ve noticed is that things are smoother. No feeling the last dose petering out around the time the next dose is due. Additionally, no constant worrying about missing doses.

Re ECT

It does sometimes work. Fun side effects can include permanent memory loss. It also doesn’t last. Liz Spikol is a bipolar columnist for the Philadelphia Weekly. She did a series on her experience with ECT. A year after the treatments, Spikol’s depression was just as bad as it had been before the ECT.

12

No stimulants for the time being. We’re made a lateral move to Effexor XR, dropping the Celexa (only at 20 mg anyway) completely, halving the Wellbutrin for a few days (200 mg) then to 100 mg for about a week.

He feels I need a med with more of noradegenergic effect. I start Effexor tomorrow at 75 mg for four days, then up to 150 mg for five days (as tolerated) until I see him next.

Now, I know many people have Effexor horror stories (particularly about getting off of it), but everyone has a horror story about a given psych med. I’ve also heard that Effexor can work wonders for treatment-resistant or very dark depressions. YMMV.

Anyway, we’ll see what happens.

13

good luck! You’re right about the effexor horror stories but it does work and work well for some people. And some people don’t have problems withdrawing for it either. I hope it’s what you need and that it works quickly.

14

Well, it always comes up in these threads: YMMV. For example:

Prozac gave some sexual side-effects (but didn’t kill my libido, that’s for sure), but getting off it was a breeze due to the long half-life of fluoxetine.

Paxil reduced by libido by about 60% - so the interest just wasn’t there - on top of making me anorgasmic. The one positive thing about the short half-life of paroxetine was that I could go on a drug holiday, say, if I was planning a slutty weekend.

Celexa gave me absolutely no sexual side-effects except for a bit of anorgasmia when I got up to 60 mg. Getting off of it was much easier than getting off Paxil.

Anyway…

As I said, I’ve heard stories about Effexor being the magic bullet after you’ve exhausted most of the other options. It’s getting off of it that seems to be the problem for most folks. However, given the whole bipolar thing, it’s likely I’ll be on meds for the rest of my life, so if Effexor works, I’ll probably be staying on it for a very long time.

(My shrink told me that some of the tricyclics are still considered very effective, especially in those for whom SSRIs/SNRIs/the other “new” drugs haven’t worked. The problem with TCAs, of course, is the litany of side-effects. He did single out Elavil as being particularly effective. However, he said it could possibly swing me into mania - in spite of the Depakote. Then there’s the MAOIs, but with these, too many dietary restrictions. Even if I were taking moclobemide, I’m sure everyone would tell me to avoid tyramine-loaded food and drink, even though with this particular MAOI you don’t have to. Plus, you have to take it right after a meal.)

So I took my first dose of Effexor XR this morning (75 mg) along with my other meds (no more Celexa, and tapering off Wellbutrin), including the Depakote. I made a point to stay up and not go back to bed, just to see if I noticed any side-effects that I can’t pin on the other meds. As for how long it will take to work, I’ve found that for me, ever since the “channels have been opened” (having been on one med or another for about six years now), I see results sooner, like in 10 days or so. This could be my imagination, but some drugs can and do start working within the first week (e.g. Celexa; the yet-to-be-released-if-at-all Cymbalta).

15

Probably the longest periods of stability my kid’s had has been on tricyclics. It’s just their nasty little habit of stopping working that makes them a pain for us. When the effexor was working, he was pretty good but the withdrawal was pretty brutal. Actually it was one drug that kept on working but the paed felt we didn’t have enough control of anxiety and pulled him off it.

I’ve seen fewer side effects with a low dose of risperidone than with a tricyclic but the tricyclics actually worked better when they worked.