# Adderall/Parnate journal



## Caedmon (Dec 14, 2003)

*Stimulant + MAOI journal*

*Update 11/22/2015*
Mild tachycardia + increased anxiety = switched to Wellbutrin. All is well. 

______________________________________
*Update 04/02/2015*

Current combination is Parnate (60mg) Adderall (20mg) Lamictal (300mg) Valium (5mg). This is a decrease in Parnate and Adderall doses. I don't feel like I need as much Adderall and the higher doses were pushing me too much, and I'm attempting to regulate sleep better by reducing Parnate.

Loving the therapy program Mind Over Mood (Greenberger & Padesky) supplemented with the Social Anxiety Audio Series and a few other resources.

_____________________________

*Update 02/11/2015*

Current combination is Parnate (70mg) Adderall (25mg) Lamictal (300mg) Valium (5mg).

Current supplements include B-vitamin w/ methylfolate ("Seeking Health" brand), magnesium citrate, vitamin D, N-acetylcysteine, probiotics ("Align"), fish oil.

Current self-guided cognitive therapy program: Mind Over Mood (Greenberger & Padesky).

Current status: looking forward to SPRING PLANTING SEASON! 

______________________________________

*Update 11/26/14
*Current combination is Parnate (70mg) Adderall (30mg) Lamictal (300mg) Topamax (100mg) as well as some various supplements and is working very well in conjunction with Cognitive Behavioral Therapy and Mindfulness-Based therapy.

_________________________________

I am now taking an unusual medication combo that I think will help out a lot. I thought I would do a mini journal of experiences.

Combining *MAOIs *(which are rarely used to begin with) with *stimulants *is not common. They are officially contraindicated because of a risk of increased blood pressure and dangerous hypertension. However, I am convinced that they can be safely combined and can constitute an *extremely powerful *antidepressant combination where other treatments fail.

Some background. I suffer from social anxiety, depression (mild bipolarity around the edges), panic disorder, generalized anxiety, and an assortment of oddities too numerous to list.

As of 04/05/2014 I am on:

Parnate (tranylcypromine) 90 mg. MAOI type antidepressant/anxiolytic
Lamictal (lamotrigine) 300 mg. Mood stabilizer and antidepressant booster
Cytomel (liothyronine) 50 mcg - Thyroid medication used as antidepressant booster
Xanax (alprazolam) .5 mg. Benzodiazepine as needed for anxiety/panic
Also:

_Bunches _of supplements (vitamin D, Align probiotic, multivitamin, fish oil, methylfolate, B12). 
Caffeine, in coffee, soda, and pill form. I would estimate ~ 600-800 mg/day. I've built up a lot of tolerance. Reduced to 200/day
*Now adding:*

Adderall (amphetamines) 20 mg/day. Immediate release version. Stimulant Switched to Ritalin (methylphenidate) 60 mg/day immediate release.

Wish me luck!


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## Caedmon (Dec 14, 2003)

From another post on *04/04/14*:



> So far it's doing some good things, but not all that I would have liked. I have noticed:
> 
> The Good
> 
> ...


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## Caedmon (Dec 14, 2003)

For *04/05/2014*

I took 10 mg Adderall when I woke up at 6:30, 5 mg around 1:00PM, 5 mg around 3:00 PM. Dose #2 was probably taken a few hours too late. That third dose did not have much punch, I was still sleepy at 5:30 and ended up taking a nap.

Blood pressure does go up. It looks like 5 mg Adderall raises BP by about 10 mm systolic, 0-5 diastolic. Around that? I'll keep measuring and come up with an average.

I am noticing a correlation between BP elevation and drug benefit. WHEN my BP went up, it correlated to times when I feel better, more energetic, motivated.

Each dose seemed to deliver positive effects ~ 1-2 hours afterwards and lasted 2 hours, followed by a let down. It was a real roller coaster day. So at some times I was feeling fantastic, at other times I felt slow, lethargic, unfocused. The word finding and odd memory problems I noted previously, I think were symptoms of the drug 'wearing off'.

Perhaps the dose is too high? Too low? There is Adderall XR - perhaps that would work better? Switch to methylphenidate type options? I don't know. It will take some time to iron it out.

Tomorrow I'll try 4 x 5mg for the day and try to get a steadier benefit.

I enjoyed the 10 mg dose. Nothing to write home about. It was enough that I played The Thermals a notch louder than usual and played air guitar for the cats. (They are a tough audience btw)


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## Caedmon (Dec 14, 2003)

*04/07/2014
*
Yesterday I had the day off, pretty much stuck to gardening and testing the Adderall (hereafter I'll just say amphetamine). Getting the garden beds ready for potatoes, pumpkins, and peas (the three P's) plus ornnamental tubers (dahlias, oxalis, four oclocks, crocosmia etc). Trying strawberries in containers.

I did some safety checks. I tried stretching the dosing as 2.5 mg every 2 hours with blood pressure checks each time. The highest BP reading was 126/83, around mid-day. The lowest was 95/67 (in the evening). The low BP was yucky, very tired. I was on my usual caffeine regimen. I figured I should keep everything else consistent.

Average overall BP on 20 mg amphetamine/day over a fistful of days: 113/75. Just fine. I'm not interested in exceeding about 120/80 so I figure, I could probably go up to 30 maybe 40 mg, wouldn't do more than that. I can reduce caffeine, for one thing. Today I had less caffeine (maybe 300 mg) and 20 mg amphetamine stretched out throughout the day in 5mg or 2.5mg doses. It's kind of ridiculous that way but I was trying to see if I could keep it going level.

Been reading up on how amphetamine works, especially compared to methylphenidate (Ritalin). I had never really thought to study it. Ken Gillman (smart MAOI researcher) appears to endorse methylphenidate as the safer drug in combination with MAOIs. Looking at mechanism of action methylphenidate does _look _a little cleaner, since amphetamine can hijack things inside the presynaptic cell and dump out dopamine. I think? I could be reading this wrong.

I think methylphenidate is probably the better first choice in general and if amph. doesn't work, I'll see if I can switch. Frankly I was not expecting any offering of a C-II stimulant from the psych. I figured modafinil. I was not going to say no to Adderall. Okay, I _guess_ I'll try it. wink.

Stahl, Essential Pharmacology, talks about tonic vs. phasic dopamine firing. You really have to watch the dosing. My _impression_, at least, is that improving tonic dopamine could provide benefits to motivation, energy, concentration etc. whereas phasic firing causes tolerance and problems. Long-acting, low doses are good. Short acting, high doses are bad. Basically, if you get euphoric, you're on too much. Bupropion works for depression but only affects 10-30% of DAT. Doesn't take much.

__

At work I had a louder voice (something I always struggle with), less mumbling, better eye contact, less mental fatigue. Mild headache. Felt a bit more on edge. Not prosocial. I _spoke _better, but I didn't necessarily want to talk to people more. More awake and less lethargic. I need to sit down and plan out some organized chunks of days that I can trial different doses.

___

Side note:

You know what needs the stimulant augmentation? *NARDIL*. The stims would help counter a _lot_ of side effects (weight gain, fatigue, hypotension). You'd make a billion dollars off a* pre-packaged med, pills of 15mg phenelzine and 2-5 mg amphetamine (or equivalent methylphenidate) in extended-release formulation*. You could titrate them safely at the same time. Seriously this needs to be done. Pfizer, give me a call, let's talk.


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## Caedmon (Dec 14, 2003)

*04/08/2014
*
I didn't sleep well last night. I woke up early around 5 am. The sleep quality was bad too, in a way I can't really describe but it "felt" different. I stayed on 20 mg today and it helped me stay plenty alert but I could feel sleep debt underneath. I felt very sped up and on edge. I think the dose is actually too high. At this point I'm comfortable with any dose up to 20 mg, in terms of blood pressure. So it's more a matter of finding the right amount. I'm going to take a day off, then restart it at 10 mg/day.


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## loneliness (Oct 3, 2013)

> The Bad
> - I seem to have word-finding difficulties. I keep forgetting what things are called. I almost feel slightly dumber. I dunno. It's really odd.
> - Sometimes I'm very focused but then other times I will forget what I was doing next, or blank out. Almost like my short term memory is reduced. This seems at odds with how amphetamines work so I can't figure this one out.


Have you tried taking out the caffeine? You're taking quite a lot. I noticed when I completely quit caffeine, taking adderall felt a lot smoother and a lot of the cognitive problems I experienced (similar to yours) disappeared.

IME Adderall + caffeine causes too much stimulation to the point that cognitive faculties are diminished, rather than enhanced as would be expected with stimulants.


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## Caedmon (Dec 14, 2003)

loneliness said:


> Have you tried taking out the caffeine? You're taking quite a lot. I noticed when I completely quit caffeine, taking adderall felt a lot smoother and a lot of the cognitive problems I experienced (similar to yours) disappeared.
> 
> IME Adderall + caffeine causes too much stimulation to the point that cognitive faculties are diminished, rather than enhanced as would be expected with stimulants.


Hmm that is a very good idea!

I haven't quit caffeine altogether, I have decreased substantially, just naturally. I might not go through caffeine withdrawals since Adderall would keep me alert and is a vasoconstrictor.


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## loneliness (Oct 3, 2013)

Caedmon said:


> Hmm that is a very good idea!
> 
> I haven't quit caffeine altogether, I have decreased substantially, just naturally. *I might not go through caffeine withdrawals since Adderall would keep me alert and is a vasoconstrictor*


I noticed adderall made quitting caffeine very easy. Since I was addicted to caffeine the psychological craving for caffeine was there, but basically any of the usual effects of caffeine w/d (headache, lethargy, depression) were masked by adderall.

To make quitting caffeine 100% pain free, maybe you can just reduce the dose by a certain fraction everyday until you're down to zero. The taper doesn't have to be too long since again adderall seems to take away a lot of the discomfort of caffeine w/d.

At the very least it's worth seeing what your current drug cocktail is like without caffeine. If nothing comes from it, at least you'd have lowered your caffeine tolerance, which is always nice.


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## AstralBody (Feb 11, 2014)

Caedmon, have you tried the Eugeroics? (Modafinil, adrafinil, armodafinil.) I just got put on Parnate, and I'm thinking of adding one for augmented effect, and to combat lack of energy/motivation. I found an interesting study that used modafinil as an add-on treatment for depressed patients...


"...The analysis revealed that modafinil improved the severity of depression as well as remission rates. Modafinil also showed beneficial effects on fatigue and sleepiness, with the added benefit of the comparable side effects to placebo."


Very clean profile, safe, effective; adrafinil can even be purchased over the counter...just a thought if ever you're interested. I'm quite jealous of your Parnate-Adderal combo, by the way. Do keep us updated with your progress.


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## Caedmon (Dec 14, 2003)

They have done studies specifically on modafinil combined with MAOI (I think phenelzine) and found beneficial. Modafinil has the advantage of having less effect on blood pressure and is only a schedule-IV substance in the U.S. I haven't taken it with Parnate but it is actually what I had asked for.

The doc suggested Adderall instead, so I decided to shut the hell up and let him be the expert. 

Modafinil is an enzyme inducer, not sure on adrafinil. You'd need to check interactions.


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## watertouch (Nov 4, 2013)

Caedmon how is the musclefatuige? I get it on Parnate if say i hanging laundry, a feeling of Lacticacid in my shoulders. Could be BP though...
Does adderal help with this?


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## GotAnxiety (Oct 14, 2011)

Caedmon said:


> I am now taking an unusual medication combo that I think will help out a lot. I thought I would do a mini journal of experiences.
> 
> Combining *MAOIs *(which are rarely used to begin with) with *stimulants *is not common. They are officially contraindicated because of a risk of increased blood pressure and dangerous hypertension. However, I am convinced that they can be safely combined and can constitute an *extremely powerful *antidepressant combination where other treatments fail.
> 
> ...


Good luck!, Caedmon.

How's the Lamictal, Does it help with oxidative stress induced by the stimulant and Parnate ?

Does the Lamictal help with muscle wear and tear and improves endurances/stress?

And

Mentally does it provide an uplifting mood?


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## watertouch (Nov 4, 2013)

Caedmon. The methylfolate is intressting though, assuming it didn't help fully, henche the Adderal..
Did it help a little?

Tried 5-MTHF but only like 3mg/ day for 2 weeks, but thats to low a dose.
Thinking about buying some of the brand name Deplin. Or something equall

Prof Stahl take on methylfolate.
http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid=1267


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## Caedmon (Dec 14, 2003)

watertouch said:


> Caedmon. The methylfolate is intressting though, assuming it didn't help fully, henche the Adderal..Did it help a little?


Thanks for that link! It looks like Stahl is on board with the astronomical doses that are in Deplin. I haven't tried that option. Pricey!

I'm not sure how much my current use of methylfolate is helping. It probably doesn't hurt, and might prevent some problems.

Lamictal has some sort of folate interfering properties. I take the methylfolate kind under the assumption that perhaps it not only makes up the difference, but perhaps there is additional availability to my lil brain. I take "Active B12 Lozenge With L-5-MTHF" by Seeking Health Link: http://amzn.com/B00822JNTC 2 per day which is 1600 mcg folate.


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## watertouch (Nov 4, 2013)

It's from 2007 though, but i have his latest book from mid 2013 and he somewhat writes the same.


But yeah the whole "methylation" thing is... Something i don't have the energy to read up on... But Methyl-Cobalamin(B-12) and such plays roles. Endocrinology...


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## Caedmon (Dec 14, 2003)

watertouch said:


> Caedmon how is the musclefatuige? I get it on Parnate if say i hanging laundry, a feeling of Lacticacid in my shoulders. Could be BP though...


I haven't really paid attention, I will though. I hurt my left knee a few days ago so I have not done much physical activity while it repairs itself.


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## watertouch (Nov 4, 2013)

Caedmon said:


> I haven't really paid attention, I will though. I hurt my left knee a few days ago so I have not done much physical activity while it repairs itself.


But that could take weeks!!! ....


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## Caedmon (Dec 14, 2003)

GotAnxiety said:


> Good luck!, Caedmon.
> 
> How's the Lamictal, Does it help with oxidative stress induced by the stimulant and Parnate ?
> 
> ...


On the first two, I'm not sure. On the third question, it does. I forget that it does until I go without it. There is a very distinct mood boost when starting it and each time increasing the dose, at least for me. It seems to have some stimulating qualities. Over time that feeling diminishes but it prevents depression from "sticking" too much.

Think of it as like Teflon coating, and your mood as a frying pan. (oh boy) Keeps bad moments from "sticking" and threatening a relapse. Even when the acute benefits are gone, there is an underlying non-stick quality to it so that you can have 3 really ****ty days but the fourth day can be okay. Hope that makes sense. My _guess _is this is the antiglutamate property, which prevents overactivation from stress and downstream brain atrophy that can lead to depression. I'm talking out of my butt though, I'm not really sure.


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## watertouch (Nov 4, 2013)

Vitamine C and E works against Oxidative stress... Im assuming that Parnate that has stimulating properties and liklyness to AMPH also can cause this.


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## Caedmon (Dec 14, 2003)

I thought MAOIs are actually neuroprotective, since they are inhibiting an oxidation enzyme. I might be confused though.

*04/10/2014*

I tried scaling back on caffeine. I only took 200 mg today + 17.5 mg amph. But by 2:00 I was tired again, yawning, falling asleep, and I could feel some hypotension. I got a really solid 8 hours of sleep last night so I don't think that was it. I think the balance was low. I need more of one or the other. Headaches are gone now though. At home, blood pressure 109/71

Mood was just fine. I noticed behaviorally, some things come easier. It's easier not to binge my flippin' face out in fritos and candy. I've stuck to my diet pretty well. It's also easier to let things go... things that would annoy me, something that would cause me to hold a grudge, I can let go. I have a much more animated affect, less blunted and weak.

My knee is still healing. Frustrating that I had built my way up in exercise to where i could run for 2 miles, now I'm socked and I haven't jogged in a week. Today I walked for 15 minutes on the treadmill and then it twinged. The exercise pre-dates taking amphetamine. I think it's just the longer days and warmer weather.

Motivation - very improved
Agoraphobic patterns - about the same, can't wait to hide
Irritability - better, because I can let arguments go
Anxiety - so-so, kind of generally amorphously anxious
Tiredness - _much _improved
Sociability - louder voice and more animation, but hyper-introverted as always

MAOI-induced fatigue - a little better. I can still feel the afternoon nap trying to take me down. Unfortunately the nap sensation kicks in around when the amph. levels are decreasing.
MAOI-induced hypotension - helps normalize it. I'm titrating off caffeine, and it's all balancing out.

_Not a problem in sight_ in terms of hypertension. I think I've cleared that hurdle.


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## Caedmon (Dec 14, 2003)

*04/13/2014*

I took a day off of Adderall yesterday. Today restarting at 10 mg. I had chest discomfort that worried me until I figured out that a some H2 blockers took care of it (heartburn).

On the "off day" I felt slow, like I did before trying the new med. Not particularly anxious but rather withdrawn. However I don't know if I can draw good conclusions from the day. My knees were hurting and I tried working in the yard, which was frustratingly painful. Also we have to pay $1300 for tree pruning on our property of several _very_ tall douglas firs that surround the house, and I wrote the check for that, which also put me in a sour mood. Long story. Guess we'll be scaling back our summer plans.

Either way I do feel better today. More alert and not so slow. And, uh, poorer. Anyway we'll see how the week goes. Work schedule looks to be awfully busy. I'm dreading that.


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## Caedmon (Dec 14, 2003)

*04/14/2014*

10 mg Adderall + all the rest. Today was okay. Still sensitive to caffeine. I stayed awake well. Didn't need a nap. Mostly I felt like baseline.

So...
Been thinking it over. The pdoc gave me an option to try methylphenidate (ritalin) instead, if I wanted to. I honestly had not thought about it. I do anticipate, if I like amph., I would ask if I could switch to the less agitating dextroamphetamine (Dexedrine).

The more I've read, the more that Ritalin sounds better on paper. (Safer and perhaps more effective long-term).

I don't have a good conclusion for now. I really just want something effective. On paper that's all nice and tidy, but in real life I could just hum along fine on one med or feel gross on another, for no apparent reason. Brains are weird.

I have _so many _meetings tomorrow and a 10 hour work day. I'm nervous about an afternoon meeting I have. There will be like 7-8 intense people there and I have to speak in front of them and act all smarty pants. Wednesday I'm going to see if I can take the afternoon off and see a doc about my knee, maybe run some errands. Cats need some new litter, garden needs compost, and that line at the post office just isn't the same without me.


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## CD700 (Apr 22, 2010)

What do you want to achieve with the stimulant ?

Your concentration is good enough to do big posts and your maintaining 10 hour work days...
Even on dex I cant do that stuff


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## Caedmon (Dec 14, 2003)

> What do you want to achieve with the stimulant ?


Years ago I had a good remission on a combination of Parnate and NDRI (Wellbutrin). I had hoped to replicate that effect and address some other residual problems - mainly fatigue. As it was, I had been taking 2-3 naps per day to get by. I don't really know how it climbed up to that number. I had days where I would just lay on the couch deflated and empty. A bizarre feeling. Even talking felt effortful; I had to take time to gather my strength between breaths. Went to the doctor several times because I really lthought it was something nonpsychiatric. I felt more moody and irritable last Fall. Eating disorder fired up, initiated binging.

I couldn't keep up with work. While I make through many work days, I almost always use all my sick days each year. I crawl through many of them and come home feeling spent. Nothing happens, I don't do hobbies or talk to people outside of the home, just come home sleep and couch surf. Talk therapy didn't help me change habits and neither did various other self-initiated attempts to change my environment.

My Goldberg depression scores have hovered from 40-65 at various times. Now, this is far down from where it was during my Parnate break (constant irritability, panic, behavioral shutdowns, incredible anxiety) but nowhere near where I want to be.

I suppose I could just be okay with what I have but it's left me dissatisfied, worn down my relationships and resolve, caused me to gain 50 pounds in a year, gotten in trouble at work for avoiding tasks because I couldn't get started on it or felt overwhelmed.

I want to have kids some day and be a good dad and make a friend (haven't "hung out" in years), be physically healthy and feel effective/useful at work, stay awake during the day (one little nap is fine), and even have some energy to give back to society. I want to be able to say _"I have mild depression and sometimes I really struggle, but I can always overcome it"_. I'm not running for state senate or anything.

All I really wanted was Wellbutrin or possibly modafinil to provide an energy boost, help with daytime somnolence and fatigue, address some of the anhedonia and difficulty with task completion. The doctor however suggested a stimulant, which sounded like a particularly powerful option that I was more than willing to try, since (unlike Wellbutrin) there is some history behind the combination of an MAOI and stim. So, here I am.


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## CD700 (Apr 22, 2010)

In my experience dex doesn't help with motivation to get off the couch. 
Its great for reading/focus but that's about it...

Do you consider dopamine your main problem ?
Have you tried L-dopa or any precursor supplements ?


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## Jawi96 (May 15, 2012)

Did you ever get good remission from just Parnate, or did it only ever work when it was with a DNRI?


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## Caedmon (Dec 14, 2003)

Jawi96 said:


> Did you ever get good remission from just Parnate, or did it only ever work when it was with a DNRI?


My guess is that the additional NE/DA part seems to be needed, for me. But it's hard to say. Anyway at this point in time it seems to need a boost.



CD700 said:


> Do you consider dopamine your main problem ?
> Have you tried L-dopa or any precursor supplements ?


Not sure if it's dopamine or norepinephrine or both. Probably dopamine. I haven't tried L-dopa, I did try tyrosine (I think?).


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## Jawi96 (May 15, 2012)

I'm exactly where you are right now! I take Parnate 3x a day/4 hours apart that does completely zilch, and I've been moving them closer over the past week or two. Now that they're about 30 minutes apart, I'm starting to feel a bit a bit better a little after the 3rd dose, which means I'm responding to the stronger DA and NE release, but I don't know which one helps or if it's both of them..

I''m really hoping to try Selegiline incase Parnate doesn't work out to answer my NE or DA question, and maybe even achieve remission. Have you tried Selegiline, Caedmon?


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## ddiamondds (Nov 29, 2013)

Wellbutrin has a negligible effect on dopamine, so therefore I don't think adding it to Parnate would address apathy/indifference too much... assuming dopamine is the main factor.


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## Caedmon (Dec 14, 2003)

I tried EMSAM (transdermal selegiline) years ago, can't recall how it went but it must not have worked because i went to Parnate afterwards.

As I understand it, Wellbutrin(bupropion) occupies somewhere between 10-30% dopamine transporters at therapeutic doses, which is sufficient for an antidepressant response. in fact, past 50% tends to be counterproductive. Of course with an MAOI there is a general synergism. I found that 150 mg of wellbutrin was really helpful. At a full 300 mg, i got angry a lot and wanted to punch people, though I sure had energy!


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## Caedmon (Dec 14, 2003)

*04/17/2014*

I have been able to reduce my caffeine which helps a TON. In the process of balancing the see-saw I bumped Adderall to 15mg, caffeine is now down to about 250-300 mg (1-2 caffeine pills + cup of coffee). I stayed awake, with smoother energy and less anxiety. No headaches. I would love to ditch that last caffeine pill. My guess is it would require all 20 mg to get there.

Reducing the caffeine had caused a side effect - constipation. I'm just used to caffeine. It was getting REALLY sucky. However I have come across a solution: magnesium/calcium antacids. Pop about 3-4 Rolaids with dinner. So far so good.

I was at a meeting and the other people were talking and _I could follow their conversation!_ I didn't space out and get into my head. I nodded my head along and said "uh huh", stuff like that, and I wasn't faking it. So that's nice. I would like that to stick around, if it can.


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## Caedmon (Dec 14, 2003)

*04/21/2014
*

Between my knees being in pain and being sick this weekend, I really don't have good insights. I overused my knees and I basically hobble around. It will take some weeks for them to get back to normal. I also had a stomach flu all weekend and part of today and have been off Adderall as a result. What I need is rest and sleep for now.

I am pretty sure I will ask for something with less vasoconstriction - dextroamphetamine or methylphenidate. I just don't know which is better.

Methyl. has a higher ratio of DA to NE, so it's probably better in that way. It's also less neurotoxic and is a safer agent to combine with MAOIs. Less likely to cause hypertension.

I have been considering mode of action. Since Parnate is an NE and DA releaser, it could be doing something like amphetamine. So perhaps by adding some sort of amphetamine, it enhances that effect. An *additive* effect.

Then again, maybe since methyl. is a reuptake inhibitor, it would be *complimentary*. If I knew how Parnate causes release of DA I might know better. It could be that they end up competing for dopamine transporter sites, and the methylphenidate even _reduces _the effects of Parnate. But then maybe that's okay because maybe most of the therapeutic effects of Parnate are from increased monoamine levels. To make things more complicated, Parnate has a metabolite that is a gentle reuptake inhibitor on NE and DA (pretty sure anyway... I should double check which one(s)). Maybe it is like amphetamine and fits into the DA transporter and sneaks into the presynaptic cell.

I have the general impression that dextroamphetamine is more of a mood booster, not that that's a guarantee, but it does tend to recommend it more.

Little thoughts like these could have no bearing on how it affects me. Even very good paper guesses are _often_ wrong. Fact is I don't know and part of that is because there is no pharma company doing oodles of research on these old, complicated medicines.

In reality, I will probably just let the doctor decide. Because I have no clue, really, anyway.

I have done some trials on lower doses, now going to go back to 20 full on milligrams and stay steady. I'm going to wait until I'm sure the stomach bug is gone first. By re-evaluating 20 mg for a week I should know better if this is going to work. I intend to try and stay juuuust below the threshold for goody-joy-euphoria, so that I just get some steady dopamine firing in the background instead of tolerance and crashing. At some point a switch to an extended release version would be nice, if I can determine the med and the dose that is best.


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## watertouch (Nov 4, 2013)

I tried an Antipsychotic Solian in low doses that raises Dopamine DA with Parnate but that just made me tired, at first, then it kind of lost its effect... But i assume that it didnt bind, where say Dex would...

But still intersting if you try Dex since it's like the only one you can get in Sweden, (well you can get other if your Dr writes some speciel licens request that gets approved by our FDA).


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## Caedmon (Dec 14, 2003)

*04/23/2014*

Back on 20 mg Adderall. I feel so much better on it. Like I am finally "awake" and have the ability to handle things, and not just lay on the couch for four hours when work is over. No euphoria, just a subtle drive to finish things. i can almost stay awake without my intense nap sensation. 10 mg was just a sad dosage, doing nothing. This is much better.


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## Caedmon (Dec 14, 2003)

*04/29/2014
*
Doc's appointment tomorrow morning. I need to review for myself before I go.

1- It really does work. I feel really a lot better on the amphetamine
2- No blood pressure problems
3- Seems to poop out ~ 6:00pm at 20 mg. Doesn't do anything at 10mg. 
4- Kinda freaked out about possible tolerance. Side effect mainly vasoconstriction, otherwise none. Overamped with caffeine
4a - Vasoconstriction: try dextroamphetamine?
4b - Tolerance to releasing action: try methylphenidate?
4c - I'm okay with trying amph. longer or in an extended release.
5- Knee injury interfered with a clear picture of how the med could work. Might have subdued the response.

Altogether, a good augmentation. Time to write out some notes and then go to bed.


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## Caedmon (Dec 14, 2003)

Doc switched me to methylphenidate 60 mg/day


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## Caedmon (Dec 14, 2003)

*05/05/2014

*I'm trying *Ritalin *now. 60 mg/day. I haven't got a great handle on it yet. It seems smoother... to the point that I can hardly tell I'm taking anything. I've only tried it 2 days but I already miss the energizing component of Adderall. Today I had a hard crash from it. Got home from work and slept like the dead for an hour from 5:30-6:30. If I stay on Ritalin I think I will need a slow-release formulation. I was really frustrated to get home from work and just feel drained. I mainly sat on the couch and doing ipad crosswords. I didn't get any of my chores done that I wanted to do.

However - I was super worried today about a supervisor evaluation at work. So last night, took some Xanax which bled over to this morning to reduce anxiety. Even though I think it wore off by noon, it might have smothered some of the effects from Ritalin.

_____________

So... been doing some reading. What I've got so far:

If combining stimulant with MAOI, Ritalin is safer. Being a reuptake inhibitor of norepinephrine is an advantage - mitigates tyramine reactions.

Amphetamine types being a noradrenaline releaser, they will cause greater increases in blood pressure, possibly followed by unpleasant downregulation of norepinephrine receptors.

I think amphetamine type stims have one advantage augmenting MAOIs. MAOIs cause catecholamine release (at least Parnate does) probably by reversing the dopamine transporter. This is what amphetamines do too. Ritalin, being a DRI, *freezes* the transporters (inhibts reuptake) so it shuts down one of the lovelier aspects of MAOIs. I'm hoping to try dosing them at different times to get both mechanisms but I don't know if it will work. I think Ritalin could reduce the "MAOI high". Bummer.

Another option is Dexedrine, which I can try if Ritalin doesn't work. In terms of dopamine/norepinephrine ratio they rank as Ritalin > Dexedrine > Adderall. So Ritalin is most pro-dopamine. However, I really benefit from a norepinephrine punch.

^ Uh, not super sure on all the above but it's what I'm gathering. It may have no bearing on real-world results.


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## watertouch (Nov 4, 2013)

Yeah im reading Stahl Psychophamacology v4. It kind of says that Methylphenidate and Amph works the same way at "theraputical doses"... 

The "releasing" action of Amines from Amph he explains later... But it's also an reuptake inhibitor...

If possible im gonna try one first, Ritalin, or Dexamph?... After, if that dont work im gonna add my old friend Parnate...


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## Caedmon (Dec 14, 2003)

Are you on anything now, watertouch?


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## watertouch (Nov 4, 2013)

Caedmon said:


> Are you on anything now, watertouch?


Only Benzo (Xanax,rohypnol) for sleep, some antihistmines. Have bought some "SAMe" to try... But it's a real downstep from Parnate.

So i got somewhat Major Depression going on...But yeah i know whats going on and why i feel suicidal...I could go back on Parnate but im thinking about trying MAOi Selegelin to give me more energy, or Parnate+augmentation...

aaa it's crap like 20 people in the whole country that is on MAOi...


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## watertouch (Nov 4, 2013)

So Caedmon how does the Ritalin working? Does the Parnate still have its releaseing effect on amines? You know when you start feeling the morning dose after an hour or so.


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## Caedmon (Dec 14, 2003)

Hi watertouch, guess I am due for an update.

*05/12/2014*

90 mg Parnate + 60 mg Ritalin: works okay. Ritalin helped a little with focus but not as much with energy vs. Adderall. Big afternoon crashes regardless of how I'm dosing it (even tried a big slug of a dose an hour before the crash... still went right to sleep after 20 mg Ritalin).

A bit agitated at the end of the day. If I didn't have something to do, i would feel like I _should _be doing something, yet I couldn't readily decide what.

Overall an improvement though. I could remain engaged at work and got away with somewhat less caffeine.

This week - 25 mg Ritalin. I took the weekend off and restarted. I am trying a lower dose to see if the issue is too much, rather than too little. Trying to simulate a Wellbutrin antidepressant/type effect instead of a stimulant effect. Today was the first day of that.

Ritalin does block the monoamine release I get in the morning from Parnate, unless I delay taking Ritalin. My hope is that the lower dose might interfere less. To be clear - it's not necessarily that bad to have the reduced release of neurotransmitters if the overall effect is helpful.

So far I am leaning towards the amphetamine type. If I pursue that I would want to try Dexedrine. Though even Adderall was fine. I mainly didn't like the amount of peripheral stimulation, but I might acclimate to that.

Read an article which specifically found great results from dextroamphetamine:

J Clin Psychopharmacol. 1991 Apr;11(2):127-32.
CNS stimulant potentiation of monoamine oxidase inhibitors in treatment-refractory depression.
Fawcett J1, Kravitz HM, Zajecka JM, Schaff MR.

We report on our clinical experience with a combination of a CNS stimulant (either pemoline or dextroamphetamine) and a monoamine oxidase inhibitor (MAOI) for treating 32 depressed patients (mainly outpatients) refractory to standard antidepressant pharmacotherapy. This combination, though not approved by the FDA, appears to be safe and effective. *Twenty-five (78%) of these patients experienced at least 6 months of symptom remission with a stimulant + MAOI combination*. Many patients required adjunctive antidepressant treatment, including tricyclics and lithium. Side effects were not excessive, though 6 patients (3 unipolar and 3 bipolar) cycled to mania (N = 1) or hypomania (N = 5). None developed hypertensive crises. With properly motivated and complaint patients and careful clinical monitoring by the prescribing psychiatrist, stimulant potentiation of MAOIs may be a viable option for treatment-resistant depressed patients.

They took people who had failed trials of multiple antidepressants, various MAOI/TCA combos, and even ECT.

There was *not tolerance *even 6 months out and *dextroamphetamine *had the better result, *83% remission* which is an amazing result, particularly in treatment resistant depression. You simply cannot get that for a treatment resistant patient by piling on some Abilify, and if anything happens, it would be a "response", aka better than nothing.

I think Parnate is a distant cousin of amphetamine and the two probably mirror each other. Parnate is a strong MAOI with small amounts of neurotransmitter release. Amphetamine is a strong neurotransmitter releaser/reuptake inhibitor with a very small amount of MAOI activity. One could view it as a matter of balancing neuro. release and MAOI using more or less, of one or another.

I will try 25 mg Ritalin for a week or so, then try the Adderall again to fully compare. If I like Adderall more I will either continue it or try to switch to Dexedrine. If I prefer Ritalin, I will be set.

My score on the Goldberg Depression Test is the lowest it has been in ages. I am hoping to continue this trend as I get healthier. It has been a helpful addition.


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## watertouch (Nov 4, 2013)

Thanks for the info, yeah you only get some energy in the morning dose of Parnate, it doesnt help to take another dose against tiredness in the afternoon.. At least for me...

Do you get vasoconstriction from Parnate alone or in combo with Adderall?.
I get it from just Parnate "amp-penis" feeling cold, but its gonna be nice in the summer/used to sweat like hell before.


Got a Pdoc appointment tomorrow/today, think its gonna be one of these:
Methylphenidate/Ritalin- monotherapy
Selegeline
Dexamphetamine-monotherapy
Parnate+Methylphenidate (if my Dr have the balls)

Or he Stonewalls me and if im lucky, atleast he refills my benzo.


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## Caedmon (Dec 14, 2003)

Parnate by itself is not so vasoconstricting for me. Maybe I am used to it. But at times does induce lowered blood pressure - sometimes so much that I get a little pale and weak feeling. 

Any of the stimulant-y meds (Wellbutrin, Adderall, Ritalin) alter it and add on some vasoconstriction effect. Especially the Adderall. 

On various days off I have been taking a little bit of ziprasidone the evening before to reverse course on the dopamine activity and vasoconstriction, and it acts as a potent sleeping pill. It is probably not necessary, but I like the fact that I can sleep in on it. Otherwise I try to get up at 6:30 no matter what.

I think you can go ahead and ask for the MAOI/stimulant combo, if it's what you really want. Bring some articles i.e. small studies, references to Stahl, Gillman, etc. and phrase it humbly, "what do you think about this?" You'll be suggesting it while still appearing respectful of the doctor's expertise. Giving the doctor your references, provides a rationale in case he is ever questioned by his/her supervisor or in some way has to justify a potentially risky combination. Explain you can do blood pressure monitoring for small doses at a time and will stop if it ever goes up a substantial amount. Well, you've probably thought about all this but anyway it did work for me.


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## watertouch (Nov 4, 2013)

Ritalin 20mg SR, mono... 

Mention Ken Gillman, and that my doc should check out his website, haha he said:- Is that youre "houseGOD"?.. I said yeas him and Prof Stahl. He went ohh Stahl yeah he writes books... Its like finally! ive been quoting Stahl to 4Pdocs and they never even heard of him..


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## watertouch (Nov 4, 2013)

Bump! hehe Not to nag you, but hows Ritalin with Parnate?...

Got a phone meating with my do like a week from now, and trying to choose what meds to go for...


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## Caedmon (Dec 14, 2003)

The Ritalin is just okay. It gives me some nausea and dizziness. I am a little bit more assertive on it. I'm back on the full 60 mg dose. My #1 problem, fatigue, is not well addressed by it. I'm still tired a lot.

I feel better with the Ritalin added than with nothing added. Just not tons, not as dramatically as with Adderall.


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## A Sense of Purpose (May 8, 2011)

Ritalin worked really well for me for about 3 months. They I started getting daily headaches and feeling like I was going to throw up, but not because of my stomach. It would also make my throat really sore after about 3 hours and it would persist the whole day.

Its a shame, I really like Ritalin, however Vyvanse is very good too.

Sidenote Caedmon, is it safe to drink alcohol on Parnate? And apart from the obvious health issues, what would happen if you had a few too many drinks?


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## Caedmon (Dec 14, 2003)

Yeah alcohol is okay. Suppsed to avoid certain wines or tap beers... I think... I dont drink enough to have ever needed to discriminate. Anyway you might double check one of the various food lists out there.

If you have too much alcohol on Parnate, you will probably barf. :b


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## infinityplusone (Jun 5, 2011)

Caedmon said:


> Yeah alcohol is okay. Suppsed to avoid certain wines or tap beers... I think... I dont drink enough to have ever needed to discriminate. Anyway you might double check one of the various food lists out there.
> 
> If you have too much alcohol on Parnate, you will probably barf. :b


I only drink once or twice a month at the very most, as I don't venture out too often. But yeah, 10-12 drinks is nothing on Parnate; while when I'm off medication just a few drinks could make me spew my guts up.

My psychiatrist said to stick to clear spirits, but they're not really my thing. I'm also not into wine - red or white. I've gone the whole last year without alcohol, but since going on Parnate on the 12th March this year, I've finally built up the courage to venture out again to the city and to see friends - which means having a couple of drinks.

I hope some of that was relevant to you *A Sense of Purpose*. By the way, I don't condone excessive drinking - even if it's fun, it can sneak up on you quickly on Parnate.


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## infinityplusone (Jun 5, 2011)

*Caedmon* is Dexedrine suggested by Stahl in his book as an adjunct to Parnate? Because as great as Parnate is, stopping my suicidal thought process, I'm still stuck lying on the couch 90% of the time.

I've tried Dexedrine before on its own with success, but my psychiatrist is super cautious, and there's no way in hell he'd prescribe Dexedrine with Parnate, without a good source of background information. I get orthostatic hypotension with Parnate - very low blood pressure readouts too.

I'd like to combat the afternoon fatigue from Parnate.

Thanks, and all the best.


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## Caedmon (Dec 14, 2003)

Stahl, Essential Pharmacology, mentions amphetamine specifically (sorry i have the kindle version on ipad app so i dont know the page number).

His website lists d-amph and methylphenidate
http://stahlonline.cambridge.org/pr...utics&name=Tranylcypromine&title=Therapeutics

Ken Gillman's writeup on the matter could also help. Though he states methylphenidate is safer.
http://www.psychotropical.com/index.php/maois-pharmacology-and-use-pt-1-maois-and-cns-stimulants

A thorough pubmed search can be useful too.

----

W/ bipolar disorder, maybe consider Abilify as augmentation?



infinityplusone said:


> *Caedmon* is Dexedrine suggested by Stahl in his book as an adjunct to Parnate? Because as great as Parnate is, stopping my suicidal thought process, I'm still stuck lying on the couch 90% of the time.
> 
> I've tried Dexedrine before on its own with success, but my psychiatrist is super cautious, and there's no way in hell he'd prescribe Dexedrine with Parnate, without a good source of background information. I get orthostatic hypotension with Parnate - very low blood pressure readouts too.
> 
> ...


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## infinityplusone (Jun 5, 2011)

Caedmon said:


> Stahl, Essential Pharmacology, mentions amphetamine specifically (sorry i have the kindle version on ipad app so i dont know the page number).
> 
> His website lists d-amph and methylphenidate
> http://stahlonline.cambridge.org/pr...utics&name=Tranylcypromine&title=Therapeutics
> ...


I asked my psych for Abilify, but he knocked it back unless I came off Parnate.
He thought Abilify would be too activating.

If Parnate poops out, the next med on the list for me is Abilify, and my psych said he would load me up on benzo's until I acclimated to Abilify.

There's no way I'm coming off Parnate though - it's a god send. Have you tried dexedrine at any point out of interest? On its own or with another med?

I only go manic because of meds or coming off meds, and it's only been a handful of times. Effexor was the main culprit, especially coming off it, it tended to send me loopy.

Thanks for the info, I'll make sure to read the links you posted


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## Caedmon (Dec 14, 2003)

I did find this, particularly simple and appealing, document:
_Monoamine Oxidase Inhibitors: A Modern Guide to an Unrequited Class of Antidepressants_
By Stephen M. Stahl, MD, PhD, and Angela Felker, MA

http://www.psy-world.com/1008CNS_Stahl.pdf


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## Caedmon (Dec 14, 2003)

*05/29/2014
*
Doc appointment tomorrow. Well the results are in. I have tried Ritalin for a few weeks now.

Week 1: 60 mg Ritalin
-Good focus, motivation. Good sleep/wake cycle regulation
-More "grumpy" mood, more vulnerable to getting angry
-Very mild hand tremors. Infrequent but noticeable.
-Needed more caffeine [versus Adderall], so it was not as wake-promoting.
-Less energizing than Adderall
-Average blood pressure: 110/68; no significant hypertension or cardiac concerns

Week 2: 30 mg Ritalin
-Could not tell if I was taking anything

Week 3: 60 mg Ritalin - again
-Same results as first trial
-Noticed afternoon crash continuing regardless of dosing pattern
-Goldberg Depression Test score: *35*

2 days off

Week 4: Adderall, 25 mg (using leftover prescription)
-Increased energy, mood
-Decreased anxiety and improved sleep/wake cycle. Less insomnia
-Better task completion
-Follow conversations much better
-Easier to think through decisions
-Doing things after work: out to dinner, at a voluntary study group. Not as "wiped out" afterwards
-Mild headache first 3 days - no associated change in blood pressure
-Vasoconstriction present
-Average blood pressure: 107/65
-Goldberg Depression Test Score: *24* [that is an amazing score for someone used to numbers in the 40s, 50s, 60s etc]

*Ritalin IR (methylphenidate)* vs. *Adderall IR (amphetamines)*:

*Winner: :yay amphetamine!* :yay

Hoping he will consider dextroamphetamine but Adderall is okay too.


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## Caedmon (Dec 14, 2003)

Update: Now on Adderall, 30 mg. I'm pretty happy with this outcome.


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## CelestiaSun (May 22, 2014)

I was on Ritalin for about 3-4 months. I really hated it, man.
My anxiety got so much worse while on Ritalin.. super fidgety, nervous, heart beating fast, etc. It was great in the sense that I had enough energy to do things & complete tasks, but I just couldn't deal with the amount of anxiety it was giving me.
Just switched to Adderall, and it is waaaay better. 
Less anxiety, no comedown, clear head, more calm/relaxed, and I can stay up all night to get things done. But I feel sleepy after I've come down from it. Is that normal?


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## Caedmon (Dec 14, 2003)

*06/11/2014*

I wrote a separate post detailing some results (see: "I feel 'normal' for the first time in YEARS") but thought it worth following up on this one since it has a continuous theme.

The addition of Adderall to my med combo has fit like a glove. It has been added to (at this time) Parnate/Lamictal/T3. While 20 mg did give a good response, 30 mg has provided a great response. There was a HUGE difference in the 10 mg jump. That was important.

I feel less spacey, sleepy, slow, fatigued, and numb. More like my "good" self - the self that I know I can be. I don't get any significant side effects at this point. My blood pressure takes it in stride with no more of a blink than I'd get from a can of soda. *It can be done safely* under medical supervision. The two meds are force multipliers for each other.

For me - it is great. I feel like I have walked out of a fog and can see for miles, clearly. Quiet and sudden. I feel normal and positive. For me that is a big deal.


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## Jawi96 (May 15, 2012)

Cue follow up? How's the trial so far?


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## Caedmon (Dec 14, 2003)

Oh! Well let's see.

*06/23/2014*

Things are good. I have some days off so I'm working in the garden a TON. Lost 15 pounds since March. Very happy with my combo.

In the short term - I had an attack of vertigo 5 days ago which sucked. I get this periodically. The only treatment is meclizine (antihistamine/motion sickness pill), tylenol, and a benzo (clonazepam), and then about a week of carefulness and slow tapering off. I ALWAYS carry meclizine with me wherever I go because if I get it, it's completely disabling.

I think a lot of the remaining issues are related to health conditions that - I think, finally - I can start to treat more effectively and with better results.

Anyway aside from that things are good. I have noticed more animation, better task completion. And ENTHUSIASM to do things that I once enjoyed! It is hard to be enthusiastic when you just want to lay on the couch.

It's easier to make my weekly phone call to my parents because I don't feel like I sound so down. I don't have to make my voice bend into a fake happy shape to keep them from worrying. My voice just takes that shape - naturally - part of a neurological shift to adequate functioning.

I am just... evenly, steadily happy, with some ups and some downs, with energy to do what I want, and overall positive orientation. No complaints here. _10/10, would ingest again._


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## watertouch (Nov 4, 2013)

Just to be clear it's IR on the Adderall?


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## Caedmon (Dec 14, 2003)

Yep, generic instant release. 10 mg pill, 3 times per day. Equates to 30mg total per day. 

The mixture of amphetamine salts is actually fairly long-acting as it is, so I haven't yet felt the drive to ask for XR.

I wound up being content to stick with Adderall's l- and d-amphetamine mixture. It has more noradrenergic activity than the d-amphetamine isomer alone. (Not by much - just a little tiny bit. Adderall is still 75% dextroamphetamine.) So, while dextroamphetamine is "smoother", it probably would provide a bit less energy.


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## watertouch (Nov 4, 2013)

Caedmon said:


> Yep, generic instant release. 10 mg pill, 3 times per day. Equates to 30mg total per day.
> 
> The mixture of amphetamine salts is actually fairly long-acting as it is, so I haven't yet felt the drive to ask for XR.
> 
> I wound up being content to stick with Adderall's l- and d-amphetamine mixture. It has more noradrenergic activity than the d-amphetamine isomer alone. (Not by much - just a little tiny bit. Adderall is still 75% dextroamphetamine.) So, while dextroamphetamine is "smoother", it probably would provide a bit less energy.


Ok just checking saw on the page before that 20mg adderall IR was the winner over Rita, wasnt sure that was the same now with 30mg...

Of course they dont really have that in Sweden, there is Dexa but they phasing out the IR form for LA Vyvanse. The Dr can write a really nice letter to our "FDA" requesting it on licens though...


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## Caedmon (Dec 14, 2003)

He bumped the dose to 30 per day (3 x 10 mg pills) and this was great.

He offered 15 mg pills - 45 mg per day - which i declined as i felt 30 was enough for right now. Maybe save it for a winter dose :lol


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## MRDIGBY (Jun 25, 2014)

Im taking Parnate 80mg, Vyvanse 70mg and Ritalin 5mg as needed. I have no idea why but if your MAOI resistant it works like a charm. I'll probably keep climbing Parnate up to 100-120. My BP has been great.

_Posted via *Topify* using iPhone/iPad_


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## Caedmon (Dec 14, 2003)

MRDIGBY said:


> Im taking Parnate 80mg, Vyvanse 70mg and Ritalin 5mg as needed. I have no idea why but if your MAOI resistant it works like a charm. I'll probably keep climbing Parnate up to 100-120. My BP has been great.


Parnate and amphetamine type stims (like vyvanse) seem to have *strong* cross enhancement effects while decreasing each others side effects. It's really cool.

I would just be wary of crawling upward on the dose too much, especially the amph. Once you find your happy place, just stay there.


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## watertouch (Nov 4, 2013)

MRDIGBY said:


> Im taking Parnate 80mg, Vyvanse 70mg and Ritalin 5mg as needed. I have no idea why but if your MAOI resistant it works like a charm. I'll probably keep climbing Parnate up to 100-120. My BP has been great.
> 
> _Posted via *Topify* using iPhone/iPad_


Great as not getting low-really low, or that it dont raise to high with the stims?


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## watertouch (Nov 4, 2013)

MRDIGBY said:


> Im taking Parnate 80mg, Vyvanse 70mg and Ritalin 5mg as needed. I have no idea why but if your MAOI resistant it works like a charm. I'll probably keep climbing Parnate up to 100-120. My BP has been great.
> 
> _Posted via *Topify* using iPhone/iPad_


I can only dose Parnate 30mg at a time otherwise i get the Orthostatic BP side-effect... Strangely i don't get much sleep problem if i up the dose and say take 3x30 spreaded out...
But i use nicotine/Snus like hell and that contribute to the Orthostatic bp...:blank


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## Caedmon (Dec 14, 2003)

*07/09/2014*

Everything is going fine, brain-wise.

Summer is here, very beautiful days. I live in a climate where summer days are consistently in the 60s and 70s, sunny, long, everything very alive but calm.

There is always something to do in the garden. I left dahlias in the ground over winter and this year they are blooming profusely, already many are 3-4 feet tall and need hacking back to keep from hugging each other. Pumpkins are beginning to show their bossy side. Fuchsias and lamium baskets look great.

I posted a recently released article, reposting here. Columbia Univ. study on MAOIs with higher doses and with stimulant or NRI augmentation:



> _J Affect Disord._ 2014 Jun 4;167C:148-152. doi: 10.1016/j.jad.2014.05.047. [Epub ahead of print]
> How treatable is refractory depression?
> Stewart JW1, Deliyannides DA2, McGrath PJ2.
> 
> ...


My only issue with this is that a TCA/lithium/Nardil combo could have a lot of side effects. This was also pointed out by another user on this board. Would have liked to see results from cleaner options like Remeron, Wellbutrin, Lamictal, Ritalin, Abilify, T3, etc. but the TCA and lithium options are old school and well established.

The STAR*D trials put stage four treatment resistant patients, at less than 20% likely to attain remission. This was using either "California Rocket Fuel" (Effexor/Remeron) or lower, conservative doses of Parnate. http://www.ncbi.nlm.nih.gov/pubmed/16946177

Compare to these trial results. Pretty sure 64% > 20%. It should be very clear what kind of treatment is likely to _*work*_.


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## watertouch (Nov 4, 2013)

Caedmon said:


> He bumped the dose to 30 per day (3 x 10 mg pills) and this was great.
> 
> He offered 15 mg pills - 45 mg per day - which i declined as i felt 30 was enough for right now. Maybe save it for a winter dose :lol


So how is it going?
A question or two what time do you take your last dose of Adderall...Do you get any comedown from it? Any sleeping problem with the Adderall?


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## Caedmon (Dec 14, 2003)

Going great! I sleep as well as before (which has never been great, but at least is not worse). I am still trying dose schedules. Right now trying:
Morning: Parnate 30 mg/ Adderall 10 mg/ Lamictal 150 mg
Late morning: Parnate 30 mg/ Adderall 5 mg
Lunch: Parnate 30 mg/ Adderall 10 mg
Afternoon: Adderall 5 mg afternoon / Lamictal 150 mg

Dropped the thyroid to see if the other stuff takes care of things.

I did try a 6-day break. After a long spell of stimulant use. The first two days are not very different, just not much energy or motivation, then two days of being sleepy. Cleared up after that. Caffeine withdrawals are much worse, for me.

Parents have visited (only happens 1-2 times a year) and noticed a big change since Christmas.  more upbeat, in a better mood.


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## watertouch (Nov 4, 2013)

Tnx for reply...I probly have to go with Vyvanse to my Parnate... Well ill be messing around with Modafinil and Ritalin also... To see wich works best.

But it also makes me wounder, taking betablockers and antihistamins that have some Dopamine lowering actions, wich inhibits the effects of stimulants. It's probly contraproductive to this depression im feeling. Both if using Parnate or stimulants...

And also has depression listed as sideeffects... ehh...:b


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## Caedmon (Dec 14, 2003)

*08/02/2014*

This just in: I LOVE my meds! :love


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## DeafBoy36 (Dec 12, 2009)

Glad to hear that it's working for you. So inspiring! I have a question…..do you fear that those meds will poop out eventually? If so, what's next in the action plan


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## Caedmon (Dec 14, 2003)

Good question! The studies i have looked at showed pretty good maintenance at least months out. (Hard to do multiyear studies.) i feel good about the long term effectiveness.

But it can and does happen. I would probably try *switching* meds either short term or long term. For example Parnate switched to Nardil, or Adderall switch to Wellbutrin or Strattera or just withdrawn for a while and reset. Lamictal could be *increased*. Even Parnate and Adderall increased but I would rather not. Or meds could be *added* such as daily diazepam, trazodone, low dose lithium, modafinil, Remeron, Latuda, Lyrica, etc... Depending on need. There are also *procedural treatments* like vagus nerve stimulation. I don't know much about those.

My initial hunch - for today at least:
If depression worsens - i would try an Adderall break/ reset or reintroduce thyroid augmentation
If anxiety worsens - play with benzo, probably change to daily diazepam
Option for both anxiety and depression - add trazodone ~ 100 mg (start with tiny divided doses to acclimate).

Regular ol takers of a single dose of an SSRI can get poop out too. It is a known risk. But like I say, the available evidence shows good maintenance and i am confident that things will go well for a very long time.


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## watertouch (Nov 4, 2013)

I had to start Parnate again, due to anxiety(got construction worker running around)..
Of course i get the "crash" so i fall asleep, hehe it's nice that it helps the anxiety that much that i can sleep while they are here...

So today im testing Vyvanse 30mg to not fall asleep... We'll se how that goes... BP before 112/73 pulse68.


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## watertouch (Nov 4, 2013)

3 hours after taking 30mg vyvanse BP 112/73 pulse 67...
Im surprised... Did not expect that, gonna take some Caffeine pills...


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## watertouch (Nov 4, 2013)

Well that did't do much, gonna try some more Parnate and se if its releasing propertys does anything.


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## Caedmon (Dec 14, 2003)

*08/19/2014*

I am several days into an Adderall holiday. This wasn't planned far in advance, but my work schedule made it possible and I felt like I should try it.

Days 1-3 were mainly munchies and sleepiness. I only just recently have noticed a clear decrease in mood and more fatigue. Return to some "I can't handle so many things" feelings, lethargy, poor follow-through on tasks, and even some increased anxiety. The question is whether it is withdrawals, or is a reset to baseline. I was planning on just 1 week off and going back on it tomorrow but i don't want to if I am not back to a baseline of sorts.

I recently have access to nortryptiline and cant help my curiosity about trying it, just to see how an MAOI/TCA combo compares to stimulant. It should be safe, just wonder about effectiveness. Perhaps that would buy me any extra time I need for an Adderall break.

As a disclosure - the holiday is not doc initiated and not a documented need in literature, just based on anecdotes here and there and a curiosity as to how everything compares to baseline. I continue to fill all scripts and now I have a crapload of blue amp. pills in my medication safe. (Soon I will be ready for the zombie apocalypse.)


----------



## watertouch (Nov 4, 2013)

I tried the Parnate+Nortriptylin 75mg, It has antihistamine effect, and antichollinergic. It kinda ruined my litte Parnate buzz i get in the morning at first dose,(never really get a "kick" from the second dose tough) It doesn't feel like a "normal" antihistamine like Atarax/hydroxyzine, or Propiomazine.

Anyway, the combo, wow i felt so calm (like is this how normal people feel), it would be a nice mix for anxiety,gad n such. It has a different feel to it then Benzo.

And anytime, when Parnate is involved it's like better then other AD meds.
But i kind of need the more stim effekt to get out of bed and do housechoirs and tend to my dog.


----------



## Caedmon (Dec 14, 2003)

Do you think 20-30 mg would do much of anything? At what point do you think serotonin is affected?
Did you take it at night?


----------



## watertouch (Nov 4, 2013)

Caedmon said:


> Do you think 20-30 mg would do much of anything? At what point do you think serotonin is affected?
> Did you take it at night?


I wouldn't dare to guess about the Serotonin, but i was on Anafranil150mg+150 zoloft then switched zoloft to 60mg Prozac. I probably should have gotten SS but i didnt so i risked it with Parnate and nortriptyline

But i been on Nortrityline several times so, yeah i gambled

I started with 25mg at night then after some days i tock 25 in the morning, and soon after that 25mg afternoon. But that calming effekt comes already at 25mg.

found the Parnate ph link.
5.2: Excretion is pH dependent
http://www.medicines.org.uk/emc/medicine/25577

And i searched around on that Citric acid, it can be used to alter pH, but its so small amount so i think its to preserve the pill.


----------



## watertouch (Nov 4, 2013)

I found this in a article Ken Gillman has written about TCA..

Was just gonna clip out some highlights, and pretty soon i realized just read it yourself, but it was so interesting so keept going
u probably allready read it.

But now im starting to think about making another run, i got a 100pill 25mg can, and it works fast, im tempted,
http://onlinelibrary.wiley.com/doi/10.1038/sj.bjp.0707253/pdf

Also if one search on Dr Gillmans page, it comd up some interesting articles with Nortriptyline
http://psychotropical.com/index.php...d=nortriptyline&searchphrase=all&limitstart=0

Also i just learned googletranslate so this is from FASS, our Dr.s Bible if it isnt written in stone there, they don't got the stones. But it was reported death mixing it with MAOi, but on a second wieving it was OD.. But still somewhat good medsite.
https://translate.google.se/translate?sl=sv&tl=en&js=y&prev=_t&hl=sv&ie=UTF-8&u=http%3A%2F%2Fwww.fass.se%2FLIF%2Fproduct%3F8%26userType%3D2%26nplId%3D19650520000011%26docType%3D3&edit-text=

This was from the first link!.

This indicates that even small
elevations of serotonin, added to the effects of an MAOI, are
sufficient to precipitate clinical features of ST (for a detailed
exposition of this argument see Gillman, 2006a). Amitripty-
line does not produce ST when added to an MAOI (Gillman,
1998). It may thus be inferred that amitriptyline does not
significantly raise serotonin levels in humans.

Tyramine
utilizes, and requires, the NAT to enter the pre-synaptic
terminal, where it then induces depolarization-independent
release of NA. NRIs inhibit tyramine uptake and thus
attenuate the response, which gives an
in vivo
measure of
their NRI potency: indeed the NRIs with the highest affinity
for the NAT (reboxetine, desipramine and nortriptyline;
Table 3) have all been demonstrated to block this response
almost completely, even when it has been potentiated in the
presence of MAOIs

The present evidence indicates that
drugs with an NRI potency less than nortriptyline may be
suboptimally effective, because they produce only weak
attenuation of the TYR30 response: that is, they do not
produce a maximal effect on noradrenaline reuptake at
therapeutic doses.

A degreeof SRI potency, as revealed by amitriptyline's small reduction
of platelet serotonin, may constitute measurable serotoner-
gic activity, but that cannot be equated logically with clinical
efficacy via serotonin: that probably requires considerably
more potent antagonism, as exemplified by clomipramine.


The problem withcombining MAOIs with re-uptake inhibitors (i.e., either
SSRIs or TCAs) is the pharmacodynamic interaction of ST
(SS). This reaction only occurs with drugs that possess
potency as SRIs. Of the TCAs, this only includes imipramine
and clomipramine. The other TCAs are safe to combine with
the MAOIs because they do not possess significant SRI
potency 


NRIs such as nortriptyline attenuatethe hypertensive 'cheese reaction' (due to tyramine in cheese
and some other foods) (Pare
et al
., 1982; Dostert
et al
., 1994)
that can be problematic occasionally in patients on MAOIs.
This combination would be expected to provide partial or
complete (depending on dose) protection against a tyra-
mine-induced hypertensive episode.


Nortriptyline has superior pharmacological properties to all
other TCAs as a psychotropic; it is potent as an NRI and has a
wide margin between desired effects, side effects and
toxicity. It is safe to combine it with either MAOIs (including
moclobemide)

nortriptyline has favourablecharacteristics, including minimal CYP450 interaction
propensity and, because of this, it may be combined with
sertraline without the need for therapeutic drug monitoring

Yeah, ive been researching this for 3.5hours. Yes! hehe abit long, just say the word and i delete it!


----------



## Caedmon (Dec 14, 2003)

Wow!  it would seem there are some good reasons for adding nortrip. in some cases. Seems a good option for anxiety or for worries about food interactions.

I only have 40 of the 10 mg pills left over from wife's trial of the med. half life is ~ 1 day and is a strong antihistamine. So thinking of starting with 10 mg at night for 3 days, go up to 20 mg for 3 days, then 30 mg for rest of the trial (10 days).

I would not be sure about effectiveness since it is below the typical threshold (50 mg?) but could get some hints at tolerability. The affinity for H1 and for NET are fairly similar so it is possible to see some psychotropic effects even at a low dose, if synergistic with MAOI. Could provide additional coverage on anxiety especially with insomnia.

By then my stim holiday would be three weeks and i can sort of compare with a TCA. Hmmmm.


----------



## watertouch (Nov 4, 2013)

Naa i think you feel like 20mg,or 30, the NET inhibition is, normally makes one more energized but i had to drink 8caffee a day anyway. But that was probably the NETi.. The Parnate helped abit with energy


----------



## Caedmon (Dec 14, 2003)

10 milligrams nortriptyline: so far no effects. I thought it would knock me out. Instead it is 1:45 a.m. and I'm wide awake! I assume it accumulates over time. Better have some warm milk and read Wikipedia.


----------



## watertouch (Nov 4, 2013)

I feel like i can "pop" my new Parnate from GSK like "tic tacs"... Im assuming thats because ive come from Nyvanse 100mg=30mg/dexamphetamine, and thats why i don't feel the "boost". I normally take 30mg in the morning with caffeine...

You having tried Adderall, do you feel anything from Parnate?


----------



## Caedmon (Dec 14, 2003)

I still do feel the warm fuzzies from Parnate, usually need a stout dose at once (like 30-50 mg) and usually only if it has been a while.

I don't feel sedated at all from nortriptyline which is really surprising to me. I guess. So I am just going to try 30 mg of it for a while. So far I feel good. It seems to cancel out the post-Adderall depression. In many ways it feels more "solid" than Adderall. Like driving a pickup instead of a sports car.

Nortriptyline is an NRI + activity at 5HT2a, 5HT2c. That's actually a really nice profile. Starting to be impressed by this old medication. 

In early September probably start back on Adderall. It's nice to compare the two.


----------



## watertouch (Nov 4, 2013)

Ok was thinking it was the new GSK brand, but the other didn't really work either...

30mg, hmm i actually think i sweat some on 25mg at night, but i get like "anxiety" at night, or cortisol output normally so, but i actually used Nortritylin and its antichollinergic properties against sweating...

During the day it was no problems.

But stuff works somewhat different when one throw in an MAOI.....


----------



## watertouch (Nov 4, 2013)

Damn the Betablocker Inderal/propranolol totally destroys the Stim effects... Well naturally since it affects Chatecolomines...

Ehh it is what it is, but like no idea to take Vyvanse or Ritalin when taken Inderal...Ill try some caffein that mimics the Adension on the 4 receptor....


----------



## Caedmon (Dec 14, 2003)

Beta blockers are for anxiety or for hypertension?


----------



## watertouch (Nov 4, 2013)

Caedmon said:


> Beta blockers are for anxiety or for hypertension?


Anxiety, the Parnate i fairly good 118/73 p65 and before like 145/87 or such... So thats nice, weirdest thing i dont get OH since i changed Parnate to the GSK brand...

And that also means i can raise the dose,im on 60mg but yeah in some studies they use more. (i sent in an old can (mercurypharma) for analyze at the pharmacy, but they never heard back)


----------



## Caedmon (Dec 14, 2003)

*09/11/2014*

Verdict on Nortriptyline augmentation (30 mg): works fine. Nice sleep aid! Put me right out, in a nice cozy way. It did add antidepressant effects, not as strong as Adderall but beneficial in its own right, especially for those with insomnia or GAD. Would be great to try 50 mg and then stay there for a month.

Back on Adderall though. 25 mg per day. Have been for about 10 days. I feel the same bright fire again, the same normalcy. 

My remaining issues are:
GAD
Trichotillomania
Health (weight/sugar addiction)

I added n-acetylcysteine a while back, 1200 mg. It is supposedly the best thing out there for trich and may help some other stuff. Seems like lamotrigine would already be a heavy inhibitor of glutamate so I dont know if this stuff will do much, but i will try it. I may increase the amount. So far it seems to reduce trich by about 40%.


----------



## watertouch (Nov 4, 2013)

I cried wolf, the OH came:blank, gonna resarch if there is some A1 adrenerg agonist i could take to counteract it.
@Caedmon how did you find the Nortrip worked during the day? 
Did it effect some stim effect of Parnate? Also did you get tired coming of 30mg Adderall?


----------



## Caedmon (Dec 14, 2003)

Nortript was fairly motivating but its hard to judge from the time and dose. Not energizing like stimulants but no crash, either. No anticholinergic effects (dry mouth, urinary retention) thank GOODNESS as those bother me a lot. At least not from 30 mg.

Going off of amphetamine, i did a short taper then stopped. Actually I wasn't as sleepy as I thought I would be.


----------



## DeafBoy36 (Dec 12, 2009)

So you would say that your social anxiety is gone, Caedmon?


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## Caedmon (Dec 14, 2003)

SA about 75% gone, depression about 90% gone. I still have issues. I am still a worrier (generalized anxiety), trichotillomania (had since I was a kid), and some health problems that make me vulnerable to feeling bad again. I am trying out n-acetylcysteine to see what it does for me. What I really need to do is get into shape, to reduce a lot of other problems.


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## barry1685 (May 25, 2011)

Caedmon, did parnate take care of physical symptoms?


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## Caedmon (Dec 14, 2003)

barry1685 said:


> Caedmon, did parnate take care of physical symptoms?


Yeah i would say so. Maybe too much. For a long time i had so much hypotension i would feel weak and even get pale. I would feel less anxiety but also feel like i wanted to lay down. I mean, if this drug is "stimulating" then i'm Scott Baio. Adding an NRI helps me by evening that out and reducing the tiring effects. (I am also severely fatigued in general... Seems to run in the family. Sometimes triggered by events, so is a depressive symptom treated well by the stimulant).


----------



## watertouch (Nov 4, 2013)

I had the Goldshield brand when i started, so that worket stimulating for me, but then you get some down regulation and stuff... Now its 4th time on it added Vyvavanse works ok, 50-100mg... its not that super activating compared to Adderall... But compared to Ritalin and Modafinil its better... If you invite inderal/propranolol well it kinda ruin it.


----------



## DeafBoy36 (Dec 12, 2009)

I'll be starting Parnate tomorrow so I'm following this thread. Off topic, but related to this:

Anyone know of any upcoming medications that are supposedly going to be better than Nardil/Parnate? I do know Nardil is the current gold standard. Parnate isn't too far from that gold standard.


----------



## watertouch (Nov 4, 2013)

DeafBoy36 said:


> I'll be starting Parnate tomorrow so I'm following this thread. Off topic, but related to this:
> 
> Anyone know of any upcoming medications that are supposedly going to be better than Nardil/Parnate? I do know Nardil is the current gold standard. Parnate isn't too far from that gold standard.


The "triple reuptakeinhibitors" is probably the next "big thing" Viibryd
is already aproved by FDA
http://en.wikipedia.org/wiki/Vilazodone

The Danish company Lundbeck also is working on a "triple reuptake-inhibitor" so that will be interesting, don't have a launch date though
http://en.wikipedia.org/wiki/Tedatioxetine

.And so does GSK and others. Problem is, once you invented a new medicin you need to sell it to gain some money back for the costs, and hopefully go+... Are they gonna be better then the MAOIs... probably not.


----------



## watertouch (Nov 4, 2013)

Hey Mon, ever heard of anybody using a COMT inhibitor, for depression, or augment it with an MAO-A+B i, its used alot for Parkinsonism....

http://www.ncbi.nlm.nih.gov/pubmed/1888633

It does sound interesting... Remember Stahl writing about vit-B9 Folicacid or 5-mthf,L-methylfolate.... Sold under the name Deplin cost a crapload of money... but it would also inhibith COMT...


----------



## Caedmon (Dec 14, 2003)

I wonder at the possibility of hypertensive reaction to a lot of COMT inhibition along with MAOI?


----------



## watertouch (Nov 4, 2013)

Caedmon said:


> I wonder at the possibility of hypertensive reaction to a lot of COMT inhibition along with MAOI?


Yeah i get you there, i also see here in Stahls book it effect Serotonine, so im dropping the idea.


----------



## watertouch (Nov 4, 2013)

Although i did try Green Tea extract before that has some probably not that strong depending on study COMP-inhibition without side effect, but that was on Parnate only.
Now with Vyvanse augmentation, im scared of SS.


----------



## AtRockBottom (Sep 3, 2014)

Caedmon said:


> *Update 05/02/14
> *Changed stimulant to methylphenidate (Ritalin). See post #32.
> 
> _________________________________
> ...


This is very interesting and i wish u the best of luck 
This forum is a gem of information, i love it.

Kev


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## Caedmon (Dec 14, 2003)

*09.18.2014*

Maybe you have had a small time you were in a good mood, just in your day. For once your insides were not cold, scared, tarred, churning, tense, empty. Even just a distant memory. A ten minute window.

For example, maybe you went and bought a coffee and for some reason felt just fine. When you ordered you spoke clear and well and when they gave you your drink, you said thank you with genuine (not fake) warmth. You walked away and felt okay inside, calm, like walking through your own living room unconcerned about being out of place. You sat with the ease you feel at home and spoke with happiness that you knew was real. It felt really normal and nice. When you smiled, you did it because it you just did. You didnt force it.

No rushing thoughts or impulsive reckless activity or exaggerated self esteem, no fuzzy headed sleepy drunkenness, no numbness or zombie feelings. Just normal.

Now stretch that feeling out in all directions, pervasive and defining your hours. *Normal is great*. 

---

Still on Parnate, Adderall, Lamictal. This is like the _*holy f-ing trinity*_ for depression. I have never felt more normal. My good self, still me. The better part of me, now armed to the teeth and winning against its hopeless shadow.


----------



## jim_morrison (Aug 17, 2008)

infinityplusone said:


> *Caedmon* is Dexedrine suggested by Stahl in his book as an adjunct to Parnate? Because as great as Parnate is, stopping my suicidal thought process, I'm still stuck lying on the couch 90% of the time.
> 
> I've tried Dexedrine before on its own with success, but my psychiatrist is super cautious, and there's no way in hell he'd prescribe Dexedrine with Parnate, without a good source of background information. I get orthostatic hypotension with Parnate - very low blood pressure readouts too.
> 
> ...


I'm on Parnate along with 72mg of Concerta (aswell as Saphris and Lamictal). My blood pressure is pretty normal so far, slightly on the low side with some mild tachycardia. I don't get any tiredness unless I take my second dose of lamictal too early.


----------



## Caedmon (Dec 14, 2003)

*10.10.2014
*
I saw the pdoc and brought up a complicating issue: my nighttime insomnia- binge- eating issue. He wrote up a script for Topamax (topiramate) 50 mg to start with. We'll see how it goes. I am optimistic since I think this is probably the missing piece for long-term mental health. I took Topamax a long-ish time ago and I seem to recall it was tolerable and did help with eating issues.

Topamax is also a GABAergic (either agonist or increases GABA levels or something - I can't tell from my brief research). So it may help if there is an anxiety component to it.

Otherwise things going well. Very productive at work and happier at home. I started a chromium supplement a few days ago to see what that does. See if it helps with energy dips. I have felt pretty even keeled. BUT it really takes time to get an accurate picture of any med/supplement changes. I'll probably start a very very slow titration of Topamax tomorrow. Low enough dose to adequately judge how the chromium affects me while still firing up this new med. (The likelihood of cognitive side effects is lower on Topamax if slowly increased.)

Also: the pdoc also gave me Rozerem (ramelteon) sleeping pill samples for good measure. I was hoping for Saphris but figured I would try this other one first. It was a "let the doctor be the doctor" kind of visit.

I gave him a copy of the Stewart et al 2014 study on MAOIs and TCA/stimulant augmentations, which he found pretty interesting, especially when it was compared with the STAR*D trial results.

-------------

I thought about something recently. I have worked my current job for five years and things are changing. I feel confident. I had a coworker question my abilities in a pretty serious, accusatory way. I was steady eyed and responded well, with diplomacy and assertiveness, and put my foot down. I was so proud of myself!!! I can accept challenges better because I know what I'm doing. Or rather: *I know that* I know what I'm doing. That's huge! Depression would have had me believe otherwise.

But all the same, _TGIF!_

--------------

I look forward to seeing the Seahawks destroy the Cowboys on Sunday. mwa haha.


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## Madara Uchiha (Oct 11, 2014)

@ caedmon Did you do any thyroid labs? I wonder what you TSH,ft3 and ft4 are at such a high dose of T3. Do you have symptoms of hyperthyroidism?


----------



## Madara Uchiha (Oct 11, 2014)

And what exactly for do you take lamictal? Do you suspect that you have a glutamate issue? Did you doc suggest lamictal or did you?


----------



## sadness (May 9, 2006)

_"The Bad
- I seem to have word-finding difficulties. I keep forgetting what things are called. I almost feel slightly dumber. I dunno. It's really odd."
_

I also found this happening when I started taking Lamictal. Additionally found anecdotal reports on the web confirming it.

Are you still having this issue?


----------



## sadness (May 9, 2006)

Madara Uchiha said:


> And what exactly for do you take lamictal? Do you suspect that you have a glutamate issue? Did you doc suggest lamictal or did you?


I can speak for why my pdoc prescribed it. She said some people get anxiolytic effects from it as well as being a great med for major depression.


----------



## Caedmon (Dec 14, 2003)

@Madara Uchiha I had thyroid tested prior to the thyroid augmentation. I've since discontinued it and replaced with Adderall. One could of course, take both if needed.

I'm due for more labs and actually doing a followup for all my various bloodwork and endocrine thingies in a couple of weeks.

Lamictal is for depression and long term mood stability. It works pretty quietly but I have always done better with it on board. A possible analogy: it's like having a nice wide shoulder off to the side of the road. If you have to swerve the car or lose traction on a bad bit of road, you are more likely to be able to recover instead of crash.
@sadness
No word finding issues anymore! I was on too much caffeine at the time. I hadn't reduced it proportionally with the Adderall. Once I reduced my caffeine intake, the word finding problems resolved themselves.

The combination Parnate/stimulant (amphetamine, methylphenidate, bupropion, modafinil...) has been very well tolerated. I have few if any side effects. I cannot recommend it enough. (In some cases Parnate/ TCA is a fine alternative for people who are too amped up on any of these stimulants).


----------



## sadness (May 9, 2006)

^ more on Lamictal. It does seem like a quiet drug. But I know it does something because it completely destroyed my twice weekly migraines. Still works 10 months later too!

I can't wait to try out Nardil at the end of this month! I really have high hopes that an MAOI will help me with SA. Probably won't be a long term cure, but hopefully it'll allow me to do some CBT/exposure therapy.

Actually... now that I think about it... If I'm *not* anxious talking to people while I'm on Nardil, how would CBT help? Wouldn't I be free of negative self talk?

Hmm.. now I'm confused how medication and CBT work together.


----------



## Caedmon (Dec 14, 2003)

Update... Tried Rozerem last night. Best quality sleep in a long time! I have to admit I was not expecting that. Far more pleasant than melatonin, worked quickly and well.

Unfortunately, I still want to sleep, can't seem to quite wake up. I am freaking tired. I bet there is an interaction keeping it from clearing quickly since it "isn't supposed to" cause hangover but I sure feel like post surgery. In a weirdly good way- kinda just chilled out and buzzed. But I have chores to do and stuff, and this is not helping.

There is no way I can try this again tonight, I would be a mess at work. Maybe next weekend can try half the dose. Need to see if the pills can be split.

http://www.rxlist.com/rozerem-drug/clinical-pharmacology.htm :


> Pharmacokinetics
> 
> The pharmacokinetic profile of ROZEREM (ramelteon) has been evaluated in healthy subjects as well as in subjects with hepatic or renal impairment. When administered orally to humans in doses ranging from 4 to 64 mg, ramelteon undergoes rapid, high first-pass metabolism, and exhibits linear pharmacokinetics. Maximal serum concentration (Cmax) and area under the concentration-time curve (AUC) data show substantial intersubject variability, consistent with the high first-pass effect; the coefficient of variation for these values is approximately 100%. Several metabolites have been identified in human serum and urine.
> 
> ...


I'll see if the wife will take me to get some drive-thru coffee. This is mainly an excuse for a peppermint mocha.


----------



## Iwillovercomeanxiety1 (Aug 23, 2010)

I've been on Nardil for close to 6 months. It has not given me the results I desired. It has worked ok overall, but was no better for me than Zoloft. I am thinking about switching back to Zoloft in a month or so. 

Should I try Parnate first? I just don't want to have to give another medication a whole 6 month trial again. How long would it take for me to know if Parnate works for me or not, after switching over from Nardil?


----------



## Madara Uchiha (Oct 11, 2014)

Lamictal is interesting but it has a lot of dangerous side effects. It's not comparable to drugs like ssris. I dont know if I would dare to try something like this. Lyrica was already damn scary. :/


----------



## Caedmon (Dec 14, 2003)

Iwillovercomeanxiety1 said:


> I've been on Nardil for close to 6 months. It has not given me the results I desired. It has worked ok overall, but was no better for me than Zoloft. I am thinking about switching back to Zoloft in a month or so.
> 
> Should I try Parnate first? I just don't want to have to give another medication a whole 6 month trial again. How long would it take for me to know if Parnate works for me or not, after switching over from Nardil?


Definitely worth trying Parnate next. No reason to switch med classes without trying them both first!


----------



## Caedmon (Dec 14, 2003)

Madara Uchiha said:


> Lamictal is interesting but it has a lot of dangerous side effects. It's not comparable to drugs like ssris. I dont know if I would dare to try something like this. Lyrica was already damn scary.


Dangerous side effects?


----------



## Iwillovercomeanxiety1 (Aug 23, 2010)

Caedmon said:


> Definitely worth trying Parnate next. No reason to switch med classes without trying them both first!


Cool, how long should I give Parnate?

And I didn't have to worry about my diet on Nardil. Will I have to worry about my diet on Parnate? Is the diet more strict?


----------



## Caedmon (Dec 14, 2003)

Usually 2-3 of weeks for depression, couple of months for anxiety. This is assuming the dose is appropriate. I could be wrong about the timeline since this is just from memory. Even though you're coming over from another MAO inhibitor, it'd be hard to predict if that speeds up anything. 

Diet is just the same! Parnate is sometimes associated with a (non-dangerous) acute rise in blood pressure ~2 hours after a dose, in some people (especially if you're new to it). But this is independent of the tyramine reaction.

Whatever you do - I wish you good luck!


----------



## Iwillovercomeanxiety1 (Aug 23, 2010)

Caedmon said:


> Definitely worth trying Parnate next. No reason to switch med classes without trying them both first!


Should I be concerned at all about hair loss on Parnate? I'm on Propecia and don't want to lose any more hair, but saw hair loss as a possible effect of Parnate. How likely is it to cause hair loss and how soon would I know if it is causing it?


----------



## infinityplusone (Jun 5, 2011)

jim_morrison said:


> I'm on Parnate along with 72mg of Concerta (aswell as Saphris and Lamictal). My blood pressure is pretty normal so far, slightly on the low side with some mild tachycardia. I don't get any tiredness unless I take my second dose of lamictal too early.


I've just started on Lamictal, adding it to Parnate and Saphris. Hopefully I get some energy back. I was way too tired on Parnate and Saphris alone.


----------



## sadness (May 9, 2006)

infinityplusone said:


> I've just started on Lamictal, adding it to Parnate and Saphris. Hopefully I get some energy back. I was way too tired on Parnate and Saphris alone.


what dosage you starting at?


----------



## infinityplusone (Jun 5, 2011)

sadness said:


> what dosage you starting at?


Started Lamictal yesterday at 50mg, going up every few days in 50mg increments. Aiming for between 150mg and 200mg, as that's what's worked in the past. I haven't tried it in combination with Parnate or Saphris before.


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## jim_morrison (Aug 17, 2008)

infinityplusone said:


> I've just started on Lamictal, adding it to Parnate and Saphris. Hopefully I get some energy back. I was way too tired on Parnate and Saphris alone.


Hope it helps, Lamictal can supposedly be stimulating for some though I'd suspect most of the stimulation from my combo comes from Concerta. Can't say I'm tired or lethargic, and that's something I'd battled for years prior to this combo, so I'm happy. Your doctor may be more comfortable with a low dose of Ritalin if appropriate. Good luck!


----------



## infinityplusone (Jun 5, 2011)

jim_morrison said:


> Hope it helps, Lamictal can supposedly be stimulating for some though I'd suspect most of the stimulation from my combo comes from Concerta. Can't say I'm tired or lethargic, and that's something I'd battled for years prior to this combo, so I'm happy. Your doctor may be more comfortable with a low dose of Ritalin if appropriate. Good luck!


I find Lamictal somewhat stimulating, but will keep Ritalin in mind. Thanks mate.


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## jim_morrison (Aug 17, 2008)

infinityplusone said:


> I find Lamictal somewhat stimulating, but will keep Ritalin in mind. Thanks mate.


No problem, I'm on 15mg of Saphris too actually. Do you think that dose might be responsible for your tiredness vs say 10mg?


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## infinityplusone (Jun 5, 2011)

jim_morrison said:


> No problem, I'm on 15mg of Saphris too actually. Do you think that dose might be responsible for your tiredness vs say 10mg?


I tried Saphris on its own at 10mg a month ago, and found I wasn't as tired during the day, and it reduced some anxiety. I was depressed though, so I definitely need the Parnate.

I've tried Parnate on its own, and I get tired in the morning and can't sleep at night. While on Parnate, I need at least 15mg Saphris in order to sleep at night. Without Parnate, 10mg Saphris is enough to get me to sleep.

I'm up to 150mg Lamictal after 7 days, and I'm not too tired at all. It's early days, but at the moment I'm happy with the Lamictal, Parnate, Saphris combo.


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## jim_morrison (Aug 17, 2008)

infinityplusone said:


> I tried Saphris on its own at 10mg a month ago, and found I wasn't as tired during the day, and it reduced some anxiety. I was depressed though, so I definitely need the Parnate.
> 
> I've tried Parnate on its own, and I get tired in the morning and can't sleep at night. While on Parnate, I need at least 15mg Saphris in order to sleep at night. Without Parnate, 10mg Saphris is enough to get me to sleep.
> 
> I'm up to 150mg Lamictal after 7 days, and I'm not too tired at all. It's early days, but at the moment I'm happy with the Lamictal, Parnate, Saphris combo.


I can definitely attest to the combo of Parnate (lows) and Saphris (stabilisation) being good for BP II. Saphris and Lamictal alone weren't covering the depressive aspects for me either.

That's the other brilliance of saphris really, it enables me to sleep at night and has done so consistently since I started taking it about 6 months ago.


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## Caedmon (Dec 14, 2003)

*11.21.2014*

Been going through a lot of personal stuff. Also trying to move away from "meds are the answer to everything" mindset. They're not. I/we have to know how to be calm, to think well, to navigate our worlds, to communicate.

I noticed a new slew of youngin's on Nardil that they probably bought online and will take for about 8 months before giving up. *Old man head-shaking* They never learn.

I'm now on 20 mg Adderall, trying to taper down where I can to avoid tolerance and dependence.

Topamax works. Lost 5 pounds.

Okay that's all!


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## Caedmon (Dec 14, 2003)

*02.03.2015*

Lots happened since last post, some of it not good. Updates:


Topamax didn't work out. It pretty much wiped out any benefit from Adderall and even induced mood swings. It was anxiolytic at first, then nothing really. So I am now off of that.
My grandmother died. 
My mom was diagnosed with cancer. 
I have a new coworker who is a bully and completely toxic.
Blehhhh.

Grief is normal, a lot of my feelings are normal for everyone, my fear of course is a continued low mood/raised anxiety and relapse. So I am on diazepam for the time being so that I can better handle the work stresses and get to sleep. Honestly, it's been a godsend. I'm not as chipper as I was several months ago, but I am on the upswing and I think I will recover. Still stressed about Mom though.

---

I've been doing the *Mind Over Mood* cognitive therapy program. (Dennis Greenberger et al. Look on Amazon.)
Been a long time since I really invested significant energy into it. I have a number of resources and workbooks, but particularly like this book for CBT related to depression or depression comorbid with anxiety. It emphasizes "balanced thinking" and doesn't feel as intellectually dismissive or Pollyanna as a lot of CBT programs. The text is a little dated but the principles are sound.

I have gotten 10x as much out of this book as I did from my last therapist who was merely "reflective" and seemed to want to just jump from week to week. I think most community counselors are pretty replaceable if you have the cognitive capacity and dedication to do a workbook.

I could not do this program in a severe depressive state. I think you have to have a certain degree of motivation and cognitive capacity. A little desperation helps too, of course. But there could come a point where you want to give up because the thought records are thorough and take time, and I think I would have given up if I had tried this program a year ago. Now... I can do it and feel good about it.

---

So... current meds (daily total):

Parnate 70 mg 
Lamictal 300 mg
Adderall 25 mg
diazepam 10 mg
caffeine 300 mg
OTC: 

multivitamin
NAC 600 mg
Magnesium citrate 500mg
B-complex from "Seeking Health" (really good one)
vitamin D 2000 IU
B. infantis probiotics "Align". 
Keep trying to get back into fish oil but I constantly forget.
Also aerobics from wood splitting the logs from some trees I cut down along the back of the property. Wood splitting is the absolute BOMB for exercise. There is nothing as satisfying slamming the axe down and hearing that *crack* and seeing it just split. It's even better on big logs that take several thwacks. You really earn it. Too bad these trees were infected and gross (which is why I cut them down) they have rot in the center that I can't use, but the outer 1/2 is usable and should be fine.


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## Learydp01 (May 2, 2013)

watertouch said:


> The "triple reuptakeinhibitors" is probably the next "big thing" Viibryd
> is already aproved by FDA
> http://en.wikipedia.org/wiki/Vilazodone
> 
> ...


Viibryd is not a triple reuptakeihibitor... it's more similar to an SSRI. And I can tell you from personally being on it myself, it also feels very similar to other SSRI's that I've been on.


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## Caedmon (Dec 14, 2003)

*02.09.2015*

I bought a "fitbit" to track my sleep. I will try to post some results after i have used it a while. I would like to get my sleep more regular. I don't like wearing it during the day for tracking steps but it is nice for the sleep thing. I should have bought the one that doubles as a watch! It looks cool.

I have a cold, so not on stimulants while i recover from that. Good chance to rest.


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## butterz (Aug 8, 2013)

@ caed

Are you being treated by an ordinary pdoc or a specialist? I really wonder how many pdocs would dare to mix parnate and adderall. 

I also wonder did your doc talk to you about dangerous complications like serotonin syndrome and how to recognize it and what to do if it happened?

And how much Lamictal do you take?
Do you get any noticable side effects? I asked my pdoc about lamictal for depression and he said it had too many side effects. :blank
I wonder if I should try this out, when regular antidepressants simply don't work, or if Lamictal only makes sense combined with other meds.


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## Caedmon (Dec 14, 2003)

I don't get any side effects from Lamictal that I'm aware of. 300 mg. I had sore muscles and tension the first month I took it.

There is virtually no risk of serotonin syndrome from adding amphetamine because it has such low affinity for serotonin that it is clinically meaningless at normal doses. Someone prone to substance abuse could get into trouble, that is true, but I have not had that problem. I just have a regular pdoc but he is open minded and has been open to my carefully-worded input.

(I make sure and make life easy on him, I give him all kinds of resources and self assessments, citations supporting the drug combination, etc, blood pressure readings... so if he were to get audited he would have a rock solid footing.)

I have never once, ever said the words "Can I try taking XXXX". I always put it indirectly so that it's his idea. "What do you think about XXXXX" so that I'm _sharing ideas_, not requesting per se. That's a magic phrase. Even so, it took a year and a half of insufficient augmentation trials and a psychiatric referral.

I LOVE getting my blood pressure checked when I go to a general practitioner. I like to ask the nurse what it is. "115 over 70". Yup. Put that in the notes, honey.


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## butterz (Aug 8, 2013)

Do you feel the Lamictal? I mean can you clearly tell that it makes a difference in how you feel? If yes, how would you describe its effect?
Does it make you less depressed or does it prevent strong depression or what exactly does it do?

There are warnings about amphetamines mixed with ssri causing serotonin syndrome. There also seem to be cases where people got a serotonin syndrome on therapeutic doses of ssri and amphetamines. This is scary.
Amphetamines seem to also release some serotonin.

What do you do if you want to try a med and ask your doc what he thinks about it and he says that he doesn't like it or made bad experiences with it? What do you say then?


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## UltraShy (Nov 8, 2003)

butterz said:


> *There are warnings* about amphetamines mixed with ssri causing serotonin syndrome. There also seem to be cases where people got a serotonin syndrome on therapeutic doses of ssri and amphetamines. *This is scary.*
> Amphetamines seem to also release some serotonin.


1) Every med comes with seemingly endless warnings about things that are exceedingly unlikely. If one were to take them seriously, they'd be too afraid to take any medication. I take 81mg of aspirin daily, even though aspirin (or any other NSAID) could result in death by gastrointestinal bleeding. Not gonna happen on 81mg though. A stunning number of meds have *DEATH* as a potential side effect.

2) Your many posts provide abundant evidence that you're a hypochondriac, so I'm not surprised that you're scared by even the most remote risks.

3) Serotonin syndrome is so highly unlikely that after 15 years of regularly reading med forums I have never yet come across a single case where it actually happened.


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## UltraShy (Nov 8, 2003)

Caedmon said:


> So... current meds (daily total):
> 
> Parnate 70 mg
> Lamictal 300 mg
> ...


You dare to mix caffeine with an MAOI, a suicidal act! You're supposed to be just as dead as I am, seeing how I too munch on caffeine pills.

I never heard of NAC before and had to look it up. What do you take it for?

Can I assume the magnesium is an attempt to avoid amphetamine tolerance?

I take a multivitamin daily in addition to 1gram of Lovaza (fancy prescription fish oil). That's just for general health and the fish oil for cardiovascular health. I don't expect any mental benefits from it. I've been taking fish oil daily for quite a few years, evidently having a better memory than you.



> Also aerobics from wood splitting the logs from some trees I cut down along the back of the property. Wood splitting is the absolute BOMB for exercise. There is nothing as satisfying slamming the axe down and hearing that *crack* and seeing it just split. It's even better on big logs that take several thwacks. You really earn it. Too bad these trees were infected and gross (which is why I cut them down) they have rot in the center that I can't use, but the outer 1/2 is usable and should be fine.


Sounds like an excellent work out program. My exercise program used to consist of daily walks for a hour. I gave that up due to a total lack of motivation. Now merely getting my a** out of bed is a monumental chore.


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## butterz (Aug 8, 2013)

@ ultra

Even drugs.com says amphetamines + ssri has a strong interaction risk cause of serotonin syndrome. Then why am I a hypochondriac for being scared?


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## Caedmon (Dec 14, 2003)

@UltraShy 
The NAC (n-acetylcysteine) was started for hair pulling, and it helped a little bit, but have kept it on because of potential health benefits and no real downside. In fact it is probably a better medication for amphetamine tolerance than magnesium, or a lot of other little hoops people jump through. Granted, Lamictal and Parnate are probably more neuroprotective than NAC.

Magnesium I started in an effort to keep gastric motility going. Ever since cutting back on caffeine I have been more constipated. I'm basically down to 1 caffeine pill per day (or equivalent caffeine via delicious beverages). I 'hear that' magnesium is good for relaxation and possibly alkilinity of stomach acid when taking amphetamines so I've just kept it on board.
@butterz if a doctor turns down my idea for a medication then I just listen and try what they suggest. Who knows, maybe it will work? I don't know everything. And I am building a positive relationship that respects their position, and where I can try asking again. If their idea fails then it's just another reason to try whatever I had in mind.

I can ask directly and they could still say no. My thinking is that docs - who have their own egos and agendas - will be more likely to go with something if they think it's their idea. You gotta realize I follow up my "idea" with solid peer-reviewed (or respectable) sources. So I share "something I've heard about" and then hand them printouts - abstracts/articles, clinical texts, etc - which does the arguing for me.

The doc needs to weigh pros and cons quickly. When the well-reknowned Stahl is telling them directly, "you can augment with stiiiiiiimulants" and I've let them know that they will get to claim credit for success, I'm basically being manipulative.

Yeah s/he might still say no but I get farther this way, usually. If you have the kind of doctor to whom you can just outright ask for your pills, well then I suppose you should just ask!

-----------

I haven't gotten to the wood piles for a few days. I have a cold and sinus headaches. So I've stayed in bed and rested for the most part. I find that high doses of guaifenisen and nasal irrigation helpful for nasal congestion. Oxymetazoline (Afrin), sparingly, if it's real bad. Stick sucks though.


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## Caedmon (Dec 14, 2003)

butterz said:


> Even drugs.com says amphetamines + ssri has a strong interaction risk cause of serotonin syndrome. Then why am I a hypochondriac for being scared?


I guess what you do, butterz, is this: don't take an amphetamine med with ssris or maois. Then you don't have to be scared.

As for me, I'm pretty okay with it. Gonna take a red pill AND a blue pill now. 









+








=


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## butterz (Aug 8, 2013)

Yes having something printed out like a study or a paper from a book is always helpful. This makes the doc feel more secure in prescribing the drug.

What drug is the blue pill? I thought adderall was a capsule.


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## Caedmon (Dec 14, 2003)

*05.12.2015*

Parnate - 60 mg
Adderall - 25 mg (10mg on weekends)
Lamictal - 300mg
diazepam - 2.5 mg

Currently tapering off diazepam from 10mg, now down to small amount nightly.

No real issues right now. Things are good.

I'm doing a lot of cognitive therapy and studying it quite a lot. Both consumer-level books as well as published research, professional-level literature, books aimed at clinicians, etc. It's incredibly interesting and informative. There are a lot of very smart people on the medication forum who I think would enjoy learning about psychology involved in the various anxiety and depressive disorders.

Cognitive reappraisal is a skill everyone should learn and become proficient in. It is vital to staying resilient, and overcoming depression & anxiety over the long term.


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## butterz (Aug 8, 2013)

Maybe you can share some of your insights here, caedmon.


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## Caedmon (Dec 14, 2003)

About psychological processes? Yeah guess I could. It's not directly medication-related. Hmm I'll think on it. 

Several good starting points:
Clark & Wells' cognitive model of SA
Heimberg's cognitive model of SA
Abramson 'hopelessness depression' model
Papageorgieu (?) & Wells, depressive rumination research

Good stuff.


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## butterz (Aug 8, 2013)

What is Abramson 'hopelessness depression' model all about?
Can you explain this in short? Does this offer solutions?


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## watertouch (Nov 4, 2013)

butterz said:


> What is Abramson 'hopelessness depression' model all about?
> Can you explain this in short? Does this offer solutions?


Now i know you didn't ask me but still... 
Its more of a pessimistic thoughts of the outcome or results. "nothing helps, or gonna work".

http://www.researchgate.net/profile...Depression/links/0912f5093efa5ed577000000.pdf


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## Caedmon (Dec 14, 2003)

Yep it is a conceptualization of depression and includes significant psychomotor slowness, anhedonia, fatigue, lack of motivation, etc. the "low dopamine" kind. Attributional styles that are involved. Big name attached to this model is Lyn Abramson.

It complements the medical models of melancholic symptoms by analyzing the contributory thought processes and attributional styles. 

"I'll never finish this project" --> why bother? (Low motivation)
"i feel awful and depressed" --> patient constantly focuses on how bad he/she feels --> self-perpetuating rumination cycle -–> lay in bed all day & poor cognitive functioning
"Nothing works for my depression" --> no initiation of mood-improving activities
"I'm a failure, stupid, can't do it" --> why try? Withdrawal and fatigue

It is worth learning what your attributional styles are and how to do cognitive reappraisals, and healthy techniques for breaking out of rumination cycles. I hope that makes sense :lol


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## Caedmon (Dec 14, 2003)

*05.29.2015
*
Just back from the doctor's. I have a new doctor. I was INCREDIBLY nervous because all I knew was that I had heard she does not like benzos. I am going off diazepam but couldn't help worrying what it would mean for my other meds.

It went just fine! She thought I had a diagnosis of ADD (my old doc had put that down). She asked me some questions to verify if I had it. I wasn't sure how to answer them (do I play along to get the meds? do I face up to the fact that it's off-label for depression?). I just answered as best I could.

My main point was to go in and say "don't mess with my meds". And since it's the same clinic and everything, and I reported no depression, no reason to change things. I continue to work on mild or mild-moderate social anxiety (depends on the situation) through CBT. I don't feel that I need any additional meds for that because I need to change my thinking styles and deeply-seeded beliefs about myself and the world.

Anyway she wanted to switch to extended release (understandable) and preferred Vyvanse, but I need to check my insurance to see if that's covered. So I got a Rx for 30 mg of the Adderall XR instead, while I check. If she is worried about stimulants off label, I'm sure that Vyvanse is friendlier since it has indication for binge eating disorder (which I do confidently have). I'm fine with trying any of these variations since i think they will all probably work just fine for me.

Yay!

She didn't say anything with diazepam, got refilled for that at 10mg/day (I didn't bring up the titration... don't worry, I will!)

I am on Rozerem (ramelteon) for sleep too and will report on that later. It regulates circadian rhythms so it sometimes takes a week or two to get the brain going. I can affirm it provides very high quality sleep though. Very restful.

The meds I am now taking are:
Parnate 60mg
Lamictal 300 mg
Adderall XR 30 mg
Rozerem 8 mg
Diazepam 2.5 mg


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## butterz (Aug 8, 2013)

If adderall helps you who cares if you have adhd or not? I'd simply say that I have it.

What's lamictal doing for you? Can you identify if it really makes a difference?


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## Caedmon (Dec 14, 2003)

I walked in with a typed, bulleted list of medications, events, health-questionnaire results, blood pressure readings, and graphs of medication results from the past 18 months. I also gave her a research paper with 19 references, specifically advocating augmentation of an MAOI for depression. I sat calmly in my chair and answered questions thoughtfully and well. I didn't really scream "attention deficit disorder".

In a somewhat concerned and even nervous voice she said that the old doctor "was a really good counselor... but he diagnosed adult ADHD quite a lot and used doses far above PDR recommendations") (Damn, I missed the boat! haha.) 

It's better in the long run to have a good relationship. It would have felt silly and insulting to suddenly fake that I have hardcore ADHD in order to get amphetamine. So I went with the Jesus route: "thou sayest". (In other words, "I don't know how you want to handle this, but that's what he diagnosed me with, so... you know, it's in my chart and stuff, and it's not a super high dose or anything".) I made it clear from the onset that the purpose of it was for residual depressive symptoms, no reason to change my tune.


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## Nibs (Jun 28, 2014)

I think a congrats is in order! haha

My current pdoc is so focused on my anxiety that she won't even consider anything stimulating. Gahh....not sure if i should push it or wait it out....or simply find a new doc. I've only had 2 appointments with her and she didn't even ask for a follow up appointment; she just said call if you have any issues. This worries me, because I want to try provigil or nuvigil yet I don't know how to approach her and tell her I need stimulation. 

Should I just schedule an appointment with her? And what should I say?


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## Caedmon (Dec 14, 2003)

Yeah just schedule an appointment. Not sure what you'd say because it depends on if anxiety is fairly well treated or not, and if you have established that idea with her or if you're still evaluating a bit. If it is working well but there are residual depressive symptoms that cluster around psychomotor retardation, fatigue, sleepiness etc then you are more likely to have a shot at a complimenting NDRI or NRI.


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## watertouch (Nov 4, 2013)

Nibs said:


> My current pdoc is so focused on my anxiety that she won't even consider anything stimulating. Gahh....not sure if i should push it or wait it out....or simply find a new doc. I've only had 2 appointments with her and she didn't even ask for a follow up appointment; she just said call if you have any issues. This worries me, because I want to try provigil or nuvigil yet I don't know how to approach her and tell her I need stimulation.
> 
> Should I just schedule an appointment with her? And what should I say?


Its a somewhat different AMPH from say Methylphenidate or Modafinil... But then of course once doc could go "who doesn't feel better on stimulants"

If your on an MAOI- Complain about the afternoon fatiuge! and that you tried coffee (not caffeine pills):wink2:


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## Nibs (Jun 28, 2014)

watertouch said:


> Its a somewhat different AMPH from say Methylphenidate or Modafinil... But then of course once doc could go "who doesn't feel better on stimulants"
> 
> If your on an MAOI- Complain about the afternoon fatiuge! and that you tried coffee (not caffeine pills):wink2:


The afternoon fatigue has long since disappeared.....I just have no motivation to get off the couch. Literally zero.


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## watertouch (Nov 4, 2013)

Nibs said:


> The afternoon fatigue has long since disappeared.....I just have no motivation to get off the couch. Literally zero.


Yeah i know of that feeling... :frown2:
Have you tried Modafinil? Before?, that is?... Otherwise i think this forum is, well i joined itbecause i was looking for info on MAOI and experience from other users... I was on MAOI-Parnate.

I think it would not be that far fetched to say you are on a forum with people that also use MAOI, and have tried the combo and it worked well with non to little increase in BP...

Il PM you!.


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## Nibs (Jun 28, 2014)

watertouch said:


> Yeah i know of that feeling... :frown2:
> Have you tried Modafinil? Before?, that is?... Otherwise i think this forum is, well i joined itbecause i was looking for info on MAOI and experience from other users... I was on MAOI-Parnate.
> 
> I think it would not be that far fetched to say you are on a forum with people that also use MAOI, and have tried the combo and it worked well with non to little increase in BP...
> ...


Nope never tried modafinil. Yeah, I mainly hang out here in the meds section because of the awesome amount of MAOI info/users. I don't think any other site on the net has this many MAOI users lol.

Looking forward to the PM!


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## Caedmon (Dec 14, 2003)

*06.09.2015
*

Have spent some time trying Parnate & Lamictal with the XR version of Adderall (15 mg capsules).

I find Adderall XR highly preferable to the IR version. It works just as well with a smoother feeling. The doctor recommended 15mg at waking and 15mg around 9am or so. My official script is for 30mg XR, but I generally take less. I'm finding that a total of 30 is too much, but 15mg disappears a little early in the day. 15mg XR when waking (at 6:00am) and then 5mg IR ~4:00pm, seems fairly well balanced. I think if I were to continue the XR version I would ask for 20mg and just take it once in the AM. (Or try this anyway.)

I prefer not to "think about" the blue Addy pills throughout the day. Thinking about it more often, and getting a faster onset, causes more associated salience than I would like. I can sense a little whisper of drug-mediated dopamine increase on the IR version. I think that risks addiction more. The brain is more likely to tag the substance with a sense of relief and normality, and hence craving. I haven't had any real problems with this, and Parnate has been like that for almost a decade. I can "feel" Parnate kick in (and I greatly prefer that feeling to Adderall!) but I've been able to manipulate the dose or quit altogether without craving. BUT I would prefer to avoid anything that might "tag" the blue Addy's with craving and salience.

I still plan on asking to try Vyvanse at the next appointment however. That it metabolizes only to dextroamphetamine, and slowly, is appealing to me. My insurance will cover Vyvanse if they have prior authorization. But certainly the XR version of Adderall is an improvement as well.


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## sadness (May 9, 2006)

Nibs said:


> The afternoon fatigue has long since disappeared.....I just have no motivation to get off the couch. Literally zero.


Same here. I have no motivation to find a job. Ugh.

I used to be on adderall withOUT nardil, and it definitely motivated me to get **** done. i might see if i can try out modafinil also. My doc wont prescribe anything contraindicated for sure. He hadn't ever even heard of Nardil.


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## butterz (Aug 8, 2013)

Caed, since you take so many different drugs can you tell if lamictal makes any difference if yes what difference?
I don't really know what to try next and since my doc makes no suggestions it's all up to me.


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## Learydp01 (May 2, 2013)

I am only on Lamictal at the moment. It definitely helps, although it's extremely subtle and not even close to a solution. It lessons my anhedonia and slightly increases my social energy. At the very least, at least for me, it's better than SSRI's, benzos and antipsychotics. Lyrica is a similar medication to Lamictal: another option you can float with a doctor


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## Caedmon (Dec 14, 2003)

Yeah Lamictal is great; it is less sexy because there are no variations in dose or timing. And while monkeys will self administer Parnate and amphetamine they could care less abut lamotrigine. Like leary's experience i get a boost in motivation and mood, not gonna sing on the rooftops but it helps, and long term lamotrigine has significant neuroprotective qualities. with no cyp interactions and no side effects i just keep it on board and let it roll along.


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## butterz (Aug 8, 2013)

How is lamictal neuroprotective? Is it because of glutamate?

I'd like to try it but what worries me a bit it SJS and I also read that it builds up in the retina and it's not known if this is safe on the long run. What if it damages the eyes?


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## Learydp01 (May 2, 2013)

SJS is rare and if you are looking for it, the worst that will happen to you is having a mild, itchy rash and you'll know to stop the medication. If you don't notice the rash early, it might get spotty and painful, but it will heal like a normal rash when you stop the medication and you'll be fine.

As for retinal damage:



> Dear Becky --
> 
> This concern has been raised before, I have always had difficulty finding the references on which it is based. So I looked again today.
> 
> ...


http://www.bipolarworld.net/Phelps/ph_2008/ph1721.htm


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## Caedmon (Dec 14, 2003)

butterz said:


> How is lamictal neuroprotective? Is it because of glutamate?
> 
> I'd like to try it but what worries me a bit it SJS and I also read that it builds up in the retina and it's not known if this is safe on the long run. What if it damages the eyes?


Yes, it reduces glutamate release, and excess glutamate is not good.

It is neuroprotective of dopamine for example: http://www.ncbi.nlm.nih.gov/pubmed/19789969

It decreases stress response (cortisol). http://www.ncbi.nlm.nih.gov/pubmed/...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

It might have other mechanisms that i dont recall.

A good option OTC is n-acetylcysteine. I actually take both.


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## butterz (Aug 8, 2013)

I take NAC sometimes but it doesn't seem to make me feel any better.

I'd really like to try lamictal. I hope next time my doc will agree. 
But I wouldn't want to go very high on it. I'd not want to go higher than maybe 150mg. I read stuff where people said they cannot get off it anymore or they become suicidal. I also worry how healthy it is to take lamictal. I mean who knows what this stuff does in the body and what side effects it could cause.


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## Nibs (Jun 28, 2014)

sadness said:


> Same here. I have no motivation to find a job. Ugh.
> 
> I used to be on adderall withOUT nardil, and it definitely motivated me to get **** done. i might see if i can try out modafinil also. My doc wont prescribe anything contraindicated for sure. He hadn't ever even heard of Nardil.


Looks like were in the same boat! No job here too :clap


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## Learydp01 (May 2, 2013)

butterz said:


> I take NAC sometimes but it doesn't seem to make me feel any better.
> 
> I'd really like to try lamictal. I hope next time my doc will agree.
> But I wouldn't want to go very high on it. I'd not want to go higher than maybe 150mg. I read stuff where people said they cannot get off it anymore or they become suicidal. I also worry how healthy it is to take lamictal. I mean who knows what this stuff does in the body and what side effects it could cause.


SSRI's often cause people to get stuck on them or have suicidal thoughts, and you seem to be fine on those, no?

As for not knowing what it does in your body, this is a problem with pretty much every medication that currently exists, and I don't think Lamictal is any worse than SSRI's in this regard.

Another thing that might be particularly good in your case is that Lamictal does not cause brain zaps.


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## butterz (Aug 8, 2013)

But getting off lamictal also seems to be not that easy at least I read stuff where people said they cannot get off it or they become suicidal when they lower the dose.
This sounds scary.


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## Caedmon (Dec 14, 2003)

*07.02.2015*

I found that 15mg Adderall XR per day and 5 mg IR in the afternoon was a good option.

Still on the same Parnate dose, 60mg/day.
Still Lamictal, 300mg
Rozerem 8 mg (seems to be less effective lately?)

Wierd - but lately I have tried trazodone again - 25 mg - and it is less yucky and quite nice. Perhaps it's some a1 antagonism reducing agitation? I will have to keep an eye out.

----

But at last appointment, last Friday, I'm now trying Vyvanse (my idea). I'm very happy with Adderall, and the idea to try Vyvanse was my own. I requested it due to the pharmacokinetic advantages (long acting, slow onset, only metabolizes to dextroamphetamine, no CYP 2D6 interactions). And the fact that doctors perceive it as less abusable.

She put me on 40mg to start with which is about 15 mg Addy.
Definitely not as strong. I slept a ton and could tell it was less active; it'll definitely have to be a higher dose.

However, I have a big family get-together for 5 days at my house next week. We're fitting 10 people in our house. Right now just trying to clean and get ready. I'm not sure I can afford to jostle meds right now so I'm going to go back to Adderall for two weeks and then try the Vyvanse again afterwards, for a more thorough trial.


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## Madara Uchiha (Oct 11, 2014)

Caedmon are you sure that d-amph does not use 2D6? Do you have proof for that?
I only know that prozac and adderall should not be taken together because of 2D6.
I assumed that this also goes for d-amph.


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## Caedmon (Dec 14, 2003)

Yes you're right, good call - I think any amphetamine is a substrate for 2D6. So I'm not sure now about my previous statement. This would mean other meds that are 2D6 inhibitors might prevent dextroamphetamine from breaking down properly and increase/prolong the action.

The PI sheet says that lisdexamfetamine is *not *metabolized via CYP enzymes... For example:

_Lisdexamfetamine is not metabolized by CYP isoenzymes.1 In vitro studies suggest only minor inhibition of CYP isoenzymes 1A2, 2D6, and 3A4 by amphetamine and/or its metabolites_
-http://www.drugs.com/monograph/vyvanse.html

Which is what i was basing it on.

*But *it is a prodrug which is converted to dextroamphetamine... so I don't know what any of this means. I understood that lisdexamfetamine is not psychologically active until converted from blood cells which then becomes lysine + dextroamphetamine. I'm not sure how it works or what biological pathway it takes besides that. I guess I should ask my pharmacist or something. Any ideas?

Oh... thought of something... maybe the parent drug is not metabolized via 2D6 (because it is converted by red blood cells) but the metabolite is???


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## jim_morrison (Aug 17, 2008)

Caedmon said:


> Oh... thought of something... maybe the parent drug is not metabolized via 2D6 (because it is converted by red blood cells) but the metabolite is???


Yes, I think this is the case.


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## Caedmon (Dec 14, 2003)

*07.22.2015*

Recent meds have been: 
-Parnate 60mg
-Lamictal 300mg
-Vyvanse 40mg (this was my new change)
-Trazodone 25mg (for sleep)

So I can report on the Vyvanse. This has taken me a while to get a handle on.

BTW, this is the conversion rate to Adderall - took a long time to find!
_*30 mg Vyvanse = 11.8 mg Adderall. _

PROS:
The onset and offset are smooth as butter, and much less peripheral stimulation vs Adderall (which could sometimes cause headaches and tense muscles). I can't "feel" a point at which Vyvanse kicks in, or stops, which is beautiful, and don't notice a crash. It just hums in the background. These benefits seem to exist even at higher doses (see below).

CONS:
The Vyvanse dose is a bit lower than the equivalent I had been taking of Adderall. And indeed this felt to be the case. Small increase in psychomotor retardation. Not HUGE changes but noticeable.

One other issue is the onset is so gradual, and given the lower equivalent dose, means it doesn't seem to provide benefit for several hours. I take Vyvanse the moment my alarm clock goes off at 6:30AM but I don't see a functional improvement until about 10:00 or so.

RESULTS:
I tried 20mg (does very little) 
40mg (comes up short in the AM but helpful mid-day onward) 
60mg (seems too high, leaves some evening agitation)
So I suspect *50* mg is the sweet spot. I believe you can open the capsules and sprinkle into food - useful for kids who have ADHD - and it does not affect pharmacokinetics. So I will probably try 50mg starting tomorrow.

I just took my blood pressure to write down for my doc, it is 106/67. There ya go.

-----------

I am enrolled in *AI-Therapy.com* - https://www.ai-therapy.com/ - which is online CBT for social anxiety. I really wanted to address lingering core beliefs that often re-emerge when I'm not expecting it. CBT is a good innoculator to med poop-out too. No downside!

My initial-impressions review here: http://www.socialanxietysupport.com/forum/f43/ai-therapy-1473250/#post1081223042


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## watertouch (Nov 4, 2013)

^ I think read somewhere that you posted about the Dopamine "raise" and after that it falls... 
Tried to justify that with why my Vyvanse only worked for like 6hours, and not 14 like the leaflet/tamplet said. 
*I got the "Tired but wired" effect.*

For me Vyvanse it starts "working" about 1 hour-2... Probably some "placebo" to it...

Max concentrations of "lisdexa" 1hour, 
max concentration of D-AMPH 3.5hours...

The Enzymes you mentioned, yes AMPH, effect them minimally! The clinical relevence for interactions are also probably minimal! (u probably know this, i just... input from what ive read) 

Also i have written down in my "to check list", if "Funlight" effect the Vyvanse (it's a beverege one mix with water) 
It has Aspartame in it, but it also i meassured with PH-sticks has a PH of 3, compare to water:7.

But i think that damn "Trypsin" enzyme that is needed to split lisdexa, likes about ph:7...

Also with Vyvanse one could dissolve the capsuel in a "waterbottle"... 
And drink half, and either save the rest for the nextday, or in my case where i felt effect for just a couple of hours, Drink half, in the morning and the other half at lunchtime/early afternoon...

But yeah i do get "peripheral" symtoms from D-AMPH, mostly "stim-penis"... 
But then i also don't take it on a daily basis, and i don't like the whole, 50mg pill=15mg Dexa working for 11-14hours...

Take care Mon!


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## Caedmon (Dec 14, 2003)

*08.23.2015*

Having tried Vyvanse I'm not loving it too much. It seems to cause me to feel tense, rushed, and grumpy. I don't know why, but there it is. I'll go back to Adderall IR or XR. No other medication news. I like trazodone for anxiety and have been trying 2 small doses during the day (AM + afternoon) and 1 large dose at night. This has been a nice augmentation. It is probably from 5ht2a antagonism. I may see about a higher dose, I dunno.


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## Learydp01 (May 2, 2013)

How have you been holding up in terms of the stimulant crash Caedmon? I remember Concerta would make me crash hard into depression towards the end of the day, when the dose began to wear off.


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## Caedmon (Dec 14, 2003)

I don't notice much of a crash. I am back to Adderall but at a lower dose and there isn't much in the way of crashing


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## Caedmon (Dec 14, 2003)

11.20.2015

Well, we had a good run. Adderall seems to make me too anxious lately, and causing mild tachycardia (80-90 bpm resting). So I asked to switch to Wellbutrin. (I took Parnate + Wellbutrin for several years with very good results.) I have been on Wellbutrin for a week and already feel much better.

I don't feel burned out or anhedonic without the Adderall (always a concern after taking stimulants). I do think it was stress-y on my system though. I think the stress is a little hard to see. Sometimes you can "feel" that you need to get sleep, drink water, take a break, or whatever, but you know you can push through it too. So it kind of "covers up" those restorative needs. I think HPA axis activation is something to watch for too.

All in all Adderall worked very well to augment Parnate, for about a year and 2-3 months before ceasing its benefits. It also helped me realize that I do have mild ADHD-PI, in addition to depression; treating the inattention symptoms was very helpful. But, time to rotate back to my old combo! So far so good.

LONG-TERM EXPERIENCE ON COMBO:
Depression: A
Anxiety: variable, B to D
ADHD-PI: A
Fatigue/psychomotor: A-
Tolerance: low-medium
Side effects: medium-high


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## Jkid (Nov 2, 2015)

How did you get Adderall prescribed?
_Posted via Mobile Device_


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## watertouch (Nov 4, 2013)

Interesting im also gonna try Wellbutrin with Parnate now that i hade to lower my dose. Problem is that the ones i got is 300mg XL.

Or maybe one could cut them, in half...Need to research that option better.

I was on that Zyban some years ago, i think they where IR, 
But i think take a "drugfree holiday" from the Parnate the first days, and have some Beta blockers ready...
@Caedmon How did you go about it, augmenting Wellbutrin that is?

Best wishes!!!/Alex


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## versikk (Nov 25, 2013)

So are you on Wellbutrin + Parnate now? Why doesn't Wellbutrin work on its own for you?


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## Caedmon (Dec 14, 2003)

The combination of Parnate + NRI + Lamictal has always been optimal for my depression.

I'm on 150mg Wellbutrin SR to start. After two weeks go to 300 mg.
@watertouch you could try the XL and divide it, it becomes IR but still works. Sharp pill splitter can do it. You could split in fourths and play with the dose.


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## Hotznplotz123 (Nov 15, 2014)

Any update for the Parnate+Wellbutrin combo?

I'm just wondering how the Wellbutrin could be synergic to the effects of Parnate. Wellbutrin hits on noradrenaline but so do other medications (Protriptyline, Atomoxetine, Dibenzepin etc.). When you do some internet research on Wellbutrins supposed dopaminergic actions, you'll find a lot of sources that challenge that assertion, at least when it comes to the normal (oral) intake of the drug.

I took Wellbutrin, Ritalin and Dexedrine on their own (without Parnate). Ritalin and Dexedrine felt quite similar, speaking of the typical stimulant boost. Even after ingesting a sufficient single dose of Parnate I get a nice (though short-lived) dopamine kick. With Wellbutrin alone I felt actually not mutch at all (even after 4 weeks on 300mg). 

Would you say that Wellbutrin+Parnate could produce the similar beneficial effects as Ritalin/Adderall+Parnate?


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## Narparit (Dec 2, 2014)

Yo, what kind of psych you have bro? I mean its actually cool not bad. No doc will risk the maoi+stim combo. They are actually working for you and very powerful and nice combo but again no doc will try that.


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## genisys (Jan 2, 2016)

Parnate + wellbutrin? Is this a safe combo?
My doctor would never ever mess with such a combo at all. Looks like my doc sucks. Wish I had a real "expert".


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## Caedmon (Dec 14, 2003)

@Hotznplotz123 Things are okay. The holidays threw me off, lots of stress with travel across time zones and in-laws and unable to maintain my behavioral treatments (aerobics, light therapy) and crazy sleep schedules every night. Merry Christmas, and glad that's over!

Wellbutrin will be different in nature I think. Less potent or immediately noticeable, but this isn't a bad thing. It is not as stimm-y, will not cause accumulating stress in the same way as a stimulant. I have liked it so far. For many years I had good remission with Parnate, Wellbutrin, Lamictal, and good behavioral strategies (i.e. exercise, sleep cycles). So, it is familiar territory for me. I think the only way to know how Welly and traditional stims differ is to try them, since everyone will have a unique experience.


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## Hotznplotz123 (Nov 15, 2014)

Well, I'm taking Parnate and Wellbutrin together now for more than two weeks and there is absolutely no problem with that. But I don't feel much from the Wellbutrin either. My intension for adding it to the Parnate is that it might help me with motivational issues and fatigue which are still present.

I'm wondering if augmenting Parnate with supplements like gingko biloba and/or Korean red ginseng could also work for that purpose. Anyone with experience around here?

@*Caedmon* Nice to hear back from you. You mentioned that you took the Parnate+Wellbutrin combo also before. Was there a particular reason why you stopped with that regime back then?


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## Caedmon (Dec 14, 2003)

Hotznplotz123 said:


> You mentioned that you took the Parnate+Wellbutrin combo also before. Was there a particular reason why you stopped with that regime back then?


Many years ago I moved, had to transfer docs, and couldn't find a doctor who would go with the combo. I had to choose one or the other so I stuck with Parnate. Eventually the bupropion scripts ran out.

For a couple years I tried all kinds of things to replace it and to stay okay. It just wasn't the same and I went into a persistent mild-moderate depression. To be fair I also went through some awful events and circumstances that kept me down. Anyway got in to a psychiatric practice and did the merry-go-round of various augmentations for a year.

When I brought up re-trying the NRI/NDRI augmentation the pdoc suggested Adderall instead of Wellbutrin. Adderall is awesome. It sure worked for a while, but then felt too stressy, so here I am again on Wellbutrin. The cirrrrcle of liiiiiife.


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## Hotznplotz123 (Nov 15, 2014)

Caedmon said:


> Many years ago I moved, had to transfer docs, and couldn't find a doctor who would go with the combo. I had to choose one or the other so I stuck with Parnate. Eventually the bupropion scripts ran out.
> 
> For a couple years I tried all kinds of things to replace it and to stay okay. It just wasn't the same and I went into a persistent mild-moderate depression. To be fair I also went through some awful events and circumstances that kept me down. Anyway got in to a psychiatric practice and did the merry-go-round of various augmentations for a year.
> 
> When I brought up re-trying the NRI/NDRI augmentation the pdoc suggested Adderall instead of Wellbutrin. Adderall is awesome. It sure worked for a while, but then felt too stressy, so here I am again on Wellbutrin. The cirrrrcle of liiiiiife.


 Ah, okay. An interesting story and also an interesting decision by your current pdoc to go with the Adderall as an augmenting agent .

I can come up with a "circle of life" story on my own. After a first depressive episode during my teenage years I was prescribed Parnate as my first (!) antidepressant (30mg/split over the day). The pdoc back then said that she is absolutely convinced of this medication. But I didn't feel anything from it so I moved on with all the usual suspects in the antidepressant arsenal, ca. 20 medications over the course of seven years, with no sustained success. Then I read a research article about high dose therapy with Parnate and I asked my (new) pdoc for it again. I raised the dose quickly, 10mg every third day, and with 60mg I had a good antidepressant response&#8230; and the thing keeps on rolling for years now, also with my lower 30mg/single dose per day.


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## InFlames (Nov 20, 2015)

I love Adderall but I doubt I'll ever get it prescribed to me. I have to buy it on the street. SA disappears on it.


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## sadness (May 9, 2006)

Caedmon said:


> When I brought up re-trying the NRI/NDRI augmentation the pdoc suggested Adderall instead of Wellbutrin. Adderall is awesome. It sure worked for a while, but then felt too stressy, so here I am again on Wellbutrin. The cirrrrcle of liiiiiife.


Adderall was great for me at the beginning too. But then it started becoming too stressful and anxiety provoking. Lost a ton of weight on it.

Can't remember, but have you tried modafinil yet? Doesn't make me anxious but I feel some agitation and anger towards people sometimes lol. But it comes with being more aggressive and confident. (sometimes). I'll just say it makes me more like Donald Trump. :grin2:


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