Chapter 35: FEELING SOME RELIEF! Antidepressant Medications

It has been 9 months since I went to the Amen Clinic in Newport Beach, California.  It has taken this long to make all of the medication changes recommended by my doctor at the clinic.  I am starting to feel better, FEELING SOME RELIEF!  I have an atypical depression that needed to be treated in layers.  The anxiety symptoms needed to be treated first, and I talk more about this in Chapter 9 of my blog.  There is a detailed treatment plan from the Amen Clinic in Chapter 10.

I am now taking 150 mg of Effexor XR in the morning with breakfast.  I have come down from 300 mg because I was not feeling any improvement of depression symptoms, and side effects were not going away.  The higher dose was causing insomnia and anxiety, flushing several times a day, and constipation.  These are the only side effects I have experienced with Effexor XR, and they are just about gone on 150 mg.

 




 

I am also taking generic Luvox, fluvoxamine.  I take 50 mg in the morning and 50 mg in the afternoon.  I was already on this drug when I went to the Amen Clinic and my brain scans showed it was helping to quiet the activity in the deep limbic system; but it was not completely effective.  Depression symptoms originate in the deep limbic system.  I am using fluvoxamine for depression, and I do not have any side effects strong enough to notice.  I have been on fluvoxamine for over a year, and a pharmacist told me the brand Luvox is no longer made. The extended-release capsule is a new medication.

Information on generic Luvox, fluvoxamine from:  PubMed Health - Fluvoxamine

 

Why is this medication prescribed?

Fluvoxamine is used to treat obsessive-compulsive disorder (bothersome thoughts that won't go away and the need to perform certain actions over and over) and social anxiety disorder (extreme fear of interacting with others or performing in front of others that interferes with normal life). Fluvoxamine is in a class of medications called selective serotonin reuptake inhibitors (SSRIs).

 

How should this medicine be used?

Fluvoxamine comes as a tablet and an extended-release capsule to take by mouth. The tablet is usually taken either once daily at bedtime or twice daily, once in the morning and once at bedtime. The extended-release capsule is usually taken, with or without food , once daily at bedtime. Swallow the extended-release capsules whole; do not crush or chew them.

Your doctor may start you on a low dose of fluvoxamine and gradually increase your dose, not more often than once every week, depending on how well the medication works for you and the side effects you experience.  It may take several weeks or longer for you to feel the full benefit of fluvoxamine. Continue to take fluvoxamine even if you feel well. Do not stop taking fluvoxamine without talking to your doctor.

If you suddenly stop taking fluvoxamine, you may experience withdrawal symptoms such as irritability; agitation; dizziness; extreme worry; uneasiness; confusion; headache; tiredness; mood changes; difficulty falling asleep or staying asleep; or pain, burning, numbness, tingling or 'electric shock' sensations in the hands or feet. Your doctor will probably decrease your dose gradually.

 

Other uses for this medicine

*Fluvoxamine is also sometimes used to treat depression. Talk with your doctor about the possible risks of using this medication for your condition.  This medication is sometimes prescribed for other uses; ask your doctor or pharmacist for more information.

 

What side effects can this medication cause?

Fluvoxamine may cause side effects. Tell your doctor if any of these symptoms are severe or do not go away:  drowsiness, difficulty concentrating, dry mouth, headache, nausea, vomiting, diarrhea, stomach pain, constipation, indigestion, gas, change in taste, decreased appetite, weight loss, nervousness, weakness, unsteadiness, and changes in sex drive or ability.

I am taking generic Neurontin, gabapentin, to help calm the activity in the basal ganglia where anxiety begins.  I take a 300 mg capsule four times a day,1,200 mg total.  Neurontin is an anticonvulsant medication the Amen Clinic has found to be effective for anxiety.  I started on this drug as soon as I got home from the clinic to help me get off the drug clonazepam.  I have written quite a bit about clonazepam in Chapter 12 - I Hate Clonazepam and Chapter 15 - Clonazepam The Beast.  (I have been off The Beast for 7 months! =)  My doctor at the clinic chose gabapentin for me because of its low side effect profile, but you will see there are many side effects listed for this drug in the following article.  I did not experience any of these side effects.

Information on generic Neurontin, gabapentin from: PubMed Health - Gabapentin

 

Why is this medication prescribed?

Gabapentin is used to help control certain types of seizures in patients who have epilepsy. Gabapentin is also used to relieve the pain of postherpetic neuralgia (PHN; the burning, stabbing pain or aches that may last for months or years after an attack of shingles). Gabapentin is in a class of medications called anticonvulsants. Gabapentin treats seizures by decreasing abnormal excitement in the brain. Gabapentin relieves the pain of PHN by changing the way the body senses pain.

 

How should this medicine be used?

Gabapentin comes as a capsule, a tablet, and an oral solution (liquid) to take by mouth. It is usually taken with a full glass of water (8 ounces [240 milliliters]) three times a day. Gabapentin may be taken with or without food. Take this medication at evenly spaced times throughout the day and night; do not let more than 12 hours pass between doses.

If your doctor tells you to take one-half of a tablet as part of your dose, carefully split the tablet along the score mark. Use the other half-tablet as part of your next dose. Properly throw away any half-tablets that you have not used within several days of breaking them.

Your doctor will probably start you on a low dose of gabapentin and gradually increase your dose as needed to treat your condition. If you are taking gabapentin to treat PHN, tell your doctor if your symptoms do not improve during your treatment.

 

Other uses for this medicine

Gabapentin is also sometimes used to relieve the pain of diabetic neuropathy (numbness or tingling due to nerve damage in people who have diabetes), and to treat and prevent hot flashes (sudden strong feelings of heat and sweating) in women who are being treated for breast cancer or who have experienced menopause (''change of life'', the end of monthly menstrual periods). Talk to your doctor about the risks of using this medication for your condition.  This medication may be prescribed for other uses; ask your doctor or pharmacist for more information.

   

What side effects can this medication cause?

Gabapentin may cause side effects. Tell your doctor if any of these symptoms are severe or do not go away:  drowsiness, tiredness or weakness, dizziness, headache, shaking of a part of your body you cannot control, double or blurred vision, unsteadiness, anxiety, memory problems, strange or unusual thoughts, unwanted eye movements, nausea, vomiting, heartburn, diarrhea, dry mouth, constipation, weight gain, swelling of the hands, feet, ankles, or lower legs, back or joint pain, fever, runny nose, sneezing, cough, sore throat, or flu-like symptoms, ear pain, and red, itchy eyes.

My favorite website to learn about medications is Crazy Meds! The Good, The Bad, and The Funny.  It will tell you about uses, pros and cons, effects, side effects, and stuff your doctor usually won't tell you.  "Crazy Meds Suck Donkey Dong"  If that quote is offensive to you, you may not like this site.

I hope you are FEELING SOME RELIEF from your antidepressant medication, or will be soon!!

Chapter 22: Serotonin, Deep Limbic System

"Depression is known to be caused by a deficit of certain neuro-chemicals or neurotransmitters, especially norephinephrine and serotonin.  In my experience, this deficit can cause increased metabolism or inflammation in the deep limbic system, which in turn causes many of the problems associated with depression. . .  Because the deep limbic system is intimately tied to moods, when it is overactive the ensuing problems with depression snowball and affect all the other deep limbic system functions."

Daniel G. Amen, M.D.; From the book, Change Your Brain, Change Your Life:  The Breakthrough Program for Conquering Anxiety, Depression, Obsessiveness, Anger, and Impulsiveness, page 47

FUNCTIONS OF THE DEEP LIMBIC SYSTEM  (page 37)

• sets the emotional tone of the mind
• filters external events through internal states (creates emotional coloring)
• tags events as internally important
• stores highly charged emotional memories
• modulates motivation
• controls appetite and sleep cycles
• promotes bonding
• directly processes the sense of smell
• modulates libido 

 

PROBLEMS IN THE DEEP LIMBIC SYSTEM  (page 43)

• moodiness, irritability, clinical depression
• increased negative thinking
• negative perception of events
• decreased motivation
• flood of negative emotions
• appetite and sleep problems
• decreased or increased sexual responsiveness
• social isolation

"We thought that excessive activity in the part of the brain that controlled emotion might correlate with enhanced feelings of all kinds, not solely negative ones.  Yet we noticed, again and again, that when this area was overactive on SPECT, it correlated with the subject's depression and negativity.  It seems that when the deep limbic system is inflamed, painful emotional shading results.  New research on depression from other laboratories around the world has borne this out."  (page 39)

     SPECT Brain Scans 3D Active View

                      White arrows are pointing to the Deep Limbic System/Thalamus areas

These scans show hyperactive areas in the brain.  A normal scan shows increased activity in the front of the brain, the cerebellum, with all else being relatively quiet. 

NORMAL SPECT BRAIN SCANS

Scans are from the Amen Clinics

I believe my body does not make enough serotonin, and other neurotransmitters, because of a genetic predisposition.  The incidence of depression is high on both sides of my parents families.  The information on page 105 in, The UltraMind Solution, by Mark Hyman, MD was interesting to me.  He says the activity of any neurotransmitter can malfunction is some way.  Below are some of the reasons why serotonin levels go down.  I want to do all I can to help my antidepressant assist my body in creating more serotonin.

1.  A tryptophan-deficient or low-protein diet.  Tryptophan is the primary amino acid out of which serotonin is created.  No tryptophan equals no serotonin equals a very unhappy mood.  In fact, studies show that if you feed a group of people a mixture of amino acids without tryptophan you can induce depression within hours! 

2.  Stress and high cortisol levels (the stress hormone).  Cortisol increases the activity of enzymes that break down tryptophan.  That leaves less around to make serotonin.

3.  Anything that causes inflammation (such as food allergies, infections, toxins, or a high-sugar diet).  Inflammatory messenger molecules called cytokines such as interferon gamma stimulate the enzymes TDO and IDO, which break down tryptophan and force it into a pathway that makes the excitatory neurotransmitter glutamate, which kills brain cells.

4.  Simply not making enough serotonin.  This happens for many reasons.  You may not have enough of the building blocks (the amino-acid tryptophan) because you eat too much sugar and not enough protein as suggested above, or you may have genetic predispositions that make it more difficult for you to create the neurotransmitter in the first place.  Those who have an SNP (single nucleotide polymorphism) or genetic variation of the enzyme THP2 have an 80 percent reduction in ability to make serotonin.

5.  Blood-sugar imbalances (insulin resistance or prediabetes).  This condition comes from eating a processed-food, high-sugar diet.  It depletes your serotonin after a short spike, leading to mood swings.

6.  You may be deficient in vitamin B-6. B-6 is the helper or catalyst for the enzyme that converts tryptophan into serotonin.  Deficiency in B-6 is often caused by stress, alcohol, and medications like birth-control pills.

7.  Magnesium deficiency.  This is so common in our society because stress, caffeine, sugar, and alcohol all deplete magnesium, which in turn prevents the body from making serotonin.

Chapter 15: Clonazepam The Beast, Effexor XR

During the past month since I posted on my blog I have been trying to eliminate the withdrawal symptoms from clonazepam (generic for Klonopin).  I have not made much progress!  The main symptom being extreme anxiety. Starting Wellbutrin also increased anxiety.  On the fourth day the anxiety was so extreme I did not take anymore.  I took regular Wellbutrin, instead of SR or XL which was what my psychiatrist at the Amen Clinic recommended.  I think that was a mistake!  I was disappointed, but I didn't want to try Wellbutrin again!  The anxiety makes my body feel like it is going to explode from the inside.  This feeling is a new one to me, very uncomfortable, and I am weary!

I was first prescribed clonazepam for the anxiety caused by the antidepressant Zoloft.  I did not feel anxious until I started on the medication, and the anxiety was mild.  There was evidence at this time of clonazepam causing scalloping on the brain and of it being highly addictive.  There was also evidence the anticonvulsive class of drugs helped with anxiety.  My psychiatrist at the time didn't know this information about clonazepam (or maybe he didn't agree with it), but he helped me recover from a major depression more than once.  Now I want to come back to the "present" and not spend any more time in the past.

One bright spot in the past month was talking to my psychiatrist at the Amen Clinic by phone on June 16.  He was happy to hear I had been off clonazepam for over 5 weeks.  He was positive and supportive and boosted my spirits.  He reminded me what an accomplishment it is to be off this drug!  He said I had been on clonazepam for so long it could be causing depression!  He recommended I wait until my body had been free of the drug for 8 weeks before we decide to change or add medications to my treatment.  I did add 5-HTP, also known as oxitriptan (INN), a naturally-occurring amino acid, chemical precursor and a metabolic intermediate in the biosynthesis of the neurotransmitters serotonin and melatonin from tryptophan.  I will talk to my psychiatrist again on July 7 after being off the beast (clonazepam) for over 8 weeks.

I have not noticed any difference in how I feel after adding 5-HTP, except maybe a little nausea.  I am ready to take the next step in my treatment plan, adding Effexor XR.  This is what my treatment plan from the Amen Clinic says about Effexor XR:  "At low dosages, Effexor XR will help anxiety, depression and obsessive thinking, and at high dosages will help ADHD symptoms.  An antidepressant with action at multiple receptor sites, Effexor XR will enhance prefrontal cortex function and decrease anterior cingulate and limbic hyperactivity.  Effexor XR has a starting dosage of 37.5 mg daily, increasing by one every 7 days as tolerated, to the therapeutic target dose of 75 mg to 350 mg.  It should be taken with food to avoid upset stomach.  Effexor should not be stopped abruptly because it has been associated with a discontinuation syndrome in some patients.  At higher dosages, blood pressure should be monitored.  If Effexor XR causes more irritability, I would increase the anticonvulsant to stabilize the temporal lobes, enhance mood stability, and decrease anxiety or irritability."

I was on Effexor (not Effexor XR) about 10 years ago.  The nausea it caused didn't stop, so I changed to Zoloft.  The problem with nausea could have been caused by going on the medication too quickly.  This time I will increase the dosage more slowly.  I experienced the discontinuation syndrome mentioned above when coming off Effexor.  At this point, I expect to be on an antidepressant for the rest of my life so I am not concerned about discontinuing the drug.  I will need to lower the dose of Luvox as I add Effexor XR.  I have a positive attitude and will discuss the treatment plan with my psychiatrist next week.

I am ready to have a normal day not based on surviving!  "Normal day, let me be aware of the treasure you are." (by Mary Jean Iron)

Chapter 13: My Brain Scans; Inside Active View

I have been off clonazepam for 15 days.  I am still taking extra Neurontin for the anxiety, I am more irritable, but I am sleeping well.  I visualize my brain healing, and I am starting to get excited about being able to start the last part of my medication treatment plan.  As soon as the anxiety calms down I will begin taking Wellbutrin.  It is important for me to wait until the anxiety calms.  The 100 milligrams of Luvox I am taking per day is helping to calm the increased activity in the deep limbic system.  The 1200 milligrams of Neurontin per day is helping calm the anxiety in the basal ganglia.  Wellbutrin will help increase the activity in my prefrontal cortex.

Here are SPECT scans of a healthy brain when it is active.  This is a 3D Active rendering, looking at the most active 15% of the brain where fluid (Ceretec) injected into an artery reached the tissues.  A normal scan shows increased fluid in the tissues of the cerebellum, with all else being relatively quiet.  Pictures are from the Amen Clinic.
                                    

                                    

                   Here are my SPECT 3D Active rendering scans after rest:  R=rest.

These are my SPECT 3D Active rendering scans after concentration:  C=concentration

                           

                                                                           

My SPECT Study Findings Report from the Amen Clinic is 4 pages long.  Here is a brief overview of what was found on my scans.  The most significant finding is decreased activity bilaterally (both sides) of the temporal lobes on the rest and concentration studies. 

Decreased activity was found in the following areas:

• Bilateral inferior orbital prefrontal cortex, worse at rest.
• Bilateral parietal lobes, worse at rest.
• Medial parietal lobe, on both studies.
• Left and medial dorsal prefrontal cortex, at rest.
• Bilateral occipital lobes, at rest.
• Anterior medial prefrontal cortex pole, on both studies.
• Internal cerebellar activity, worse at rest.

Increased activity was found in the following areas:

• Thalamo-limbic system, worse on concentration.  The basal ganglia are a group of large nuclei that partially surround the thalamus.
• Anterior cingulate gyrus, on both studies.

Below are pictures of the anatomy of the brain.  PFC=prefrontal cortex; FC=frontal cortex; TL=temporal lobe; PL=parietal lobe; OL=occipital lobe; BG=basal ganglia; ACG=anterior cingulated gyrus; PCG=posterior cingulate gyrus; R=right; L=left.  These photos were included in my notebook from the Amen Clinic.

                                                              

I am not well yet, but I am making progress toward feeling better.  Having SPECT scans done did not cure anything, but they gave my psychiatrist at the Amen Clinic more information which helped him write a treatment plan that is working for me!

Chapter 9: Three Days At The Amen Clinic

Wednesday morning I had my first SPECT brain scan.  The IV was inserted with ease and I had no bruising later.  The concentration scan is done first and I did an activity to get my brain focused.  The radioactive isotope was put into my IV during the activity.  I did not have any sensation in my body when it was injected.  After the activity I laid down on my back on the scanning machine.  I needed to hold still, but the the time went quickly; it took about 15-20 minutes.  A band was wrapped around my forehead to help me keep my head still.  The scanning machine made a noise, but it wasn't irritating.  Part of the machine went around my head, but I did not feel claustrophobic like I have during an MRI.

Wednesday afternoon I had an appointment with one of the historians.  She had read my intake questionnaire and asked me questions to clarify, or give her more details on my answers.  This was a calm, deliberate process. She gave me plenty of time to add any information to what was included in the questionnaire. She compiled a well written history for the psychiatrist I had an appointment with later in the week.

Thursday morning I had my second SPECT brain scan.  After the IV was in place I was taken to a dim lit room to prepare for the resting scan.  I was asked to let my mind wander or daydream, but not to think about any specific subject, meditate, or fall asleep.  A short time into my resting the isotope was injected.  There was an interesting rug in the room with geometric shapes on it.  I wanted to see how the pattern repeated itself, but I didn't, I kept resting.  There was also a picture of Dr. Amen with information about his work in brain imaging I wanted to look at.  I didn't, I kept resting. After 15-20 minutes, I laid down on the scanning machine for my second scan.

On Thursday afternoon, my husband and I had a delectable seafood lunch at a restaurant called Rusty Pelican.  It is on 2735 West Coast Highway, Newport Beach, CA 92663-4798, (949) 642-3431.  http://www.rustypelican.com/

On Friday afternoon I met with a psychiatrist.  He showed me my brain scans and went over what was found on them.  It was awesome to see the scans!  He showed me rippling, called scalloping, on the surface of my brain.  For me, it is probably caused by taking the drug clonazepam. I have not abused or been exposed to drugs, alcohol, or environmental toxins. I have used this drug for approximately 8-10 years and the Amen Clinic uses it only for short periods of time for severe cases of anxiety.  I am in the process of coming off clonazepam so the scalloping on my brain can heal!

Other Findings:

1. Luvox has been helping calm the activity in my deep limbic system; where depression originates. 
2. There is too much activity in my basal ganglia; causing anxiety. 
3. I have an atypical depression needing to be treated in layers.  This is why I haven't achieved a more complete remission of symptoms in the last year and a half.  The basal ganglia (anxiety) must be calmed down first. 
4. My prefrontal cortex is not functioning effectively.  After the anxiety is calmed down I will need to take a drug to stimulate the prefrontal cortex.  If I take this drug too soon, it will over stimulate the basal ganglia and cause too much anxiety.

I now have an extensive treatment plan giving me hope I can get feeling better!