AboutIvan Goldberg, M.D. Expertise I am a psychiatrist/psychopharmacologist with many years of expereince in treating individuals with depressions, manic-depression (Bipolar Disorder), other mood disorders,. I am especially interested in the psychopharmacologic treatment of individuals with so called "treatment-resistant" syndromes.
Experience I have been on the staff of the National Institute of Mental Health, Columbia's College of Physicians and Surgeons, and the Columbia-Presbyterian Medical Center. I am currently in full-time private practice in New York City.
A.B. Johns Hopkins University M.D. N.Y.U. College of Medicine
I am the creator of Depression Central:http://www.psycom.net/depression.central.html
I have recently been put on Parnate for resistant bipolar depression. There is so little information available on the drug anywhere and most doctors (including mine) have little experience using MAOI's.
I saw your comments/ discussions on Parnate at dr-bob.org so I feel you are probably the right person to ask. In fact there are quite a few new-to-Parnate people on the board with similar questions regarding what to expect from Parnate (which their doctor's are not able to answer).
I all would really appreciate your help. Thank you.
My questions are as follows:
1)Which side effects are transient and which aren't?
- Hypotension (not only orthostatic and despite dose splitting)
-Afternoon sedation despite the addition of a stimulating drug (Provigil 200mg in my case and normal sleep at night)
2)I am on 30mg/day so far and plan to increase to a much higher dose. Does the drug become more stimulating as the dose is escalated because right now I feel more exhausted and apathetic than usual?
3)Is it true that a combination of Parnate and a stimulant can precipitate dyskinesias? Is Provigil considered to be a stimulant in that respect.
4)How high a dose of Provigil could one take with Parnate (I understand if you do not want to comment on this one as there is no safety guidelines available - but a rough guess would do)
5)How long is a fair trail for Parnate? I believe it is longer than for most drugs. I am specially concerned about how long symptoms like the innate exhaustion of BP depression generally take to lift. (In fact I was led to believe that Parnate is highly stimulating which so far has not been so)
One last question not related to Parnate.
Before I was diagnosed as Bipolar, I was put on high dose venlafaxine (300mg). As I was not on a mood stabilizer at the time, I went very high but crashed 8 months later.
Due to this I cannot tell what the efficacy of high dose Venlafaxine would be on severe bipolar depression with a mood-stabilizer (if Parnate is not the right drug after all).
My question is this: If an AD made you switch into mania/hypomania before, does it mean that it made you un-depressed first and then switched you into a high or are switching and becoming un-depressed totally different things? (I hope that makes sense.)
I ask because I am not sure if it will work on me unless I switch- SSRI's certainly don't work. I am hesitant to try it because withdrawing is so hard and means you have to wait forever to start another drug.
PS: I know augmenting with an atypical anti-psychotic is an option in general but I cannot take these as I developed tardive pain syndrome on Geodon (the only drug that has ever lifted my depression 100%, all by itself)
Just for your information my current drug regime is as follows:
Parnate 30mg in split doses during the day
Lamictal 200mg
Provigil 200mg
Klonopin 2mg to sleep.
Thank you so much for reading. Hoping you will reply and shed some light on these issues.
Regards
Divya
Answer My questions are as follows:
1)Which side effects are transient and which aren't?
IT IS IMPOSSIBLE TO STATE TO WHICH SIDE EFFECTS PEOPLE MAY DEVELOP TOLERANCE.
- Hypotension (not only orthostatic and despite dose splitting)
-Afternoon sedation despite the addition of a stimulating drug (Provigil 200mg in my case and normal sleep at night)
2)I am on 30mg/day so far and plan to increase to a much higher dose. Does the drug become more stimulating as the dose is escalated because right now I feel more exhausted and apathetic than usual?
WHIEL SOME PEOPLE BECOME MORE STIMULATED WITH HIGHER DOSES OTHER BECOME MORE LETHARGIC
3)Is it true that a combination of Parnate and a stimulant can precipitate dyskinesias? Is Provigil considered to be a stimulant in that respect.
THE COMBINATION OF PARNATE AND ONE OF THE STIMULANTS IS OFTEN A USEFUL ONE. WHILE MANIA, HYPERTENSION, AND DYSKINETIC MOVEMENTS ARE ALL POSSIBLE, I HAVE SELDOM SEEN THEM IN PATIENTS ON THE COMBINATION. PROVIGIL IS A PSYCHOSTIMULANT.
4)How high a dose of Provigil could one take with Parnate (I understand if you do not want to comment on this one as there is no safety guidelines available - but a rough guess would do)
200 MG/DAY IS THE HIGHEST DOSE I HAVE USED . . . IT IS WELL ABOVE THE FDA APPROVED LABELING.
5)How long is a fair trail for Parnate? I believe it is longer than for most drugs. I am specially concerned about how long symptoms like the innate exhaustion of BP depression generally take to lift. (In fact I was led to believe that Parnate is highly stimulating which so far has not been so)
I ASK MY PATIENTS TO TOLERATE AN 8-WEEK TRIAL AT THE MAXIMALLY TOLERATED DOSE OF PARNATE.
One last question not related to Parnate.
Before I was diagnosed as Bipolar, I was put on high dose venlafaxine (300mg). As I was not on a mood stabilizer at the time, I went very high but crashed 8 months later.
Due to this I cannot tell what the efficacy of high dose Venlafaxine would be on severe bipolar depression with a mood-stabilizer (if Parnate is not the right drug after all).
My question is this: If an AD made you switch into mania/hypomania before, does it mean that it made you un-depressed first and then switched you into a high or are switching and becoming un-depressed totally different things? (I hope that makes sense.)
I ask because I am not sure if it will work on me unless I switch- SSRI's certainly don't work. I am hesitant to try it because withdrawing is so hard and means you have to wait forever to start another drug.
THERE IS SNOW WAY I CAN COMMENT ON YOUR SITUATION BUT I CAN SAY THAT SOME PEOPLE WHO HAVE BECOME MANIC OR HYPOMANIC WHEN TREATED WITH ANTIDEPRESSANTS ALONE, ARE ABLE TO TAKE THE SAME ANTIDEPRESSANTS WHEN THEY ARE TAKEN ALONG WITH LITHIUM.
