View Full Version : Negotiating with the Psychiatrist [LONG]


known_guy
01-31-12, 03:38 AM
If the globs of text prove too much to handle, skip to the bullet points near the end of my post.

I do my research. I've read over a hundred (yes, literally) research papers and journal articles, review articles, what-have-you, etc. After all, when it comes to ingesting medications, I certainly would like to know what I allow into my system. I wouldn't want to take a medication that likely won't be efficacious or has a possible side-effect profile I particularly dislike. In light of this knowledge, I can be (or have been) staunchly opposed to certain medication changes proposed by my psychiatrist. I just recently - well, a friend pointed it out to me - learned that this behavior may reflect distrust or something. It may be insulting. I'm not intentionally trying to be difficult or anything, it's just that I just know what I am willing to try and what I see no reason to try. I would feel awkward citing sources when "arguing" with my psychiatrist whenever we discuss my medications. A politely veiled "conflict".

She wants to simplify my regimen down to Cymbalta as my antidepressant, one ADHD medication (like the Ritalin SR), then something new for anxiety, I think, like Neurontin (Gabapentin), perhaps? And change Remeron back to Trazodone. Sure, I'm totally for simplifying things but I just feel there is a large risk involved. I went through multiple medication additions/changes over the course of a few months, beginning last summer. Started with one antidepressant. Added Ritalin SR. Added Strattera. Added Remeron. Added Inderal (Propranolol) and Atarax.

Switched my antidepressant from Celexa to Zoloft. Switched Strattera to Wellbutrin XL. Dropped Inderal and Atarax for Klonopin. Swapped Remeron with Trazodone. Couple months later switched back to Remeron. Added on the Adderall IR to take as needed. I decided I want to stop Klonopin only recently.

[Proposed changes/additions I rejected include: Abilify, Atarax (ha), Buspar, Neurontin, Lithium, etc.]

I have two problems with the idea of swapping out Zoloft and Wellbutrin XL for Cymbalta. I know it's an SNRI and I hear discontinuation from SNRIs like Effexor can be hell. At least in taking different antidepressants each with their own mechanism of action, I can wean off one at a time. Secondly, I'm not a fan of the idea of taking a medication that doesn't come in a generic form. My copay when it comes to generics is $15, but for example, when it came to Strattera in the past, the copay was $60. Oh, and I dislike(d) the Trazodone because it gave me unbearable dry mouth.

I want to keep the Wellbutrin XL, and either drop both the Adderall IR and the Ritalin SR in lieu of Dexedrine SR (spansules) or keep them as they are. I think I'm ambivalent about the Zoloft, so not sure if I want to continue or not. I don't think I'd care either way. I would be willing to try taking away the Remeron - if my appetite gets lost, then might as well stay on it. Or if I still need a sleep aid, I would want to give Tenex (Guanfacine) a shot since it can both help me sleep and can help ADHD (Small morning dose and then a "normal" bedtime dose). For anxiety, I guess I'm open to multiple options. I'd be willing to try Neurontin/Gabapentin, I suppose...


To summarize, this is what my psychiatrist wants me to be on.


Cymbalta
Ritalin SR
Trazodone
Anxiolytic (I think?)

This is what I would like to try and/or be on. I'd like minor change(s).


Wellbutrin XL
Dexedrine SR [Or Ritalin SR and Adderall IR]
Remeron (Maybe?)
Tenex
Anxiolytic (Or keep the Zoloft?)

What I am currently taking/prescribed is indicated in my signature.

So. The point of this post/thread? I would like advice on how to negotiate with my psychiatrist on what I'd like to ideally take. Thanks in advance!!!
Additionally, advice or your thoughts/opinions on any of the possible medication changes listed in the above lists would be greatly, greatly appreciated.

BR549
01-31-12, 12:55 PM
Okay, let me see if I understand...She wants to switch you from Wellbutrin to Cymbalta; from Remeron to Trazadone; one ADHD medication; Neurontin.

Right now you are on Remeron, Wellbutrin, Zoloft, Adderall and Ritalin.

So she wants to take you from 5 meds to 4?

I guess the first question is, how is what you are currently on working out? I mean, if it's working, why change?

known_guy
01-31-12, 02:45 PM
That's correct. One antidepressant (I guess Trazodone doesn't "really" count as one), one ADHD medication; if I can't sleep then add the Trazodone.
Then she said we can discuss the possibility of adding Neurontin on top of that for anxiety. I think.

Hard to say if we can strictly say she wants me to cut down from 5 to 4 medications. Because I asked if I could add on a substitute medication for anxiety since I wanted to stop the Klonopin. If I remember correctly she wants/wanted me to simplify things before tacking on something new. Since I still have leftover Klonopin I still take it on an as-needed basis, occasionally.

When my Zoloft dose was at 200mg and my Wellbutrin XL at 450mg all my medications were working out just fine. Shortly after I made decreases to 150mg and 300mg (the Zoloft and Wellbutrin XL, respectively) I began to experience really intense dysphoria. When I mentioned this to her that's when the Cymbalta [and all this other] talk came into the picture.

ginniebean
01-31-12, 03:06 PM
Possibly you need to discuss with your doctor the whole doctor role and patient role. As patients we're often expected to take a submissive role to the Dr's authoritative one. But, we are fully responsible for what we ingest, what advice we do take, and the consequences are all ours.

The Dr's knowledge is not magic, s/he learned it the same way you did. Explain that you're not trying to be difficult and that you do feel a strong sense of responsibility to be aware of your own health needs. Discuss with him/her that you're not wishing to be insulting, and are willing to hear her/him out. It is difficult and most certainly not traditional for Dr's to have patients challenge them and often patients really are not equipped to do so.

This Dr. is listening to your needs, and making adjustments, it sounds like a small 'let's cooperate with each other" chat could resolve some of the strain you feel.

cameron90
01-31-12, 03:38 PM
Wow. Choices, choices, choices. So basically, it's between Cymbalta and Wellbutrin for the AD? What is the reason for the Cymbalta if you prefer the bupropion? I would really try to find one antidepressant that works for you. This can be really difficult to do, though, because it takes so long for antidepressants to start to work and be eliminated from you system. And you've never tried the Cymbalta? I'm just trying to picture taking this many antidepressants at once, must not be so nice...

I recently tapered off of Prozac and now I'm on 60mg of Remeron, which is going OK so far. I've tried Wellbutrin but that wasn't for me -- mood swings and irritability. The only SNRI I've had was the first AD I was put on, Effexor (venlafaxine) and that was like opening the flood gates of anxiety. Have you tried any of the SNRI class ADs? What about experiences with other classes (e.g., SSRI, TCA, TeCA, SSRE, and so on...)?

I think that Wellbutrin is often used in conjunction with another AD such as an SSRI or SNRI. I saw my doctor yesterday and he wanted to try adding Effexor to my Remeron to boost the antidepressant effects. Probably a similar kind of thing. I said I would rather not take Effexor again, at least for now. How have you found the Remeron at 30mg? I found that 30mg made me drowsy, 45mg made me a corpse in the morning, but 60mg is tolerable. Apparently that has something to do with me being half-Asian...

The psychostimulant for ADHD is pretty straightforward, it's usually a matter of preference and individual control of ADHD symptoms. I would just say use what works best for you. I've only ever been on Dexedrine (both spansules and IR) and it works for me -- and Adderall isn't available where I am currently so it's dextroamphetamine or some kind of methylphenidate formulation.

I also just tapered my clonazepam down, which wasn't as hard as I was anticipating. The effect on my mood was noticeable, after coming down to one .5mg dose per day from a habit of about 2-3mg a day. I hope the same happens for you. I know of some success stories about Neurontin (gabapentin) but I would inquire about Lyrica (pregabablin). I'm not sure how much more Lyrica would cost, but it seems to be better fitted for generalized anxiety (approved in the EU). I've read anecdotal reports of gabapentin being just as effective, though.

Sorry, I know I asked a lot of questions, but this is quite complex. I could see something like Wellbutrin OR Remeron + an SNRI like Cymbalta being effective and a reasonable choice by the doctor for MDD and G/SAD. For ADHD, probably just the stimulant of your choice. And something additional for anxiety on a PRN basis would also be an option. I encourage getting off of the clonazepam because it can have an effect on mood over the long run, but it is useful to have for "emergencies". Gabapentin and Pregabalin seem to be the best options as non-addictive and relatively safe medications, but I don't know if they are used on a PRN basis, and I've heard of people successfully using these GABAergic medications for alcohol and medication (benzo, SSRI, other AD) withdrawal.

I agree with ginniebean, that you should not be submissive and take whatever the doctor wants to try. I hope that you have a doctor that you trust and who you feel comfortable with as a patient. Always be reasonable with the doctor, let him/her know that you've done some research, and that you know what works best for your body and mind. The amount of changes that you may be making in terms of medications is quite significant, so this will probably be a relatively long process (mostly if you decide to change or modify the ADs) and I wish you the best of luck. In general, I think that less is more (in terms of architecture and medications) so finding the minimum regimen that is effective is in my mind one of the most important things. I have been on 6 medications concurrently and it was probably the worst I've ever felt. I feel MUCH better at the moment on my Remeron, dextroamphetamine, and (lower-dosage) clonazepam.

The information above is based on my knowledge and experiences and I can't make any claim to the accuracy or legitimacy of everything stated but I have tried my best to make sure that the information is accurate to the best of my ability. If anybody finds any errors, please correct me.

StoicNate
01-31-12, 04:37 PM
I totally understand you.
I also am researching something to help my depression and panic/anxiety, but my doctor wants me on a SSRI which most likely will cause sexual dysfunction/apathy...(horrible sounding to me).

I want something that I can take and still be able to drink beer if I want to and not have any weird side effects.

If not, then I won't take anything and keep having my panic attacks/anxiety. The anxiety is the kind where my body involuntarily trembles/spasms along with that anxious feeling. I'll just drink to keep anxiety at bay.

hollywood
01-31-12, 04:44 PM
yeah man. I've been doing the whole ssri thing. I'm out . I can't do it , the side effects go from okay to worse and worse it seems. I don't even realize how much I don't do jack at work now. I cannot live a life that way. I'd rather be so tired and get used to intuniv or tenex than this. Right now I'm just on wellbutrin and focalin xr. I stopped prozac. Yes, I agree adding a 3rd med just made my head feel too full. Not for me. I need to work harder at personally controlling negative thoughts. If anything tenex does calm me down tremendously so I think if I try that I'll be in a better place.

Yeah , I have heard of stahls theory and I think it makes alot of sense. Yet , for me too much is two antidepressants.

known_guy
02-01-12, 02:38 AM
Thanks a bunch everyone. I know, I really want to give Tenex a shot! If that helps me sleep then I can cut out the Remeron. Or so I hope.

The 30mg of Remeron seems to be the right fit for me. 15mg is too sedating. Haven't tried 45mg to see how it compares to 30mg though.

Never tried any SNRI (my medication history is listed out on my profile page) but after hearing about really negative discontinuation experiences, I have no desire to. I would totally like to try Lyrica but it's not approved for that use in the US. It's approved in the EU I know, but it also doesn't come in generic form yet. Its so-called predecessor, Neurontin/Gabapentin I think is the closest I can reasonably get, liken to why I want to try Tenex over, say, Intuniv. [This example is different though because in this case the medications have the same active ingredient, essentially, Guanfacine.]

cameron90
02-01-12, 02:42 AM
Thanks a bunch everyone. I know, I really want to give Tenex a shot! If that helps me sleep then I can cut out the Remeron. Or so I hope.

The 30mg of Remeron seems to be the right fit for me. 15mg is too sedating. Haven't tried 45mg to see how it compares to 30mg though.

Never tried any SNRI (my medication history is listed out on my profile page) but after hearing about really negative discontinuation experiences, I have no desire to. I would totally like to try Lyrica but it's not approved for that use in the US. It's approved in the EU I know, but it also doesn't come in generic form yet. Its so-called predecessor, Neurontin/Gabapentin I think is the closest I can reasonably get, liken to why I want to try Tenex over, say, Intuniv.
[Different though because in this case the medications have the same active ingredient, essentially, Guanfacine.]

I'm sure you did your research and made the best decision in light of your own condition, health and situation. Let us know how it's going from time to time and I wish you a smooth transition. Changing meds can be absolutely !#&*#%

Problem_Dog
05-12-12, 12:31 AM
I see you were prescribed Guanfacine after all, but you wanted it primarily as a sedative? Do you think it's having a positive effect regarding ADHD (separately or in conjunction with stimulants)? I gather the Zoloft was already at least partially given for anxiolytic purposes, and the Pregabalin was added at the same time as Guan on top of it. Are the effects of Guanfacine distinguishable in the mix, and if so, how do they compare to Klonopin, other then the presumed lack of cognitive side effects?

known_guy
07-17-12, 10:31 PM
I see you were prescribed Guanfacine after all, but you wanted it primarily as a sedative? Do you think it's having a positive effect regarding ADHD (separately or in conjunction with stimulants)? I gather the Zoloft was already at least partially given for anxiolytic purposes, and the Pregabalin was added at the same time as Guan on top of it. Are the effects of Guanfacine distinguishable in the mix, and if so, how do they compare to Klonopin, other then the presumed lack of cognitive side effects?

That's a good point, the Zoloft and Lyrica definitely help with my anxiety symptoms. Much better than Zoloft in conjunction with Klonopin. Luckily Tenex doesn't seem too sedating. I found that a TID regimen of 1mg, 1mg, 2mg, seems to work well. 1mg I don't find sedating, but 2mg I do. So it all works out. At least, I think so.

hawkgirl80
07-21-12, 08:35 PM
wow well i have one for you........ been reading for while now never respond but need help well duh have pdoc so yea anyways been on adderall lil over yr now ir tried er twice was not good bk on ir also on antidepressant and added tenex today