| Tianeptine | Moclobemide | Deprenyl | Picamilon | Milnacipran |
                                         

from an article by Richard Brown MD

I have also found picamilon to be a helpful medication.  This Russian medication is a combination of GABA and niacin in the same molecule.  It is helpful for anxiety and depression, especially with cerebral vascular disorder with mood symptoms and/or confusion.  For example, a middle-aged divorced university professor who I have now been seeing for nine years came for treatment of a resistant depression.  She failed multiple trials of all available classes of antidepressants.  She had transient response to a course of electroconvulsive therapy.  As I tried to puzzle over why a patient with a relatively classical depression was so unresponsive to multiple trials of conventional antidepressants, I commenced a work up of her cardiovascular system that indicated she had not only abnormalities in her lipid profile and glucose metabolism (although not diabetic), but also had problems with elevated homocysteine, (a major risk factor for vascular disease) and highly sensitive C-reactive protein. These findings, combined with subtle cognitive deficits (which were not characteristic of her previous outstanding academic performance), led me to believe that she had developed a slowly progressive cerebral vascular disease which was interfering with her response to medications.  She was perhaps twenty percent better on extended release Effexor® 600 mg per day, reboxetine 4 mg a day (more made her feel uncomfortably anxious), quetiapine 100 mg at night for agitation and insomnia, and S-adenosyl methionine 400 mg per day.  The addition of picamilon ultimately at 100 mg three times a day cleared up the kind of brain fog under which she has labored for some time.  The picamilon enabled her to have more energy, more enthusiasm, and a greater sense of involvement in her daily activities.  I believe she falls into an often-ignored category now recognized by geriatric psychiatrists as being vascular depression.  

However, picamilon is more versatile than this. It can be useful in patients post-stroke. I also commonly see patients with Parkinson's disease, depression, and evidence of cerebral vascular disease from a history of strokes or abnormal findings on magnetic resonance imaging.  Picamilon can be extremely helpful in giving these patients a decrease in anxiety and depression, without sedation and with a mild pleasant stimulation.  It may be used in a variety of other organic brain syndromes.  For example, one patient in his mid-fifties had developed a treatment resistant depression during the course of which he also suffered several strokes and cognitive impairment. This was ultimately found to be due to an antiphospholipid antibody syndrome. Although his depression was at least partially responsive to Effexor®, his cognitive functioning and energy were poor. His daily activity was quite limited, particularly because of apathy and fatigue. In this case the patient was greatly helped by the addition of acetyl-L-carnitine, picamilon, and SAM-e.  For all three medications the doses had to be given aggressively.  If any one medication were decreased he would basically become non-functional. 

Racetams: The European Alternatives 

Another group of medications which are relatively unfamiliar to most American physicians are the pyrolidones or racetams. I most commonly use aniracetam or piracetam from this class.

These medications have a positive effect on nerve cell energy metabolism and seem to boost the function of cholinergic and NMDA-glutamate receptor systems.  Pyrollidones facilitate the transfer of information between the cerebral hemispheres across the corpus callosum.  They improve the function of the verbal areas of the left cerebral cortex. They can be used to lessen the cognitive side effects of anticonvulsants, as well boost the anticonvulsant efficacy of these medications.  Even less well known is that there are several studies showing that the racetams can boost the efficacy of antidepressants.  Yet they are extremely benign in terms of side effects, rarely causing stimulation and over activation. 

For example, a 55-year-old lawyer who had been extremely highly functioning came to see me several years ago, after approximately a ten-year course of deterioration following the development of an ovarian hyperstimulation syndrome, secondary to taking fertility medication. She developed physical symptoms of this disorder, as well as depression and cognitive problems that became so pronounced that she became unable to work. Her deficits were documented on neuropsychological tests which were consistent with blood flow abnormalities, seen on SPECT (Single Proton Emission Computed Tomography) scans of her brain. Her depression responded well to a combination of Zoloft® and SAM-e. However, her cognitive functioning remained poor. She was also extremely hypersensitive to light, sound, and touch. (It should be noted that ovarian hyperstimulation syndrome causes marked changes in the vasculature of animals, as well as overproduction of stress hormones through the stress response system).  The patient had great difficulty tolerating conventional psychotropic medications and experienced extremely severe side effects.  Fortunately, her brain function improved dramatically when she was given pramiracetam 600 mg twice a day.  For the first time in ten years, the patient felt that her brain had been returned to her.  She was able to read and do other mental work without collapsing in a short time. 

Another less dramatic example is a 23-year-old patient who was tested in childhood and found to possess a genius level IQ.  He went to a prestigious college.  At about that time he developed an idiopathic autoimmune disease which caused diabetes mellitus requiring insulin and an idiopathic alopecia.  He developed severe cognitive problems which were well documented, not only on neuropsychological testing but also on brain scans. Conventional treatments by neurologists and psychiatrists were to no avail. The patient had some response to donepezil, a cholinesterase inhibitor, over a nine-month period.  However, the response was not satisfactory and I began to treat him with galantamine up to 24 mg a day with a partial positive response.  Picamilon 50 mg a day further improved his cognitive functioning and energy.  Adding aniracetam 600 mg per day has enabled him to recover his previous cognitive function level as documented by repeat neuropsychological testing. If he takes more of any of these medications he is over stimulated and has trouble sleeping.  However, if any of the medications are lowered, his ability to function comes to a screeching halt. 

I have also found picamilon to be a helpful medication.  This Russian medication is a combination of GABA and niacin in the same molecule.  It is helpful for anxiety and depression  continue