Posted by bob on September 9, 2001, at 15:14:03
In reply to Doc's Experience with Zyprexa, Lamictal, more., posted by JohnL on September 9, 2001, at 7:21:25
> Hi all,
> This is kind of long, but has some really good info. I like it when a doctor shares what has been working, and why. The question and answer format has some excellent info on Zyprexa and Lamictal. Of note, he also speaks highly of Neurontin, however the writer of this stuff spelled it wrong and called it Neurotone.
>
> I praise Zyprexa all the time. I probably don't praise Lamictal enough. But this doctor says it all better than I could....
>
>
> Depression: The Invisible Illness
>
>
>
> The following is the question and answer session from the Depression: The Invisible Illness meeting in Atlanta. The
> presenter was Jay D. Fawver, M.D.
>
> Q: With perimenopausal women would your recommend estrogen as a means of treatment?
>
> Dr. Fawver: If they have perimenopausal depression, I would certainly recommend an antidepressant. I always defer to my
> gynecologists or my primary care colleagues in terms of using estrogen. But I'll tell you this about estrogen. With menopausal
> women, estrogen and an antidepressant can work very synergistically. Women who have a degree of depression during their
> menopause will feel psychologically better when they get the estrogen. Estrogen by itself will not help with menopausal major
> depression, but it can help with the overall well being. Estrogen is good for the bones, it's good for the heart, but it's also good
> for the brain because it helps with memory and mood. So if the woman is having a lot of hot flashes and feeling pretty miserable,
> as a psychiatrist, I would recommend the vegetable analog of estrogen. I would recommend at least 20 grams of soy products a
> day because that can give you a little bit of relief. But really if the primary care physician or gynecologist is recommending
> estrogen, I'm all for it. Obviously, you have to get around the risk of the thrombophlebitis, the cervical cancer and the breast
> cancer. That's why I don't mess with that as a psychiatrist. I leave that to them because they're the ones doing the Pap smears.
> They're the ones doing the breast examinations, so I leave that to them.
>
> Q: Is there any problem with combining the following MAOI's?
>
> Dr. Fawver: Depakote would be no problem. Lamictal I wouldn't combine with a monoamine oxidase inhibitor because
> Lamictal does have a selective serotonin reuptake inhibitor built into it. That's why Lamictal, also known as lamotrigine, it's an
> anticonvulsant, that's why it's very good for bipolar depression. The key with Lamictal is you have to be very careful on your
> dosing. Gradually increase the dosage so you stay away from the rash and hopefully the Stevens-Johnson syndrome (ck this),
> but I wouldn't combine Lamictal with an MAOI. Topamax, I believe that you could combine that with a MAOI. Topamax also
> being an anticonvulsant, but that does not appear to have any inherent antidepressant features in it. Finally Neurotone.
> Neurotone would indeed be safe to combine with a monoamine oxidase inhibitor. Neurotone primarily affects GABA-A
> receptors, and does not appear to have an inherent antidepressant effect.
>
> Q: Is Lamictal an effective antidepressant?
>
> Dr. Fawver: Yes, I use Lamictal for bipolar depression. The nice thing about Lamictal is that it does not cause weight gain.
> And if people have these recurrent, depressive bouts maybe with a manic episode here and there, but predominantly their
> bipolar disorder is of a depressive nature, Lamictal can be a very nice medication. Go very easy on your dosage for Lamictal.
> Twenty-five mgs at bedtime for the first two weeks, then 50 mgs at bedtime for a week, 100 mgs for a week. You're shooting
> for a dose of 200 mgs at bedtime, and you're going to slowly get up there at about five or six weeks. Go very slow on the
> dosage because the faster the dosage is kicked up for Lamictal, the more likely you're going to see the rash and the more likely
> you're going to have the liver failure that's associated with it.
>
> Q: Does double depression exist?
>
> Dr. Fawver: I think it does. Double depression is major depression with dysthymic disorder. These people have been
> depressed since they were kids. They had a low degree of depression that might not have met the criteria for major depression,
> but they're always depressed. Even when they get well, they don't seem to all the way recover from the major depression.
> That's always hanging over their heads to some degree. The key with double depression is that it's difficult to treat. They don't
> respond as well to the antidepressants. They are always kind of negativistic, and pessimistic and grouchy and irritable.
> Sometimes you need to be a little bit more aggressive with the medication. For these people, depression has become a way of
> life for them. Some therapists have referred to them as being depressive personality disorders. So the therapy can be helpful,
> but it's not uncommon that they might need a combination of antidepressants. You need to be a little more aggressive in how
> you treat them.
>
> Q: Comment on whether antidepressants or anticonvulsants have an adjunctive role with antidepressants help with
> treatment-resistant depression.
>
> Dr. Fawver: If somebody does have a mixed bipolar disorder, by all means, they often need the combination of an
> anticonvulsant or mood stabilizer with an antidepressant. If somebody has unipolar major depression without evidence of
> bipolar disorder, an anticonvulsant will probably not help them that much. The exception can be Neurotone. Neurotone I will
> use for generalized anxiety disorder. I use Neurotone nowadays where I used to use Ativan. Previously, I would use Ativan to
> help somebody with generalized anxiety to take the edge off things. I'm finding Neurotone to be a great medication for anxiety.
> One hundred to 300 mgs, three times a day, takes the edge off of things, but it doesn't dope them up and it does not seem to
> hinder their cognition, like you might see with Ativan. Obviously, Neurotone is not likely to be abused like Ativan can. I'll use
> Neurotone if I'm going to use something for anxiety if I'm going to use an anticonvulsant for unipolar depression.
>
> We're getting a lot of benefit from using the atypical antipsychotic medications for augmentation for unipolar depression.
> Zyprexa, for instance, increases the norepinephrine and dopamine in the prefrontal cortex. By doing that, you can add on
> Zyprexa with an SSRI at 10 mgs at bedtime and sometimes get an augmentation to your antidepressant effect. Risperdal, at
> doses as small as 1 mg at bedtime, can augment an antidepressant because Risperdal is indirectly affecting the serotonin
> transmission by blocking serotonin two-way receptors. So, yes, the atypical antidepressant medications can certainly be used
> for augmentation with the antidepressants. Even if a person does not have psychotic depression and even if a person does not
> have bipolar depression.
>
> Q: Please comment on the role of antidepressants in schizoaffective disorder, depression in schizophrenic patients, depression in
> borderline personality disorder and depression in bipolar disorder.
>
> Dr. Fawver: Depression is schizoaffective disorder, the antidepressants certainly do play a role. I'm hopeful that as we use the
> atypical antipsychotic medications for the treatment of schizoaffective disorder, we're going to find that antidepressants are less
> necessary. In my experience, specifically with Zyprexa, I'm finding that Zyprexa can be helpful for the patient with
> schizoaffective disorder by itself. Again, because Zyprexa can help with the highs, it can help with the lows and it's also an
> effective antipsychotic medication. So as these newer atypical antipsychotics come out, I'm more hopeful that the
> antidepressants will be less necessary to use with them.
>
> With depression in-patients with schizophrenia, 80% of patients with schizophrenia have a clinically significant degree of
> depression at some time in their lives. Antidepressants help to some degree, but the key with your patients with schizophrenia is
> to be very careful what antipsychotic medication you're using. If you're using the older antipsychotics -- Haldol, Stelazine,
> Prolixin. They cause depression. Try to stay away from them. Use exclusively the newer medications if you can get away with
> doing that, and hopefully you wouldn't have to use your antidepressants.
>
> Depression in borderline personality disorder. It's always there with these borderline patients, and antidepressants can help to
> some degree, but again, I'm using a lot of atypicals with my patients with borderline personality disorder.
>
> And finally, depression with bipolar disorder, if you use an antidepressant medication on somebody with bipolar disorder, be
> very careful they don't swing into the highs. You always want to use a mood stabilizer if you know somebody has bipolar
> disorder and they slip into a depression. You're going to use your antidepressant, perhaps, but always have a mood stabilizer on
> board--lithium, Lamictal, Depakote or Zyprexa, of the newer ones.
>
> Q: Lilly is said to be coming out with a new form of Prozac in the next few years. Do you have any information on it?
>
> Dr. Fawver: I'm a consultant with Eli Lilly. I'm not an employee with Eli Lilly. But what I can tell you, is that the answer is yes.
> They're tweaking an antidepressant that will, essentially, have fewer side effects and their hope is that it will have a faster onset
> of action.
>
> Q: With PMS symptoms, can you use the Prozac only the week of the symptoms?
>
> Dr. Fawver: I've been doing that for 10 years now. I noticed back in 1990, if I had women who were good Wellbutrin
> responders, but they still had the PMS there, I'd put them on the Prozac, 20 mgs a day just on the PMS days, maybe five days
> a month, and it did great. I've had other women who were referred to me by primary care doctors only for their PMS, which
> we would now call premenstrual dysphoric disorder. It was severe PMS that was incapacitating for five to seven days before
> their periods. You can use Prozac, 20 mgs a day or Zoloft, 50 mgs a day. They tend to do very well with that. It's called luteal
> phase dosing, also known as intermittent dosing, also known as pulse dosing. It's been compared directly with continuous
> dosing. Works just as well. So there's a lot of validity to that. Now you might think, how can an antidepressant work with just
> five or six days of treatment? Keep in mind that PMS is not a true clinical depression. Major depression or a clinical depression
> is the type of depression that causes significant receptor changes in the brain. It takes you four to six weeks to reverse those
> receptor changes with a major depression. PMS you don't have those type of receptor changes. So with PMS, you take the
> Prozac within 20 minutes and you can feel better. If any of us in this room right now took 20 mgs of Prozac, in about 20 to 30
> minutes our serotonin levels in our brain would increase. Would we notice it? Only if we were a little bit low on serotonin to
> begin with. For instance, if you were two or three days before your period, and you took a Prozac 20 mg capsule, you would
> feel better in 20 or 30 minutes. And it's not placebo effect, you actually feel better. So there's a lot of validity to that. Once the
> woman begins her menstrual flow for that month, that's when she stops the medication. I've found that to be very effective.
>
> Q: Can you repeat the drugs that inhibit cytochrome P450 3A34?
>
> Dr. Fawver: If you use Serzone in conjunction with Propulsid, it's contraindicated. Propulsid could cause you to have a
> potentially fatal cardiac arrhythmia. So do not use Propulsid with Serzone and Luvox. So Luvox and Serzone are the two
> antidepressants that we have to be very careful in using Propulsid. That's what you always ask them about. Fortunately, Seldane
> is now off the market, so we don't have to worry about that any more.
>
> Q: In elderly patients and dropouts, was there a difference between the older and the newer medications?
>
> Dr. Fawver: With the elderly patients, specifically, there was not a difference in dropouts. Curious effect. But in the general
> overall population, more people dropped out on the older medications compared to the newer populations. But for the elderly
> population, specifically, in the study I showed you, there was no difference.
>
> Q: Briefly compare and contrast the various treatment modalities in late-life depression.
>
> Dr. Fawver: A lot of people who are old-old, those being people over 80 years of age, they often respond very nicely to very
> small amounts of medication. Those are your Prozac 5 mg patients. Those are your Paxil, 10 mgs a day patients, or maybe even
> your Zoloft, 25 mgs a day patients. They are often exquisitely sensitive to very small amounts of medication. I will often combine
> a small amount of these newer medications for depression with just a pinch of Ritalin or Dexedrine, and it will perk them up very
> nicely, especially if they've given up on life, especially if they're medically ill, if they have cancer, if they have heart disease, I
> watch their blood pressure and heart rate pretty closely. You can add 5 mgs of Ritalin twice a day, start at 2.5 mgs twice a day,
> but often 5 mgs of Ritalin in the morning and 5 mgs at noon in combination with your SSRI can give them a nice energizing
> effect. They don't tend to increase the dosage and escalate that, they often do very nicely with a nice, small dosage. But the key
> with these newer medications is that a small amount goes a long way. I showed you the study with the geriatric patients with
> citalopram or Selexa. But really any of the newer agents can be beneficial.
>
> Q: Atypical antipsychotics?
>
> Dr. Fawver: Absolutely. The atypical antipsychotic medications are good for the elderly patients that have psychotic
> depression. By itself, Zyprexa does not appear to be a good medication for unipolar depression. So if you have some patient
> with major depression and you only give them Zyprexa, it's probably not going to work that well. But you give that patient
> Prozac and they partially respond, and then add Zyprexa 5 to 10 mgs to it, they can get a dramatic improvement in their
> response. For some reason, Zyprexa needs a little bit of an antidepressant to help squeeze out that extra dopamine and
> norepinephrine from the frontal lobes. Zyprexa you going to find in terms of a new indication that Lilly's going to come out with,
> and this is very public, you're going to see a bipolar indication for Zyprexa. They've already gotten a written letter of approval
> from the FDA. You're going to find that in the future, Zyprexa will be a very nice mood stabilizer and we're going to be treating
> a lot of patients with it monotherapy for bipolar disorder. I've been using Zyprexa now for two years for my patients with
> bipolar disorder, and more often than not, I'm able to get by on using Zyprexa as monotherapy. I don't have to add
> antidepressants or benzodiazepines to it. So it will be a fun treatment to watch.*************************************************
John:
Are you the same John that has been promoting Adrafanil and Amisulpride on this board? If you are, then as I read this, do I detect a shift in your strategies? It seems that you now are promoting the atypical APs, along with Lamictal, and possibly concomitan treatment with an SSRI? What happened to the Adrafanil and Amisulpride, just out of curiosity?
BTW, the science and logic behind the Zyprexa addition seems very sound. My concern is the often reported significant weight gain on Zyprexa. Also, I took Lamicatal for awhile last year, and developed a rash. I don't think I went as slowly as some... but I followed the package insert instructions. Do you think it would be worth another try with an extremely slow dosage titration?
Bob
poster:bob
thread:78359
URL: http://www.dr-bob.org/babble/20010907/msgs/78399.html