Posted by med_empowered on September 27, 2005, at 15:49:52
In reply to Re: Atypical antipsychotics for TRD? » Schess81, posted by Emily Elizabeth on September 27, 2005, at 13:26:10
Symbyax, the new-ish prozac+zyprexa combo, is FDA-approved for the treatment of Bipolar I Disorder, Depressed Phase. However, there's a pretty long history of treating treatment resistant (or agitated, severe, or psychotic) depression w/ a combination of antidepressant(s)+antipsychotic (both the older ones and the atypicals). Zyprexa was and is used pretty widely for this indication ("off-label", meaning without the official OK of the FDA), so its no surprise that the Symbyax combo was approved for Bipolar Depression, which is notoriously hard to treat. Although Symbyax is probably the best studied combo, there are other options...all of the atypicals seem to have some antidepressant effects in some people, and if they're used at lower-end dosages in combo with antidepressant(s) (usually an SSRI, but drugs like Effexor, Cymbalta, and the Tricyclics can also be used), the antidepressant effect can be very pronounced. I had good results with low dose (about 5mgs) Abilify (the usual "therapeutic" dose for Abilify when treating schizophrenia or bipolar disorder is at least 10mgs; 30mgs is preferred for florid psychosis or acute, psychotic mania) when combined with low-dose (20mgs) celexa. The biggest improvement was in my anxiety--even with Klonopin, I was stuck in my apartment b/c I was freaking out all the time. Within 2 days or so, there was a profound anti-anxiety effect; within a week, my depression had more or less resolved itself. I'd personally recommend that you look out for some major problems associated with the atypicals, namely the "metabolic syndrome" (elevated LDL cholesterol, insulin resistance, etc.) and the mega-weight gain that can occur, but is particularly common and pronounced with Zyprexa and Clozapine. Geodon is more or less weight neutral, but it does carry some cardiovascular risks (prolongation of the qTC interval). No one really knows the clinical significance of this; for this reason, I'd advise against Geodon unless nothing else is tolerable...also, when doing med combos, your doc will have to be very careful if she opts for Geodon. Seroquel can cause weight gain, type II diabetes, etc. just like zyprexa, but the risk isn't quite as great; the big problem is sedation. That said, seroquel seems to have pronounced anti-depressant effects, at least in those with Bipolar Disorder. Risperdal is another option; its "high-potency," so doses are smaller and sedation is less of an issue. However, its kind of rough; I think one can view Risperdal as drug sort of midway between the old drugs (haldol, perphenazine, thorazine) and the new drugs (clozapine, zyprexa, abilify) in terms of side effects. Abilify is my favorite b/c of the reduced drowsiness (its non-drowsy for a lot of people, but it can be a problem for some) and it doesn't cause weight gain...it can cause metabolic issues, but these seem to be less pronounced than with, say, zyprexa. Plus, Abilify both blocks (antagonises) and boosts (agonises) dopamine and serotonin; the overall effect seems to be much lower EPS (muscle twitches and jerks often seen with antipsychotics). But...it does cause anxiety in some people, especially the beginning of treatment, and there's a big difference in side effects depending on dosage; if you opt for Abilify, I'd really recommend that you try to keep dosage at or below 10mgs/day. Good luck!
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