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Dr. Bob is Robert Hsiung, MD,
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Posted by ed_uk2010 on January 26, 2015, at 13:23:13
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 26, 2015, at 13:16:30
OK, so how bad is your depression now? And how bad is the insomnia? I mean, do you feel very distressed by it? Or not so bad?
Perhaps lithium carbonate might help the depression, rather than lithium orotate.
Posted by Lamdage22 on January 27, 2015, at 3:00:09
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by ed_uk2010 on January 26, 2015, at 13:23:13
My mood is like a 4 out of 10.
I could sleep yesterday with 40 mg pipamperone and 12.5 Zyprexa (instead of 15).
Lithium at 300 led to humongous weight gain so i dont even want to know about, say 900.
Posted by ed_uk2010 on January 27, 2015, at 5:56:40
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 3:00:09
Morning.
> My mood is like a 4 out of 10.
It does sound like you need further treatment for this. Which antidepressants have you tried and how do you respond? It looks like you don't tolerate high doses of serotonergic drugs like venlafaxine.
>I could sleep yesterday with 40 mg pipamperone and 12.5 Zyprexa (instead of 15).
Excellent that you could sleep!
I suppose what I'm wondering is..... taking pipamperone may allow you to reduce Zyprexa to some extent by blocking some of the same receptors, but do you think things will be better by taking three antipsychotics instead of two? What do you plan here? The incidence of side effects with pipamperone does not seem very well established but sexual dysfunction/libido loss is often reported so I assume it elevates prolactin.
Regarding Seroquel, do you find you need the daytime doses to relieve agitation?
>Lithium at 300 led to humongous weight gain so i dont even want to know about, say 900.
You may need to be cautious about valproic acid (valproate) since it causes weight gain so frequently. It's generally more effective against manic symptoms than depression. Do you have a history of mania or mixed states? I'm wondering if this is why your doctor mentioned it.
Posted by Lamdage22 on January 27, 2015, at 7:10:50
In reply to Re: Multiple mechanism with Zyprexa and some atyp » Lamdage22, posted by ed_uk2010 on January 27, 2015, at 5:56:40
Hi Ed,
it is clear that i need depression tteatment, but this treatment is not on the market yet. Trust me we tried all that could be tried or all that is worth trying.
Im not taking the valproic acid.
Its not worth the risk.
So do you think trazodone could be better for me? The "non-addicting" sleep meds arent too many.
Posted by Lamdage22 on January 27, 2015, at 7:14:06
In reply to Re: Multiple mechanism with Zyprexa and some atyp » Lamdage22, posted by ed_uk2010 on January 27, 2015, at 5:56:40
i took like 900 seroquel all at night the other day, i still couldnt sleep. I just took like 300mgs ontop of the 500 i take at night.
No sleep until 15mg of Zyprexa.
Pipamperone is more sedating than zyprexa but it is way less potent than zyprexa.
Thats what im ttying to do. Replace the high potency stuff with lower potency.
Im still for trazodone.
Posted by Lamdage22 on January 27, 2015, at 7:20:37
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 7:14:06
Or not trazodone.
Idk seriously and im not going to worry sick about all this.
Posted by ed_uk2010 on January 27, 2015, at 8:52:09
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 7:14:06
> i took like 900 seroquel all at night the other day, i still couldnt sleep. I just took like 300mgs ontop of the 500 i take at night.
Oh right, I guess that's not going to work then.
>Pipamperone is more sedating than zyprexa but it is way less potent than zyprexa.
Less potent just means fewer milligrams though, it doesn't mean better. In general, highly potent antipsychotics like haloperidol cause less weight gain than low potency neuroleptics, but there are many exceptions (as you know!). I doubt pipamperone causes as much weight gain as Zyprexa, for example.
>I'm still for trazodone.Trazodone is probably worth a try, as a non-antipsychotic alternative to pipamperone which might allow you to sleep on a lower total antipsychotic dose. Trazodone is one of the more weight neutral options and doesn't elevate prolactin. It doesn't normally cause sexual dysfunction either. I don't know whether it would help your depression - it might. Would your doctor be up for trying it?
Posted by Lamdage22 on January 27, 2015, at 9:16:11
In reply to Re: Multiple mechanism with Zyprexa and some atyp » Lamdage22, posted by ed_uk2010 on January 27, 2015, at 8:52:09
I dont know. He might be.
But trazodone can cause arrythmias as well as Seroquel and Zyprexa.
Its hard to tell which is the better alternative for me.
Posted by ed_uk2010 on January 27, 2015, at 9:34:14
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 9:16:11
>But trazodone can cause arrhythmias as well as Seroquel and Zyprexa.
It's possible, but the same risk applies when adding another antipsychotic. Either way, you should be having an ECG to check your QTc interval.
>Its hard to tell which is the better alternative for me.
You'd really have to try trazodone to see if it helps, and to find out whether it allows you to sleep on a lower antipsychotic dose.
Posted by Lamdage22 on January 27, 2015, at 11:21:23
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by ed_uk2010 on January 27, 2015, at 9:34:14
> >But trazodone can cause arrhythmias as well as Seroquel and Zyprexa.
>
> It's possible, but the same risk applies when adding another antipsychotic. Either way, you should be having an ECG to check your QTc interval.
>
> >Its hard to tell which is the better alternative for me.
>
> You'd really have to try trazodone to see if it helps, and to find out whether it allows you to sleep on a lower antipsychotic dose.Hey ed. I had an ecg yesterday. Its totally fine.
I will think about trazodone until my next appointment.
Posted by ed_uk2010 on January 27, 2015, at 12:37:53
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 11:21:23
>I had an ecg yesterday. Its totally fine.
Good to hear.
Have you ever been stable on Seroquel without Zyprexa, apart from insomnia?
Posted by Lamdage22 on January 27, 2015, at 12:40:06
In reply to Re: Multiple mechanism with Zyprexa and some atyp » Lamdage22, posted by ed_uk2010 on January 27, 2015, at 12:37:53
Ed, i once was stable on 200mg Seroquel. (No psychosis)
A ludicrous trial with Parnate, a trial with tianeptine and a "therapeutic" session with an parents=antichrists therapist have led to the dosages i am on now.
Posted by ed_uk2010 on January 27, 2015, at 13:04:40
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 12:40:06
> Ed, i once was stable on 200mg Seroquel. (No psychosis)
OK. Was this recently, and how long were you stable for?
I was wondering really, whether your use of multiple antipsychotics was required for psychosis, or whether the doses had been increased to their current level for insomnia or other reasons?
What was your psychosis like? Schizoaffective disorder is quite variable so I'm unsure.
Posted by Lamdage22 on January 27, 2015, at 13:08:11
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by ed_uk2010 on January 27, 2015, at 13:04:40
> > Ed, i once was stable on 200mg Seroquel. (No psychosis)
>
> OK. Was this recently, and how long were you stable for?No it was 2013. For as long as i didnt try Parnate. Ok i was on 300 then after some time but i could have been on 200 as well.
> I was wondering really, whether your use of multiple antipsychotics was required for psychosis, or whether the doses had been increased to their current level for insomnia or other reasons?
Im not sure if it is psychosis. It does go away with meds though. We call it "pre-psychotic"
> What was your psychosis like? Schizoaffective disorder is quite variable so I'm unsure.
Loss of control.
Posted by Lamdage22 on January 27, 2015, at 13:09:38
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 13:08:11
And yes, after the Parnate trial, after the tianeptine trial and after this ridiculous session with the therapist i was full blown psychotic and thus increased the dosages.
Posted by ed_uk2010 on January 27, 2015, at 13:39:52
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 13:09:38
>i was full blown psychotic and thus increased the dosages...
Delusions and hallucinations?
Posted by Lamdage22 on January 27, 2015, at 13:42:14
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by ed_uk2010 on January 27, 2015, at 13:39:52
delusions.
Posted by Lamdage22 on January 27, 2015, at 14:04:16
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 13:42:14
Its like my mind takes on a life of its own.
It just goes and goes and goes.
If it wasnt psychosis but something else, would it be treated any different?
Posted by ed_uk2010 on January 27, 2015, at 16:38:36
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 14:04:16
>It just goes and goes and goes.
Like rapid thoughts? Were you depressed at the time? Or more manic/overactive/excited? What were the delusions like?
>If it wasn't psychosis but something else, would it be treated any different?Delusions are a form of psychosis, but they can occur as part of mood disorders, as well as primary psychotic illnesses like schizophrenia.
In schizoaffective disorder, delusions occur *mainly* during depressive, manic, or mixed episodes, but also occur when mood is relatively normal *on occasion*. If delusions or hallucinations *never* occur except in the setting of highly abnormal mood, the diagnosis of schizoaffective disorder is not normally applied, and a mood disorder with psychotic features is diagnosed instead eg. major depression with psychotic features ie. 'psychotic depression', or bipolar disorder with psychotic features. Some doctors may diagnose schizoaffective disorder even when delusions only occur during mood episodes, if the delusions are highly bizarre and resemble schizophrenia.
>would it be treated any different?
Schizoaffective disorder is virtually always treated with antipsychotics, other meds can be used as well but not in the absence of antipsychoics.
Treating psychotic depression, and bipolar disorder with psychotic features usually involves antipsychotics, but not absolutely always.
If you don't mind, it would be useful to know something about the delusions. And in what way did you lose control?
Delusions which occur in mood disorders are most commonly related to the mood state eg. during severe depression, someone may have the delusion that they are actually dead.... during mania, someone may believe they are the president. Delusions in schizoaffective disorder are less likely to be clearly related to the mood state, but they can be... they also tend to be more bizarre eg. someone might believe that they can read everyone else's mind, or that people can read their mind... or that their thoughts are being sent to people by the radio, for example. This type of bizarre delusion unrelated to mood is typical of schizoaffective disorder and is uncommon or exists only very briefly in primary mood disorders. The presence of bizarre delusions is strongly suggestive that antipsychotics are needed. Constant or at least very frequent hallucinations, most often voices, are much more typical of schizoaffective disorder than mood disorders - and normally respond only to antipsychotics.
.............
People with a history of psychosis should avoid dopaminergic drugs eg. amphetamines, cocaine, methylphenidate, Parnate, dopamine agonists (eg. Requip, Mirapex) and possibly bupropion. These drugs may induce psychosis. Large amounts of alcohol are also a very bad idea. Cannabis should be avoided. I'm sure you already know all this but I thought I'd write it anyway!
By the way, how do you respond to Lamictal?
Posted by ed_uk2010 on January 27, 2015, at 17:57:16
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 14:04:16
Essentially...
I'm trying to understand you better, rather than making too many suggestions based on inadequate evidence. There is often a tendency for people to make A LOT (of sometimes inappropriate) suggestions on forums like this without really knowing much/anything about the person they're making suggestions to. I'm keen to avoid this type of thing. It can be harmful.
This is the impression I get....
You have a long history of depressive illness, and some anxiety. Various trials of medication did not provide relief. You then had an episode in which you became delusional and rather out of control while taking Parnate. This episode has been difficult for you to recover from. You are currently not psychotic but feel depressed most of the time and have trouble sleeping.
Is that about right?
I don't need to know exactly, but how old are you now and how old were you when your mental health problems began? Have you ever had a psychotic or manic episode when NOT taking an antidepressant? The Parnate episode sounds like drug-induced psychosis.
About trazodone....
Have you ever taken it before?
It seems that Seroquel has been beneficial to you over quite a long period of time. You mentioned being stable on Seroquel alone at one point. Seroquel is known to have antidepressant, antimanic and antipsychotic properties. I can't really say whether you would develop psychotic symptoms again if you reduced Zyprexa too much. I think the risk depends partly on whether your psychotic symptoms occur only in response to certain antidepressants (eg. Parnate), or whether they occur spontaneously. Obviously, if you have a history of delusions, psychosis or loss of control in the *absence* of triggering medication, you are more likely to experience psychosis on reducing Zyprexa than if you experience such symptoms only when triggered by meds. Consideration of this issue is important because it could help you, and your doctor, decide whether they is any chance of reducing your antipsychotic meds in the presence of a sedating drug such as trazodone for sleep.... or whether this would be unwise. The major purpose of reducing Zyprexa would be to reduce your weight or improve your physical health, I assume? So, it would only really be of value to reduce Zyprexa if, a) you are currently needing to lose more weight even in the presence of metformin and b) if you were able to find a replacement for Zyprexa which would treat your insomnia and maintain your stability without causing weight gain itself.
Posted by ed_uk2010 on January 27, 2015, at 18:01:07
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 9:16:11
And, what are your height and weight at the moment?
Posted by ed_uk2010 on January 28, 2015, at 5:33:18
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by ed_uk2010 on January 27, 2015, at 18:01:07
I just wanted to mention. I do know people who've not put on any weight with valproate. Still, it does cause weight gain frequently. It's mainly a good choice for those who have a clear history of manic or mixed mood episodes as well as depression.
Posted by Lamdage22 on January 28, 2015, at 5:39:13
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by ed_uk2010 on January 27, 2015, at 16:38:36
>It just goes and goes and goes.
"Like rapid thoughts? Were you depressed at the time? Or more manic/overactive/excited? What were the delusions like?"
Hmm rapid i dont know. Yes i was depressed. Most of the delusions were of the depressive type. But some grandiose delusions as well. The delusions were that everything is about me in a way if that makes sense. That everything is connected.
"You have a long history of depressive illness, and some anxiety. Various trials of medication did not provide relief. You then had an episode in which you became delusional and rather out of control while taking Parnate. This episode has been difficult for you to recover from. You are currently not psychotic but feel depressed most of the time and have trouble sleeping.
Is that about right?"
YES.
"Have you ever had a psychotic or manic episode when NOT taking an antidepressant? The Parnate episode sounds like drug-induced psychosis."
Most of it drug induced. Mania, definitely no without antidepressants. Psychosis, well i never recovered from drug induced psychosis.
I dont think i can reduce Zyprexa.
I may have psychotic depression. Certainly not clean schizophrenia. I would say im somewhere in between psychotic depression and schizo-affective, type depressive.
It may be one or the other.
Tendency is definitely depression. I seem to be on a whole different scale. What is euthymia for someone else may be mania for me. Does that make sense?
Posted by ed_uk2010 on January 28, 2015, at 6:01:07
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 28, 2015, at 5:39:13
Morning.
>The delusions were that everything is about me in a way if that makes sense. That everything is connected.
Yes, it does. Sometimes called 'delusions of reference' ie. involving beliefs that things which are not really specific or even related to yourself are personal to you. People often believe that someone on television is talking to them personally, for example.
>Is that about right?"
>
> YES.Good to know I've got approx. the right idea.
>Psychosis, well i never recovered from drug induced psychosis.
It's difficult to know what your diagnosis should be, or if it indeed matters. Prominent delusions of reference are more typical of schizoaffective disorder or drug-induced psychosis than psychotic depression. To me, it sounds rather like you had a drug-induced psychotic episode superimposed on a chronic depressive illness.
>I dont think i can reduce Zyprexa.
OK, in that case, you just need to look at managing the side effects. You've already had success with metformin. If you are still overweight there are further options to consider.
>I would say im somewhere in between psychotic depression and schizo-affective, type depressive.
It does make sense yes, but I think the diagnosis has been blurred by the additional of drug-induced symptoms eg. while on MAOIs. Amongst other things, MAOIs inhibit the breakdown of dopamine in the brain - they're not a good choice for those prone to psychosis.
>Tendency is definitely depression.
I see that. That's your state much of the time. The psychotic episodes and grandiose thoughts have existed more briefly in the overall course of your illness.
So, I suppose you need:
1. Avoid all drugs likely to worsen your illness eg. stimulants, MAOIs, dopaminergics etc.
2. Keeping taking Seroquel. It should stabilise your mood and prevent psychotic relapse. It has some antidepressant effect.
3. Adjust your Zyprexa dose gradually if necessary, to find a dose which works well without causing too many side effects.
4. Continue metformin, and consider other options for weight loss if needed. Both medication and non-medication options.
5. Decide whether you'd like to continue pipamperone or try a different med to aid sleep.
6. Consider what might be a useful way of improving your depression without risking mood destabilisation or psychosis. What symptoms of depression do you have right now, apart from low mood? If you look at a list of depression symptoms online it might help to clarify what sort of mood state you're in right now, which could potentially help in treatment selection.
Do you have any other psych problems right now apart from depression and insomnia, which are in need of treatment? eg. nightmares, anxiety etc.
Posted by ed_uk2010 on January 29, 2015, at 10:32:10
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 28, 2015, at 5:39:13
Hi Lamdage,
How are you doing?
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