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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 25. This is the beginning of the thread.
Posted by chand2407 on October 28, 2005, at 0:18:13
anyone found a combo of meds good for psychotic depression
Posted by hawkeye on October 28, 2005, at 0:23:18
In reply to meds for psychotic depression, posted by chand2407 on October 28, 2005, at 0:18:13
Try Geodon. In addition to being an atypical antipsyhcotic, because it is also an SNRI it has true antidpressant qualities. I took it for depression and found it to be a VERY efffective antidepressant.
Posted by xbunny on October 28, 2005, at 4:58:06
In reply to meds for psychotic depression, posted by chand2407 on October 28, 2005, at 0:18:13
> anyone found a combo of meds good for psychotic depression
never tried it but amoxapine is supposed to be good for psychotic depression. Really though the combination of an antipsychotic and an antidepressant should work, tricyclics are often prefered for psychotic depression for some reason. The best combo for you would depend on many factors such as is your depression agitated or withdrawn, the severity of psycchotic symptoms etc.
Buns
Posted by med_empowered on October 28, 2005, at 5:38:49
In reply to Re: meds for psychotic depression, posted by xbunny on October 28, 2005, at 4:58:06
hey! xbunny made an important point--the usual combo is an antidepressant and antipsychotic..the antipsychotic is usually tapered after a while, while the antidepressant is kept longer-term. Amoxapine (Asendin) is a tricyclic that both helps with depression and deals with psychosis..its chemically related to loxapine, the old antipsychotic. Speaking from experience, I found Tofranil-PM (its the new-ish Tofranil with one-a-day dosing) and Abilify to be really helpful. Depending on your symptoms, other medications may also be useful...I found Adderall to be very helpful, and there are some studies that apparently show stimulants help with some cases of psychotic depression. Like xbunny said, tricyclics are the antidepressants of choice most of the time...I guess its because they're better studied. If you use an antipsychotic, adding a benzo and/or buspar can help with anxiety and akathisia..it can also help with some of the depressive symptoms. If your doc opts for a benzo, you could try Limbitrol, which is an Elavil/Librium combo pill. Good luck!
Posted by SLS on October 28, 2005, at 7:42:47
In reply to Re: meds for psychotic depression, posted by med_empowered on October 28, 2005, at 5:38:49
Hi.
I guess the majority opinion is to combine an antidepressant with a neuroleptic antipsychotic. The problem is, which ones?
I would look first to choose the antipsychotic. If psychotic symptoms are prominent, I think a stronger atypical AP like Risperdal 3.0 mg might do the job. I do know someone for whom Seroquel 800mg is working well.
In the past, the tricyclic antidepressants have been thought of as being more efficacious than the SSRIs for psychotic depression. I have seen Wellbutrin be helpful as well. I would have a difficult time guessing as to which tricyclic to choose, but imipramine is the standard by which others are judged. Perhaps you can start with imipramine and switch over to desipramine or nortriptyline if you do not tolerate the side effects well. I am not a big fan of amoxapine. The incidence of EPS side effects with this drug seems to be equivalent to that of the older neuroleptics.
I would be wary of Geodon. Although it can exert mild antidepressant effects, it has also shown that it can precipitate mania and psychosis.
Good luck.
- Scott
Posted by SLS on October 28, 2005, at 7:46:55
In reply to Re: meds for psychotic depression, posted by med_empowered on October 28, 2005, at 5:38:49
Hi M_E.
Which of the older neuroleptics do you like?
I have always liked perphenazine and fluphenazine, but there are so many others, it is hard to create a list of favorites.
Thanks.
- Scott
Posted by B2chica on October 28, 2005, at 9:57:38
In reply to meds for psychotic depression, posted by chand2407 on October 28, 2005, at 0:18:13
i'm on wellbutrinXL 450, zoloft 100, ritalin 20LA, zyprexa 10, and xanax 2.
i've finally found a combo that works.
i think zyprexa really helped for the "wierd stuff".
b2c.
Posted by med_empowered on October 28, 2005, at 12:11:05
In reply to Re: meds for psychotic depression, posted by med_empowered on October 28, 2005, at 5:38:49
hmmmm...I avoid all neuroleptics, and I've never taken an old one...that said, from reading about them it sounds like perphenazine and loxapine would be the "best of the rest" when it comes to old-school antipsychotics. Its worth noting that some studies show a good response rate to just an antidepressant w/o a neuroleptic. I think Risperdal is probably the harshest of the new atypicals in terms of EPS and what not...I kind of view it as a half-way point between Haldol and Clozapine in terms of side-effects and effectiveness. Geodon should probably be second-line for psychotic disorders, since it can cause cardiovascular problems. Seroquel might be the drug of choice if there's prominent agitation and anxiety, but it seems like the sedation and what not would get excessive if a Tricyclic antidepressant was used...abilify or zyprexa could offer the same benefits with less sedation (possibly none at all with abilify) and any anti-anxiety action that was necessary could be taken care of by a benzo.
Posted by chand2407 on October 28, 2005, at 12:35:19
In reply to meds for psychotic depression, posted by chand2407 on October 28, 2005, at 0:18:13
i went to psyc doc 2 days ago and told him about the thoughts of hurting my youngest son i thought it was hearing voices but it is more of thoughts of hurting my youngest son. so i leaned toward psychosis or psychotic depression. i am taking 100 mg of seroquel and 25mg of elavil and .5 of klonopin. i have social anxiety also. so he wants to up the seroquel to another 100mg twice a day. it is helping with thoughts but i am gaining weight. so i need to tell him i am. so do u think abilify and klonopin is good for psychotic depression or do i need a tricyclic med also. in the past i took only 20mg of celexa and that helped but i gained a lot of weight so i was switched to zoloft 50mg and that helped out also. but when the dr upped the zoloft to 100mg things got worse.
Posted by med_empowered on October 28, 2005, at 13:42:09
In reply to Re: meds for psychotic depression, posted by chand2407 on October 28, 2005, at 12:35:19
hi! If you're gaining weight, you can try adding metformin (glucophage, glucophage XR) and/or amantidine. Those medications seem to help **some** people gain less weight on atypicals. Abilify seems like a good option to me...its non-drowsy (usually), its easy to increase or decrese the doses, and it tends to be weight neutral (you probably won't lose or gain weight...any weight changes are usually pretty small). It seems like you could switch out the seroquel, start up the abilify, and then keep everything else more or less the same, except maybe up the Klonopin (abilify can cause some initial anxiety).
Posted by SLS on October 28, 2005, at 13:53:16
In reply to Re: meds for psychotic depression, posted by med_empowered on October 28, 2005, at 12:11:05
> hmmmm...I avoid all neuroleptics,
I thought you had used them from time to time.
> and I've never taken an old one...
I had to. At the time, only clozapine was available to represent the new class of atypical antipsychotics. I was suffering a severe and psychotic manic episode for which lithium was ineffective. For now, I can't imagine my taking one of the older ones for any reason, although I almost tried molindone. However, there might be reasons for which others would rely on them, and I was just curious which of them you favored under such circumstances.
I am in complete agreement with you regarding Risperdal. It is its mixture of typical and atypical properties that led me to mention it in the context of psychotic depression. It also has some antidepressant properties in its own right.
I think the doctor is doing the right thing by continuing to titrate the Seroquel beyond 100mg, a dosage that is probably effective only as a sleep aid and perhaps an anxiolytic.
- Scott
Posted by ed_uk on October 28, 2005, at 15:36:26
In reply to Re: meds for psychotic depression » med_empowered, posted by SLS on October 28, 2005, at 7:46:55
Hi Scott,
>I have always liked perphenazine and fluphenazine, but there are so many others, it is hard to create a list of favorites.
I'd favour (favor!?) haloperidol over perphenazine or fluphenazine. It's a very thoroughly studied drug. IMO, the low dose formulations are particularly useful eg. 0.5mg capsules, 1.5mg tablets.
Due to its potency, haloperidol is a drug which needs to be *very* carefully titrated. In practice, this usually hasn't happened!
Kind regards
~Ed
Posted by SLS on October 28, 2005, at 16:55:23
In reply to Re: meds for psychotic depression » SLS, posted by ed_uk on October 28, 2005, at 15:36:26
Hi Ed.
> Due to its potency, haloperidol is a drug which needs to be *very* carefully titrated.
Big time. It doesn't take much of a dosage difference to pass through the optimum window of receptor occupancy.
> In practice, this usually hasn't happened!
It's usually wham-bam. It's basically used as a chemical straight-jacket in emergency medicine. I would love to see some material on its optimized use and the occurence of EPS when it is.
Thanks for your input.
Thorazine was not gentle with me - immediate orofacial dyskinesia. Prolixin was better.
- Scott
Posted by ed_uk on October 28, 2005, at 17:19:18
In reply to Re: meds for psychotic depression » ed_uk, posted by SLS on October 28, 2005, at 16:55:23
Hi Scott,
Although haloperidol has acquired an particularly unpleasant and disturbing reputation (partly thanks to ER), it really isn't any worse than any of the other high-potency APs....... which perhaps isn't saying much. Nevertheless, it can be useful for some people. It does have the advantage of being a more thoroughly studied drug than any of the other typical neuroleptics.
>Thorazine was not gentle with me - immediate orofacial dyskinesia. Prolixin was better.
I expect it was a matter of dose. At an 'equivalent' antipsychotic dose, chlorpromazine is (apparantly) less likely than fluphenazine to cause a dystonic reaction. As I have discovered myself, the effects of typical neuroleptics are VERY dose-dependent. I was able to tolerate a low dose of chlorpromazine (25mg) reasonably well whereas a high dose caused intense dysphoria and akathisia. 25mg chlorpromazine caused no akathisia whatsoever, although it did make me cognitively impaired!
The exceptional potency of haloperidol (as a D2 antagonist) is illustrated by the following study.......
OBJECTIVE: The authors tested the hypothesis that a dopamine D(2) receptor occupancy level between 60% and 70% in patients with recent-onset schizophrenia would result in optimal subjective experience. In addition, they sought preliminary evidence on whether subjective experience is better with low-dose olanzapine than with low-dose haloperidol. METHOD: Subjects (N=24) who met DSM-IV criteria for schizophrenia were randomly assigned to 6 weeks of double-blind treatment with either olanzapine, 7.5 mg/day, or haloperidol, 2.5 mg/day. Subjective experience, psychopathology, and extrapyramidal symptoms were assessed at baseline and at endpoint. After 6 weeks, D(2) receptor occupancy was assessed with [(123)I]iodobenzamide single photon emission computed tomography. RESULTS: The two study groups were similar at baseline. After 6 weeks, patients receiving olanzapine had a significantly lower mean dopamine D(2) receptor occupancy (51.0%, range=36%-67%) than those given haloperidol (65.5%, range=45%-75%). Receptor occupancy between 60% and 70% was associated with optimal subjective experience, and subjective experience improved significantly in the haloperidol group. CONCLUSIONS: A level of D(2) receptor occupancy between 60% and 70% is optimal for subjective experience of patients with recent-onset schizophrenia. Substantial interindividual variation in D(2) receptor occupancy was seen at fixed low-dose levels of olanzapine and haloperidol. Olanzapine, 7.5 mg/day, showed no superior subjective response over haloperidol, 2.5 mg/day. Olanzapine may need to be dosed higher than 7.5 mg/day for most patients with recent-onset schizophrenia, and haloperidol needs to be individually titrated in the very low dose range to reach optimal occupancy.
~Ed
Posted by SLS on October 28, 2005, at 18:32:44
In reply to Re: meds for psychotic depression » SLS, posted by ed_uk on October 28, 2005, at 17:19:18
Hi Ed.
> > Thorazine was not gentle with me - immediate orofacial dyskinesia. Prolixin was better.
> I expect it was a matter of dose.This is entirely possible. I have no idea how much I was given. It was given acutely for a psychotic mania.
- Scott
Posted by xbunny on October 28, 2005, at 18:41:43
In reply to Re: meds for psychotic depression, posted by med_empowered on October 28, 2005, at 12:11:05
> from reading about them it sounds like perphenazine and loxapine would be the "best of the rest" when it comes to old-school antipsychotics.
where did you read this?
Coincidentally I read in the BNF that loxapine has a high potential for neurological and cardiac toxicity in overdose, wouldnt that make it unsuitable for psychotic depression where suicide attempt is a risk?
Buns
Posted by ed_uk on October 28, 2005, at 18:59:03
In reply to Re: meds for psychotic depression, posted by xbunny on October 28, 2005, at 18:41:43
Loxapine has been discontinued in the UK. It wasn't popular at all.
~ed
Posted by xbunny on October 28, 2005, at 19:19:18
In reply to Re: meds for psychotic depression » xbunny, posted by ed_uk on October 28, 2005, at 18:59:03
> Loxapine has been discontinued in the UK. It wasn't popular at all.
I need a more upto date BNF mines from 1998 maybe I will register on the website!
Buns
Posted by Phillipa on October 28, 2005, at 20:19:14
In reply to Re: meds for psychotic depression, posted by xbunny on October 28, 2005, at 19:19:18
Thorazine wasn't used much where worked because of the BP lowering. Haldol I've never liked. They gave it to the elderly in the hospital to keep them quiet at night. And when it didn't work right away they kept on giving it until they slept. And when they did sleep it was for a few days. Fondly, Phillipa
Posted by med_empowered on October 29, 2005, at 7:33:32
In reply to Re: meds for psychotic depression, posted by Phillipa on October 28, 2005, at 20:19:14
hi! From what I've read, there's been some investigation into seenig if loxapine can act as an atypical (or atypical-ish) antipsychotic. Apparently, some docs think it induces EPS less often than the other typicals; its also closely related to amoxapine, which has some promise in treating some forms of psychosis. It apparently isn't very popular anywhere; it doesn't seem to have really "caught" on at all..I think it might have been introduced a little later than some of the other typical antipsychotics.
Posted by SLS on October 29, 2005, at 9:14:39
In reply to loxapine, posted by med_empowered on October 29, 2005, at 7:33:32
I don't know much about loxapine, but I once did some investigation into the history of the research and development of amoxapine. It turns out that EPS was noted as early as the first pilot study of amoxapine that involved only 10 patients. That's a pretty poor showing.
- Scott
Posted by theo on October 29, 2005, at 13:22:17
In reply to Re: meds for psychotic depression, posted by SLS on October 28, 2005, at 7:42:47
The incidence of EPS side effects with this drug seems to be equivalent to that of the older neuroleptics.
> Good luck.
>
> - ScottBeing new to this class of meds, what are EPS side effects?
By the way, I just took my first dose of Abilify and have that new med 1st time dose anxiety, not knowing what to expect!
Posted by ed_uk on October 29, 2005, at 14:37:50
In reply to Re: meds for psychotic depression, posted by xbunny on October 28, 2005, at 19:19:18
>I need a more upto date BNF mines from 1998 maybe I will register on the website!
It's free!!
......and very quick to register :-)
Ed
Posted by ed_uk on October 29, 2005, at 14:54:58
In reply to Re: meds for psychotic depression, posted by xbunny on October 28, 2005, at 19:19:18
Hi again Buns,
Here's a useful site, you don't need to register.......
Ed
Posted by SLS on October 29, 2005, at 15:34:08
In reply to Re: meds for psychotic depression » SLS, posted by theo on October 29, 2005, at 13:22:17
> The incidence of EPS side effects with this drug seems to be equivalent to that of the older neuroleptics.
> > Good luck.
> >
> > - Scott
>
> Being new to this class of meds, what are EPS side effects?EPS stands for extrapyramidal symptoms. These are the result of the effects that neuroleptic dopamine D2 antagonist antipsychotics have along brain tracts that are outside (extra) the pyramidal layers. Symptoms include abnormal involuntary muscle movements and muscle rigidity. These are known as dystonia and parkinsonism. Akathisia is also a EPS that presents as an extreme motor restlessness that many describe as wanting to crawl out of their skin. It includes anxiety and an inability to sit still. If not managed properly, a person on these drugs can develop, over time, an emergence of involuntary muscle movements around the face and neck known as tardive dyskinesia (TD). This is a more malignant condition that is usually irreversible. TD and EPS in general seem to occur much less frequently with the newer atypical neuroleptics. I don't happen to know what the statistical occurence of TD is with these newer drugs, but it might be characterized as being infrequent or even rare.
> By the way, I just took my first dose of Abilify and have that new med 1st time dose anxiety, not knowing what to expect!
Knowing what to expect puts you at an advantage over the great many people whom remain uninformed by their doctors regarding Abilify startup side effects. Too many people abort their trials prematurely, only to deny themselves the benefits of what is generally a very clean drug.
I hope all goes well with your Abilify trial. I am still taking 10mg. I could probably lower that to 5.0mg and retain the anxiolytic and motivational benefits.
- Scott
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