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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 22 of 22. This is the beginning of the thread.
Posted by Schlepo on March 24, 2019, at 20:28:04
Hi. I've been on Olanzapine for almost three months (2.5mg initially, started 5mg last week) and due to some possible cognitive side effects (sluggishness, apathy, sedation, etc. - though these could also be related to depression) would really like to try something else. Other antipsychotics I've tried include Seroquel (decreased blood-pressure on a small dose) and Abilify (bad anxiety and nausea after two weeks.) I'm also on 75mg of nortriptyline (which is probably too low, but that's another story.)
I find Olanzapine to be great for anxiety, but less effective so far on depression (which just recently became severe.) Mentioned Rexulti to my pdoc, but she doesn't like prescribing "unproven" medications, and I am a bit concerned about it being too similar to Abilify.
So basically, I guess I'm looking for something that works on anxiety the same way that Olanzapine does, but pushes on depression a little bit more. I'd like to avoid dopamine agonists due to my bad reaction to Abilify, but it could be just what I need and this depression is hell. I'm also hoping for something that's easy to switch from Olanzapine, since what I'm going through is hard enough without extra withdrawal symptoms. I guess another antipsychotic would be best, but I'm open for anything. So any ideas?
Posted by Christ_empowered on March 25, 2019, at 5:08:46
In reply to Alternatives to Olanzapine., posted by Schlepo on March 24, 2019, at 20:28:04
latuda i think is the new 'it' neuroleptic for depression treatment. that's assuming, of course, that a neuroleptic is appropriate for you.
before I developed 'bipolar i,' tca (in my case, tofranil-pm, the updated tofranil) plus a stimulant helped depression, a lot. of course...
'depression' is kind of a vague term and covers a lot of ground.
a thought occurred to me; symbyax? you'd get the prozac and zyprexa in one pill, one copay...they make a 3 olanzapine/25 prozac pill now (I think?), and because its FDA-approved, there's a lot more data on that combination than on any other neuroleptic-antidepressant combination. but...
? I would think a skilled doctor could keep you on the nortip and add symbyax...then again, maybe not so much. also, more modern shrinks aren't too fond of fixed combo pills...they're a throwback to the 60s.
blah blah blah. when you say 'depression,' what's going on that you think would respond to pill treatment? what's worked for these problems in the past? what hasn't? have you done recent lab work (if possible, of course) to see how you're doing, physically?
ok. I hope this helps a bit.
Posted by Schlepo on March 25, 2019, at 15:14:12
In reply to Re: Alternatives to Olanzapine., posted by Christ_empowered on March 25, 2019, at 5:08:46
> latuda i think is the new 'it' neuroleptic for depression treatment. that's assuming, of course, that a neuroleptic is appropriate for you.
>
> before I developed 'bipolar i,' tca (in my case, tofranil-pm, the updated tofranil) plus a stimulant helped depression, a lot. of course...
>
> 'depression' is kind of a vague term and covers a lot of ground.
>
> a thought occurred to me; symbyax? you'd get the prozac and zyprexa in one pill, one copay...they make a 3 olanzapine/25 prozac pill now (I think?), and because its FDA-approved, there's a lot more data on that combination than on any other neuroleptic-antidepressant combination. but...
>
> ? I would think a skilled doctor could keep you on the nortip and add symbyax...then again, maybe not so much. also, more modern shrinks aren't too fond of fixed combo pills...they're a throwback to the 60s.
>
> blah blah blah. when you say 'depression,' what's going on that you think would respond to pill treatment? what's worked for these problems in the past? what hasn't? have you done recent lab work (if possible, of course) to see how you're doing, physically?
>
>
> ok. I hope this helps a bit.Depression seemed to begin about 5 months ago (before then I think I mainly suffered from generalized anxiety.) For the most part it was concomitant with anxiety, but now it seems to have gone severe and independent. For me it largely consists of apathy and a complete loss of interest in things; I'm just not myself anymore. I have no ideo if my pdoc would be willing to try symbax. I was thinking more in terms of a different AP or some other augment.
Posted by Schlepo on March 25, 2019, at 15:20:37
In reply to Re: Alternatives to Olanzapine., posted by Schlepo on March 25, 2019, at 15:14:12
I also should mention that I already tried Prozac (I was initially thinking Symbax was a combo of Zoloft and Olanzapine for some reason.) It was about a year after I started nortriptyline. I took it separately and it took only about two days to realize I was better off on nortriptyline.
Posted by Christ_empowered on March 25, 2019, at 19:13:38
In reply to Re: Alternatives to Olanzapine., posted by Schlepo on March 25, 2019, at 15:20:37
hi. before i went completely and totally crazy insane...and, therefore, I now -require- a full dose 'atypical,' often + mood stabilizer(s), etc...this is what really, really helped me: skip the antidepressant(s).
its 3 drugs: 1) sedative (gabapentin, lyrica, benzodiazepine...perhaps a nicer, cleaner mood drugs, such as lamictal, since they tend to be camling, too) 2) 'atypical' (take your pick...id skip over risperidone, invega, or, in your case, olanzapine) and 3) an upper (amphetamines pack a punch, but I think ritalin or focalin are better, long term).
i didn't know it when I was on it, but that was a pretty common combo back in the 50s-maybe 70s (the so-called "Golden Age of Psychopharmacology").
deal is..."antidepressant" is more a marketing term than anything else. the MAOIs were originally drugs for TB...some people went manic on them, and boom...mood elevators. tofranil, the 1st tca, was intended to be a Thorazine rip off, a 50s me-too drug...
the psychosis people got worse, a lot of the severely depressed got better, and again; something like 1/4 of the depressives turned straight up manic.
now, so many people seem to be on the constant med go 'round with the antidepressants, in particular. im oddly 'lucky' in that most of them are not an option, but the prescriber person is ok with wellbutrin, which...again, is not an 'antidepressant'; its a mild stimulant, closely related to Tenuate, a milder diet pill from back in the day.
that's just what worked for me, way back when....not all psych docs will go for it. if you have excellent insurance, Provigil/Nuvigil might be a mild, less euphoric 'upper' option. wellbutrin....maybe? i do well with it, but it seems (to paraphrase one of many former psychiatrists) "less predictable than the stimulants..."
ok. oh, and I seriously recommend orthomolecular, or at least...some heavy duty b and c and e, additional antioxidant supplementation...to anyone and everyone, especially those of us on psych drugs.
:-)
Posted by Schlepo on March 26, 2019, at 14:54:12
In reply to Re: Alternatives to Olanzapine., posted by Christ_empowered on March 25, 2019, at 19:13:38
I know that I'd go into serious withdrawal if I ever stopped nortriptyline. Is there a combo that would fool my body into thinking that I was still taking it?
Posted by Lamdage22 on March 27, 2019, at 6:07:04
In reply to Re: Alternatives to Olanzapine., posted by Schlepo on March 26, 2019, at 14:54:12
Saphris. Do you really want to take an Antipsychotic off label?
Posted by Schlepo on March 27, 2019, at 14:09:03
In reply to Re: Alternatives to Olanzapine., posted by Lamdage22 on March 27, 2019, at 6:07:04
> Saphris. Do you really want to take an Antipsychotic off label?
The Olanzapine is off label?
Posted by Christ_empowered on March 27, 2019, at 15:56:30
In reply to Re: Alternatives to Olanzapine., posted by Schlepo on March 27, 2019, at 14:09:03
hi. until recently, using most neuroleptics/antipschotics in depression was considered off label. i think...there's a 60s combo pill still out there, perphenazine and elavil together...i think that was approved for some rough forms of depression.
anyway...what drugs has your psychiatrist talked to you about? some people need antipsychotics, at least for a while. if you can make a go of things without one...
more power to you.
olanzapine is somewhat unusual...i think symbyax is approved for 'treatment resistant depression,' so in that sense, its not off label to use zyprexa.
i think a lot of the newer 'atypicals' are approved to use with an antidepressant. seroquel...i remember reading that they'd done studies showing it could, sometimes, for some people, treat some forms of depression at a low(ish) dose...
but I dont know if it has fda approval as monotherapy or not. plus, seroquel can be rough. but not always.
Posted by SLS on March 27, 2019, at 16:20:28
In reply to Re: Alternatives to Olanzapine., posted by Lamdage22 on March 27, 2019, at 6:07:04
> Saphris.
That's not a bad recommendation.
> Do you really want to take an Antipsychotic off label?
There is a new drug coming out that is a reuptake inhibitor of both dopamine and norepinephrine - solriamfetol. It was first tested as an antidepressant, but will be approved for narcolepsy. I don't know why they abandoned the depression indication. I would probably want to try it off-label, but I'm sure insurance won't cover it. Before insurance companies became too powerful, doctors were able to do such things. Unless one is a multimillionaire, paying cash for newly-approved drugs is not an option. For instance, the new postpartum antidepressant will cost $34,000 for a full course of treatments. Esketamine (Spravato) costs $700 per dose.
What drug companies and insurance companies do is unconscionable.
- Scott
Posted by Schlepo on March 27, 2019, at 18:45:43
In reply to Re: Alternatives to Olanzapine., posted by Christ_empowered on March 27, 2019, at 15:56:30
> hi. until recently, using most neuroleptics/antipschotics in depression was considered off label. i think...there's a 60s combo pill still out there, perphenazine and elavil together...i think that was approved for some rough forms of depression.
>
> anyway...what drugs has your psychiatrist talked to you about? some people need antipsychotics, at least for a while. if you can make a go of things without one...
>
> more power to you.
>
> olanzapine is somewhat unusual...i think symbyax is approved for 'treatment resistant depression,' so in that sense, its not off label to use zyprexa.
>
> i think a lot of the newer 'atypicals' are approved to use with an antidepressant. seroquel...i remember reading that they'd done studies showing it could, sometimes, for some people, treat some forms of depression at a low(ish) dose...
>
> but I dont know if it has fda approval as monotherapy or not. plus, seroquel can be rough. but not always.
>
>Actually the only thing my pdoc has talked about is raising my olanzapine. I mentioned Rexulti, but she has no interest in new "unproven" medications. Briefly spoke about switching nortriptyline to something else, but that would require closer monitoring than she could provide (and I sort of agree there.)
Posted by Lamdage22 on March 28, 2019, at 7:51:05
In reply to Re: Alternatives to Olanzapine., posted by Schlepo on March 27, 2019, at 18:45:43
Unless you have psychosis or mania, its off label. Anxiety is off label
Posted by Lamdage22 on March 28, 2019, at 7:52:17
In reply to Re: Alternatives to Olanzapine., posted by SLS on March 27, 2019, at 16:20:28
That's insane!
>$34,000 for a full course of treatments.
Posted by Christ_empowered on March 28, 2019, at 9:33:58
In reply to Re: Alternatives to Olanzapine., posted by Schlepo on March 27, 2019, at 18:45:43
maybe ask about buspar (buspirone) ? it can boost under-performing antidepressants, sometimes...
and its generic, usually inexpensive, i don't think it carries the crazy adverse effect burden of olanzapine. dosing is often 3x daily, though, which...is a pain. :-(
i think once can take Prozac w/ nortip. in fact...i seem to recall a couple, maybe more than a couple, of posters here pursuing that 'augemntation strategy,' as the pros call it. i just mention that because...
symbyax. at some point, i think they introduced a 3mgs olanzapine+25mgs Prozac combo pill. might be easier than adjusting 2 meds separately, plus you'd just get stuck with the 1 co-pay (but you know your coverage...i don't, obviously).
other than that...has the pdoc ever mentioned a sedative? gabapentin, maybe lyrica or a benzodiazepine? with lyrica and the benzodiazepines, long term use can be...tricksy. not always the best idea. however...
some older data in people labeled with "Schizophrenia" seemed to indicate that sufficient doses of benzodiazepines (keep in mind; benzodiazepines were largley unregulated until the 80s) could treat a lot of "prodromal psychotic symptoms" about as well as whatever old school neuroleptics they had floating around back then. and...
even now, its not terribly uncommon for people on long term neuroleptic Rx to be given some sort of sedative...the neuroleptic helps keep the sedative dose lower, the sedative helps keep the neuroleptic dose lower, and GABA-sedatives can help soothe akathisia, anxiety, etc.
just some random thoughts. i hope things get better in your world. :-)
Posted by Schlepo on March 28, 2019, at 18:36:38
In reply to Re: Alternatives to Olanzapine., posted by Christ_empowered on March 28, 2019, at 9:33:58
> maybe ask about buspar (buspirone) ? it can boost under-performing antidepressants, sometimes...
>
> and its generic, usually inexpensive, i don't think it carries the crazy adverse effect burden of olanzapine. dosing is often 3x daily, though, which...is a pain. :-(
>
> i think once can take Prozac w/ nortip. in fact...i seem to recall a couple, maybe more than a couple, of posters here pursuing that 'augemntation strategy,' as the pros call it. i just mention that because...
>
> symbyax. at some point, i think they introduced a 3mgs olanzapine+25mgs Prozac combo pill. might be easier than adjusting 2 meds separately, plus you'd just get stuck with the 1 co-pay (but you know your coverage...i don't, obviously).
>
> other than that...has the pdoc ever mentioned a sedative? gabapentin, maybe lyrica or a benzodiazepine? with lyrica and the benzodiazepines, long term use can be...tricksy. not always the best idea. however...
>
> some older data in people labeled with "Schizophrenia" seemed to indicate that sufficient doses of benzodiazepines (keep in mind; benzodiazepines were largley unregulated until the 80s) could treat a lot of "prodromal psychotic symptoms" about as well as whatever old school neuroleptics they had floating around back then. and...
>
> even now, its not terribly uncommon for people on long term neuroleptic Rx to be given some sort of sedative...the neuroleptic helps keep the sedative dose lower, the sedative helps keep the neuroleptic dose lower, and GABA-sedatives can help soothe akathisia, anxiety, etc.
>
> just some random thoughts. i hope things get better in your world. :-)I recently had a bad experience with benzos (clonazepam and Ativan); I'm just not reacting to meds the way I'm supposed to anymore. I was recently getting a huge mood boost from Ativan, though, and am tempted to try it again (and reluctant to, since I ended up getting anxiety from it.)
Buspar and Lyrica have also been on my mind. Buspar didn't do anything for me the time I tried it (though I was taking it on top of a number of meds.) At that time I was also on Lyrica, which had an antidepressant effect on me (but was also sedating). But as stated, meds don't seem to working properly on me, so everything feels like a gamble.
Posted by Christ_empowered on March 28, 2019, at 19:44:28
In reply to Re: Alternatives to Olanzapine., posted by Schlepo on March 28, 2019, at 18:36:38
hi. perhaps you should see a family doctor/general practitioner about some blood work? there's also the wild world of 'alternative' medicine to consider...
just a thought. shrinks are the least talented doctors out there. kind of a necessary evil, i guess. personally...
i didnt start getting the mileage i really needed out of the tranq (abilify, in my case) until after I started doing Orthomolecular. true story.
i take a low dose of gabapentin right now. im thinking about seeing about a somewhat higher dose, as a 'mood stabilizer.' the prescriber person swears it can help, if one is one other drugs (i dont get it). im really just hoping for a mild mood boost and some anti-agitation effects.
have you tried abilify? and..is there a reason your prescriber is hot to trot with the neuroleptics? i find male shrinks to be worse than female shrinks, usually. just thought id throw that out there...
anyway, hope things get better for you :-)
Posted by Lamdage22 on March 29, 2019, at 11:50:23
In reply to Re: Alternatives to Olanzapine., posted by Christ_empowered on March 28, 2019, at 19:44:28
Oh boy,
not necessarily!> i find male shrinks to be worse than female shrinks, usually. just thought id throw that out there...
Posted by bleauberry on March 30, 2019, at 10:58:18
In reply to Alternatives to Olanzapine., posted by Schlepo on March 24, 2019, at 20:28:04
My personal opinion is Zyprexa is the best antipsychotic on the market. If it falls short, then rather than replace it, add to it. You've already tried some of the others. None of them are as good as zyprexa, imo.
Add to it prozac. If that still isn't enough, add to that either Ritalin or Modafinil.
Any of these combos I just mentioned are strongly anti-depression, pro-hobby, pro-motivation, and anti-anxiety.
Posted by Schlepo on March 30, 2019, at 20:16:02
In reply to Re: Alternatives to Olanzapine., posted by bleauberry on March 30, 2019, at 10:58:18
> My personal opinion is Zyprexa is the best antipsychotic on the market. If it falls short, then rather than replace it, add to it. You've already tried some of the others. None of them are as good as zyprexa, imo.
>
> Add to it prozac. If that still isn't enough, add to that either Ritalin or Modafinil.
>
> Any of these combos I just mentioned are strongly anti-depression, pro-hobby, pro-motivation, and anti-anxiety.If my body chemistry is prone to experiencing anxiety from stimulants (which it probably is), would olanzapine help to counteract that response and balance things out?
Posted by bleauberry on March 31, 2019, at 14:11:10
In reply to Re: Alternatives to Olanzapine., posted by Schlepo on March 30, 2019, at 20:16:02
>
> If my body chemistry is prone to experiencing anxiety from stimulants (which it probably is), would olanzapine help to counteract that response and balance things out?Your question is the exact question I asked myself. Here's what happened.
I tried the stimulant Adderall because most patients find it helpful. I expected some anxiety from it. Within a couple hours of the first dose my depression turned super dark, super deep, and was clouded in massive anxiety and paranoia. It was absolutely horrible. Luckily it wore off in a few hours and I was back to my baseline the next day. It scared me.
So it was a while before I had the guts to try the other one, which was Ritalin.
When I tried Ritalin the experience was totally different. Within an hour it lifted my mood somewhat, and renewed my long lost interest in hobbies or getting things done. I actually wanted to do stuff and I found pleasure in doing stuff. That is what anti depression is supposed to be like. When it wore off there was some anxiety, but there was no anxiety when it was active. So I would time my doses to wear off at bedtime so I wouldn't feel the anxiety. Within a few weeks, Ritalin turned into a great anti-anxiety med. Which was backwards of what I expected.
I share this experience just to highlight that what you said, may not be true. Your fears may not happen.
I actually think antipsychotics can cause more anxiety than they mute. That's because they stimulate the release of NE and they block dopamine - which, depending on whether your dopamine receptors are under sensitive or over sensitive, will either help or hurt anxiety.
Ritalin works as an anti-anxiety for me because my receptors are out of whack. It works that way for school kids too. They get focused but calm.
I fear Adderall when it comes to anxiety, but not Ritalin.
Posted by Christ_empowered on March 31, 2019, at 17:51:05
In reply to Re: Alternatives to Olanzapine., posted by bleauberry on March 31, 2019, at 14:11:10
just from my own limited experience and what i've seen in other, ritalin (or focalin) can help with people on neuroleptics, unless you're on something low potency and sedating (read: seroquel), in which case an amphetamine might make more sense.
Posted by Schlepo on March 31, 2019, at 22:00:09
In reply to Re: Alternatives to Olanzapine., posted by bleauberry on March 31, 2019, at 14:11:10
>
> >
> > If my body chemistry is prone to experiencing anxiety from stimulants (which it probably is), would olanzapine help to counteract that response and balance things out?
>
> Your question is the exact question I asked myself. Here's what happened.
>
> I tried the stimulant Adderall because most patients find it helpful. I expected some anxiety from it. Within a couple hours of the first dose my depression turned super dark, super deep, and was clouded in massive anxiety and paranoia. It was absolutely horrible. Luckily it wore off in a few hours and I was back to my baseline the next day. It scared me.
>
> So it was a while before I had the guts to try the other one, which was Ritalin.
>
> When I tried Ritalin the experience was totally different. Within an hour it lifted my mood somewhat, and renewed my long lost interest in hobbies or getting things done. I actually wanted to do stuff and I found pleasure in doing stuff. That is what anti depression is supposed to be like. When it wore off there was some anxiety, but there was no anxiety when it was active. So I would time my doses to wear off at bedtime so I wouldn't feel the anxiety. Within a few weeks, Ritalin turned into a great anti-anxiety med. Which was backwards of what I expected.
>
> I share this experience just to highlight that what you said, may not be true. Your fears may not happen.
>
> I actually think antipsychotics can cause more anxiety than they mute. That's because they stimulate the release of NE and they block dopamine - which, depending on whether your dopamine receptors are under sensitive or over sensitive, will either help or hurt anxiety.
>
> Ritalin works as an anti-anxiety for me because my receptors are out of whack. It works that way for school kids too. They get focused but calm.
>
> I fear Adderall when it comes to anxiety, but not Ritalin.
>Your description of Ritalin reminds me a bit of a similar dynamic experience I had with Ativan a few months ago. When I took my first .5mg of it (while in a severe depressive state) I initially felt standard anxiety. But after about an hour the anxiety seemed to transform into a kind of euphoria and I realized that my depression had lifted. The euphoria was actually a bit too strong on a full .5mg at once, so I ended up dosing at .25mg 3X a day, and for a period of time everything was fine. What I'm really trying to get at is to figure out the reason why I was getting feelings of euphoria from Ativan and not any anti-anxiolotic or calming/sedating effects. What chemicals would have to be unbalanced for that to happen? Dopamine? Some problem with my GABA receptors? I think that if I could just figure that out I'd have a path to what would be the best treatment.
This is the end of the thread.
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