Options?

[jarn]

I am going through a depressed episode - for now, it's short term, but I see pdoc next week in an effort to nip it in the bud.  

I had a depressed period in the summer, we increased the Zyprexa to 25mg and added Saxenda (liraglutide) instead of metformin.  Liraglutide I have taken off-label for depression in the past.  I take 3mg of Saxenda.  

Thoughts on whether increasing Zyprexa again?  I don't know what pdoc will say, but I want to be prepared.  Or an add-on AD?  My psychosis has been good on Zyprexa, there is that.  It was a last ditch effort before Clozapine.  I've been on the vast majority of AAPs.  A couple of typicals (loxapine and haldol).  

Would clozapine work better?  That'll be a PITA to get right now with the lockdown in Toronto.  But if it's better...I really don't know what to do.  

 

[dancesintherain]

I'd think that adding something makes sense because it seems like you're maxed out on zyprexa (I think?).  Remind me of your experience with lithium and ADs? 

I also can't speak to clozapine, so I don't want to suggest that it's not worth considering.  I just personally can't speak to it. 

[jarn]

@dancesintherain - I've been on lithium twice - very bad results both times.  I've taken two ADs, the first I THINK was Celexa and I went manic (how I got dx'd), I forget the second but I feel like possibly Pristiq.  I was on lamotrigine and AAPs so didn't go manic, but it also didn't work that well.

[dancesintherain]

Gotcha.  I figured there was probably a reason it wasn’t raised, but I couldn’t remember what it was.

[CeremonyNewOrder]

In terms of clozapine, I had a hard time tolerating the sedation but for psychosis it's the best AP I've been on. I was thinking about getting off of it but am re-considering it now. My pdoc claims it can also help with depression. I think it also helped my OCD. If you have insomnia, it can help with that too. It's a very "dirty" drug thus it's effectiveness and large side effect profile. I assume you've tried Abilify. That can help with psychosis and depression.

[jarn]

Thanks @CeremonyNewOrder - yes, I've tried Abilify.  30mg and I still got hospitalized   It was a good med otherwise.  

[aura]

Clozapine has been a miracle drug for me. It helped with both mood and psychosis. The blood draws are a pain, but for me they are worth it. 

[Iceberg]

Clozapine is a massive pain in the ass at times, but it helped both my manic and depressed symptoms way more than zyprexa 

[Will]

There's a lot of praise on this site for clozapine.  It's never been recommended to me, and I suppose that's due to the potential side effects.   When you say it is "dirty" (in another thread), I assume you mean it affects more neurotransmitters.  Is it significantly more sedating than olanzapine?

Not trying to hijack the thread.  Hopefully these are relevant remarks.  

[Iceberg]

1 hour ago, Will said:

There's a lot of praise on this site for clozapine.  It's never been recommended to me, and I suppose that's due to the potential side effects.   When you say it is "dirty" (in another thread), I assume you mean it affects more neurotransmitters.  Is it significantly more sedating than olanzapine?

Not trying to hijack the thread.  Hopefully these are relevant remarks.  

That doesn’t seem like a hijack to me. RE: sedation. It depends. For me low does clozapine was about as sedating as high dose olanzapine. Higher dose clozaril (400 mg) forget it, I had trouble going up steps. And yes that’s usually what dirty means.

I think that whether it gets recommended also depends a lot on symptom profile. I think that pdocs are mor likely to use it when psychosis is a major factor. 

[CeremonyNewOrder]

I also gained a lot of weight on it and I hadn't really gained much weight on the other APs

[Will]

1 hour ago, Iceberg said:

I think that pdocs are mor likely to use it when psychosis is a major factor. 

Psychosis is the major factor for me.  It was weird that I had never heard of clozapine for bipolar, despite it being around forever, until within the last couple years hearing a presentation by a pdoc from Mayo during which he talked about its effectiveness for refractory psychosis in bipolar disorder. 

 

1 hour ago, CeremonyNewOrder said:

I also gained a lot of weight on it and I hadn't really gained much weight on the other APs

I don't seem to gain much weight on anything including typicals when I first started at this "back in the day" (haldol, mellaril, thorazine, lidone, you name it), including depakote, but I haven't tried clozapine.  Granted, it all comes down to individual reactions.

One thing that deters me from clozapine is my cursory looking around the web indicated that it might worsen OCD, which is something which causes me intermittent problems.   It does appear to be indicated for depression which is jarn's issue. 

Edited November 27, 2020 by Will
Saw a chance to be more verbose

[jarn]

I need a beefy anti-psychotic too...I tend very heavily to psychotic stuff.  It's been good on Zyprexa, so far (9 months in) so I'm hesitant to change it, but I also don't want him to say 'Oh, up it to 30mg' because I went from 20mg (for psychosis) to 25mg because of breakthrough depression.  

Though I barely slept last night, even with Ativan, and was angry for awhile, so it is entirely possible I'm switching to mixed.  We shall see.

[jarn]

More crying today.  The morning was productive, the afternoon I've most been on the couch.  My husband thinks its the social isolation, I really don't know.

[dancesintherain]

sorry jarn, that sounds rough.  I empathize--from 10-2ish was decent, but the afternoon I spent taking a nap, going for a walk, and taking a bath/shower (multiple times). 

[jarn]

I had a bath too!  Twinsies!  

I'm sorry you relate.  The only good thing about today is I don't feel dumb for getting my appointment with pdoc moved up to Wednesday now.  

[jarn]

I told pdoc Toby thinks a lot of my depression is isolation - and he agreed.  He doesn't want to do big changes heading into a winter break (I think they close the clinic for a bit) and because 'COVID is temporary' meanwhile I'm staring down months of isolation, because we're not going back to the office potentially until May (that's in part of an oddity of my employer, aside from COVID).

So he increased the zyprexa to 30mg.  And I see him in a couple of weeks.  I feel very frustrated.  

He said since I'm not sleeping well the 30mg should be well tolerated from a sedation standpoint.  I suppose that's one way of looking at it.