Finding a new AP... help?

[jmb252]

Hi all,

I'll try to make this as short and clear as possible, which is difficult since I'm not really thinking properly lately. I'm BP 1 w/psychotic features. My cocktail until recently has been Zonegran 300 mg twice a day, Cymbalta 120 mg, Dextrostat 10 mg, and Seroquel 600 mg.

This cocktail did provide me a significant relief from symptoms, and I was generally stable on it. However, I was still having persistent psychotic symptoms (voices. thought transmission and paranoia, mainly; I have figured out that I only really get full audio and visual hallucinations when I am fully manic or depressed). I also had significant weight gain - 60 lbs since Februrary or thereabouts.

I talked to my pdoc about trying something other than Seroquel and he said ok. We agreed to first try taking me off of the Seroquel and not replacing it, just in case it turned out I didn't need "another damn pill," as he sometimes says. Well... no major crisis, but I got severely paranoid and in a really fucked up mood that I can't even describe very well (I'm still in it and still don't know what the fuck it is).

I saw him again on Wed. and he didn't give me a new AP, just upped the Zonegran dose. I talked to my husband and was frustrated and talking about going off all my meds. My husband called my pdoc and I got dragged in yesterday (Thursday) for a second appointment.

The end result was that I got put back on 300 mg Seroquel for the next week to stabilize me. Last night it was really hard to take the pill because I was sure it was going to kill me. I still feel hungover from it and don't want to take it again tonight.

The other end result is that my pdoc has a very narrow view of which APs he wants to prescribe. We've tried Abilify and Geodon with no success. He won't do Zyprexa because of the weight gain. He says Risperdal is too much like the old school APs and won't prescribe it. He won't prescribe the old school APs because there are newer and better drugs. And that's the end of the little list he wrote out to show me and my husband of my options right now.

So I need to spend this next week coming up with some serious evidence to convince him to give me something he doesn't want to give me. But I'm too stupid and fucked in the head to do so because I need a med that I don't yet have...

Has anybody else had to bring in the big guns of documentation to get a pdoc to prescribe something they just don't "like" to prescribe?

Any help, advice, ideas, documentation on APs other than Seroquel, Geodon, Abilify or Zyprexa?

jen

[Fidget]

I am currently going through withdrawal symptoms from Risperdal.. it made me cry all the time and actually heightened my anxiety/paranoia. I have yet to find an AP that works for me. Seroquel made me gain 30 lbs in 2 months but it did have me thinking more clearly - i was morbidly afraid of becoming diabetic as i am at a higher risk. Good luck in your search and i would recoomend stay away from risperdal!

[Velvet Elvis]

The other end result is that my pdoc has a very narrow view of which APs he wants to prescribe. We've tried Abilify and Geodon with no success. He won't do Zyprexa because of the weight gain. He says Risperdal is too much like the old school APs and won't prescribe it. He won't prescribe the old school APs because there are newer and better drugs. And that's the end of the little list he wrote out to show me and my husband of my options right now.

So I need to spend this next week coming up with some serious evidence to convince him to give me something he doesn't want to give me. But I'm too stupid and fucked in the head to do so because I need a med that I don't yet have...

jen

There are newer and better drugs, but you've been through them all.  He doesn't want you on zyprexa because of the weight gain, but you're getting that on seroquel anyway.  Seroquel is also the mildest of the APs so it's the least likely to work for recalciant psychotic symptoms.  It makes no fucking sense to me. 

Yes, risp is structuraly like the older APs, but the side effect profile is far milder.  I don't get this newer = better BS anyway.  What a crock. 

[StrungOutOnLife]

Any help, advice, ideas, documentation on APs other than Seroquel, Geodon, Abilify or Zyprexa?

jen

<{POST_SNAPBACK}>

On the pharmacology board, I have a thread about Zonegran and how it's being studied for Parkinson's and how it's been known to affect dopamine since 1992.

I'm not a doctor, but between raising the dose of something like that and taking you off of a pretty high dose of a dopamine antagonist, I'm surprised that the paranoia and mood were the only things that got worse.

Amaral et al called thioridazine "very mild" in a review of studies determining it's effectiveness in tuberculosis (it was effective in susceptible, polydrug-, and multidrug-resistant types). I don't know how potent it is, though.

Edited to add: it apparently sucks less than rifampicin and streptomycin do:

Because it also enhances the activity of rifampicin and streptomycin, antibiotics that frequently have adverse effects, additional studies evaluating the use of thioridazine as an adjuvant may eventually allow a reduction in the dosages of these antibiotics and result in a decreased frequency of adverse effects. It is important to note that whereas the management of patients with thioridazine for periods in excess of many months will result in the appearance of some undesirable side effects, its use for a limited period of 2

[sun_zoom_spark]

JMB-

Have you tried a mood stabilizer to help w/ psychosis? I'm saying this because you mentioned that you had psychosis in conjuction with mania or depression. A mood stabilizer that works better than Zonegran may be the ticket.

I only have psychotic features with major depression. I haven't had a major depressive episode since February because my lithium is helping.

If mania or depression cause the symptoms why not treat the cause?

[StrungOutOnLife]

I assume you mean documentation that other APs don't suck as hard as he thinks they do?

Edited to add: this study says that Seroquel and Haldol don't cause too much EPS when used together. Or too much catalepsy. The same could not be said of Haldol + Risperdal or Haldol + Thorazine.

This was in mice, of course.

[cabal]

jmb252, I know nothing of this zonegran. Have you and your doctor ever discussed that a mood stabilizer (there are a couple mentioned on www.crazymeds.us) might prevent those psychotic episodes ?

Since you are BP, I understand that the psychotic symptoms that occur are somehow caused by mood (swings). But I know little about bipolar.

Also, maybe the dosage of Seroquel was not high enough to prevent psychotic symptoms. You could try it again, at a much higher dose. Doses of 1000 mg or 1200 mg a day are not THAT uncommon.

If you want something that specifically targets psychotic symptoms (such as the voices) and you don't want to use seroquel, Risperdal is probably your best choice.

Why Risperdal ? AT the lower doses IT IS NOT, UNLIKE WHAT YOUR DOCTOR SAID, much like a typical/traditional antipsychotic at all. If he claims it is, he either doesn't know much or is for some reason lying. At daily doses of up to 4 mg (some say 6 mg) Risperdal functions as a atypical antipsychotic. That means it blocks dopamine receptors, but it blocks serotonin even more. That means relatively little risk of EPS, tardive dyskynesia and more effectiveness compared to the typical antipsychotics. Only at the higher doses it works much like a typical antipsychotic. I have no idea how much Risperdal you'd need. But there is a good chance 2 or 3 mg of Risperdal would be enough to suppress your psychotic symptoms. When Risperdal works -and it usually does- it usually works well and becomes effective soon. It's unlikely that it would not work for you, unless the psychotic symptoms are too much associated with mood. But Risperdal (at the higher dosages) also tends to flatten mood. Disadvantages of Risperdal: it may affect your hormones, periods and cause lactation. But that certainly does not always happen. And your doctor has already rejected the other, newer, atypical antipsychotics. It seems that the only one left is Risperdal. Is that doc of yours sensitive to logical argument ?

My recommendation: try a mood stabilizer and/or  Risperdal.

And then there is also the category of the typical antipsychotics. More than I can list. Haldol is the most famous, and it would probably help you (and is dirt-cheap).

I think that it's important that your psychotic symptoms are treated soon. If you let it run its course, things will only get worse.

I have given you a couple of suggestions. Make sure that you get effective treatment of your symptoms. Try it with your current doc, and if he's unwilling/unable to help, find another.

Good luck.

[jmb252]

Ergh... So after my week of stabilization, we made one change - we dropped the Zonegran altogether. Now I'm on Seroquel and Cymbalta, period.

(As an aside, I'd like to point out here that this isn't being done all willy-nilly, that my doctor, my husband and I have all sorts of contingency plans and observation routines in place, that I don't work other than a very part time job that is done from home, and that all of this allows me to do very dramatic med changes in a relatively safe way and with a level of observation pretty close to that which I would receive in an inpatient situation.)

Anyway... back to the drugs... we ditched the Zonegran, which was my mood stabilizer and which had been working pretty well as such. Some people have a shitty response to it, but my body seemed to like that weird-ass med. However, I was having some serious cognition problems that I've noticed are already starting to clear up a bit.

Because of that change, he refused to consider changing the AP at this time. He also is still in the mode of not knowing what to change to, or not wanting to use the remaining options. If I push the issue with him, I can probably get him to give me Risperdal, which seems to me to be the most logical one to try next.

To respond directly to a few things... cabal, on Risperdal, I think my doctor was referring, like Velvet Elvis said, to the fact that, structurally, it is similar to the typical APs. Also, while I thank you for your long response, you seem to be very confrontational and kind of doing the "playing doctor" thing that is generally frowned upon in these parts.

StrungOutOnLife - I'd read through the thread on Zonegran over in the geeking out board. Really interesting stuff. Do you know of any studies that put Risperdal or Risperdal/Geodon and/or Abilify up against Seroquel for bipolar depression with psychosis? I'm only finding things that focus on mania, which is really not my problem right now.

Thanks again and any additional thoughts are welcome.

jen

[cabal]

"Also, while I thank you for your long response, you seem to be very confrontational and kind of doing the "playing doctor" thing that is generally frowned upon in these parts"

I did not intend to be confrontational, but to be direct (it's part of my nation's culture   )

I just happen to know A LOT about certain things. In some cases it has turned out that I was better informed than my psychiatrist.

Risperdal may indeed be structurally (chemically) be related (so I have been told)to typical antipsychotics (haldol anyway), but it works differently from the typical antipsychotics, as long as the dosage does not become too high. I'm certain about that. There is a difference between comparing the chemical make-up of different antipsychotics and the effects of the different antipsychotics inside the brain. For as far as I know, haldol does not touch serotonin, while risperdal blocks serotonin receptors even more than the dopamine (d2) receptor. And generally, that makes risperdal a better antipsychotic than the typical antipsychotics.

I do not want to come between you and your doctor. You should get effective treatment from "a" doctor. The same one or another one. Your choice. But this doc doesn't seem to understand Risperdal properly.

[StrungOutOnLife]

StrungOutOnLife - I'd read through the thread on Zonegran over in the geeking out board. Really interesting stuff. Do you know of any studies that put Risperdal or Risperdal/Geodon and/or Abilify up against Seroquel for bipolar depression with psychosis? I'm only finding things that focus on mania, which is really not my problem right now.

Thanks again and any additional thoughts are welcome.

jen

<{POST_SNAPBACK}>

You're welcome.

It says here that they haven't been studied that much for bipolar depression. I would show you those studies except that the fulltext articles are paid sites and I'm still not used to being able to purchase things online (here's the page with all three fulltext links, if you're interested). This is searching for aripiprazole, quetiapine, bipolar and depression.

Have to go. Sorry.

Edited to add: Risperidone has been found to be effective for major depression with psychotic features.

And here is a study comparing quetiapine to risperidone as far as drug-induced sexual dysfunction goes. Doesn't say anything about efficacy in the things it's intended to treat.

Damn it!