Jump to content
CrazyBoards.org

All antidepressants worsening psychosis?


Recommended Posts

Hey

I used to take prozac before for my ocd/panic symptoms without any problems but right now I'm no longer able to tolerate any SSRI, SNRI.

I have tried escitalopram, sertraline, desvenlafaxine, fluoxetine, vilazodone - all seem to be worsening my psychosis.

I've not tried benzodiazepines due to fear of cognitive impairment and confusion. Someone suggested I may try alpha 2 delta ligands such as pregabalin/gabapentin. But I'm not sure.

Right now I'm on clozapine 225mg for my psychosis and valproic acid 400mg(extended release) for myoclonic jerks.

Anybody have any thoughts/suggestions for my ocd/panic symptoms ?

Edited by clinic
Link to comment
Share on other sites

the only antidepressant i've taken successfully is zoloft, and only at a low dosage. i take 50mg of that and 5 mg of abilify daily for my OCD. mine's more intrusive thought based, if that makes a difference treatment wise.

thus far those two seem to play nice with the other meds i take (clozaril and ativan for schizophrenia and prns zyprexa zydis and xanax for breakthrough symptoms). i think i've been on this combination for about five t six months...ish.

prior to switching off haldol depot injections i was taking a lot more meds (to deal with EPS flares) and the zoloft/ativan seemed to be fine in combination with that, too.

 

EDIT: i wanted to add that when i first started taking the zoloft without the abilify it was dealing with some of the intrusive thoughts (maybe a 25% reduction after three to four weeks, ish), but i could feel i was starting to slip, and it wasn't doing a great job with the intrusive thoughts. my psychiatrist didn't want to increase the zoloft and continue the slippage, so he added the abilify. i think that acts to both stabilize the zoloft and amplify its squashing-of-intrusive-thoughts properties. it's probably reduced how much i'm dealing with them by 75% or more.

Edited by mellifluous
Link to comment
Share on other sites

The SARI's trazodone (Desyrel, Oleptro) and nefazodone (Serzone) can be used for OCD and panic disorder. The only thing is trazodone is excessively sedating, and nefazodone has a bad rep due to its liver toxicity (which really is overhyped).

Trazodone in low doses (25-150 mg) is typically used as a hypnotic due to its α1, H1, and 5-HT2A antagonism at these doses. At higher doses (150-600 mg) it becomes an antidepressant, recruiting 5-HT2C antagonism and saturation of the serotonin transporter (SERT), causing serotonin reuptake inhibition. It's also a partial agonist of 5-HT1A.

Nefazodone is much less sedating (maybe still a tad sedating for some) than trazodone. It, too, is a 5-HT2A and α1 antagonist, and a 5-HT1A partial agonist, but has little to no affinity for the H1 histamine receptor (hence less sedation).

The 5-HT2A antagonism of these meds mediate an anxiolytic effect, possibly helping OCD, but also share this mechanism of action with the atypical antipsychotics, so perhaps the SARI's would be less likely to cause psychosis for you?

 

Link to comment
Share on other sites

Personally I really liked lyrica (pregabalin), but I discontinued it after a couple of weeks as it increased my appetite even at small doses of 150mg daily, food that I ate daily tasted so much better, as well as sodas and anything with sugar. I noticed my self eating without thinking and then I stopped as I lost a lot of weight last years and do not want to take it back. Lyrica was working well for GAD and was making me kind of high - not really high but different from the apathy of SSRIs

Link to comment
Share on other sites

On 8/24/2016 at 1:26 AM, mikrw33 said:

The SARI's trazodone (Desyrel, Oleptro) and nefazodone (Serzone) can be used for OCD and panic disorder. The only thing is trazodone is excessively sedating, and nefazodone has a bad rep due to its liver toxicity (which really is overhyped).

Trazodone in low doses (25-150 mg) is typically used as a hypnotic due to its α1, H1, and 5-HT2A antagonism at these doses. At higher doses (150-600 mg) it becomes an antidepressant, recruiting 5-HT2C antagonism and saturation of the serotonin transporter (SERT), causing serotonin reuptake inhibition. It's also a partial agonist of 5-HT1A.

Nefazodone is much less sedating (maybe still a tad sedating for some) than trazodone. It, too, is a 5-HT2A and α1 antagonist, and a 5-HT1A partial agonist, but has little to no affinity for the H1 histamine receptor (hence less sedation).

The 5-HT2A antagonism of these meds mediate an anxiolytic effect, possibly helping OCD, but also share this mechanism of action with the atypical antipsychotics, so perhaps the SARI's would be less likely to cause psychosis for you?

 

 

viibryd(vilazodone) and clozapine both share 5HT-1A partial agonist property but viibryd still make me paranoid.

Not sure about 5-HT2A.

Link to comment
Share on other sites

  • 2 months later...
On 8/24/2016 at 1:26 AM, mikrw33 said:

The SARI's trazodone (Desyrel, Oleptro) and nefazodone (Serzone) can be used for OCD and panic disorder. The only thing is trazodone is excessively sedating, and nefazodone has a bad rep due to its liver toxicity (which really is overhyped).

Trazodone in low doses (25-150 mg) is typically used as a hypnotic due to its α1, H1, and 5-HT2A antagonism at these doses. At higher doses (150-600 mg) it becomes an antidepressant, recruiting 5-HT2C antagonism and saturation of the serotonin transporter (SERT), causing serotonin reuptake inhibition. It's also a partial agonist of 5-HT1A.

Nefazodone is much less sedating (maybe still a tad sedating for some) than trazodone. It, too, is a 5-HT2A and α1 antagonist, and a 5-HT1A partial agonist, but has little to no affinity for the H1 histamine receptor (hence less sedation).

The 5-HT2A antagonism of these meds mediate an anxiolytic effect, possibly helping OCD, but also share this mechanism of action with the atypical antipsychotics, so perhaps the SARI's would be less likely to cause psychosis for you?

 

What do u think about gabapentin/pregabalin for anxiety ? Will they work for me ? I read that these drugs may cause cognitive impairment.

Trazodone has short half life, will it work if I take total dose at bedtime. Will it provide relief for daytime anxiety ?

Edited by clinic
Link to comment
Share on other sites

 

On 8/23/2016 at 10:25 AM, clinic said:

Anybody have any thoughts/suggestions for my ocd/panic symptoms ?

The one SSRI that has never affected me is Prozac.

Idk about wellbutrin as an anti-depressant ... I can see how it might make the ocd/panic worse because it is activating.  However I have OCD and panic disorder also and it hasn't been a problem ever for me.  But I think it depends on the cocktail of meds you are on, and how all the meds work with each other.

Edited by melissaw72
Link to comment
Share on other sites

I would like to add something.

It all started after my 2nd psychotic relapse. After my relapse i was no longer able to tolerate any ssri/snri. Before my relapse SSRIs were working for me without any problems.

Maybe my dose of antipsychotic(clozapine) is low, thats why psychosis comes back when I take the SSRIs. I have increased my clozapine to 250mg, maybe I should increase it further.

Edited by clinic
Link to comment
Share on other sites

I don't want to sound like the fanclub for benzos because they have baggage and things effect people in a different way but....   In the right dose they work for me on serious anxiety without vegging me out of putting me into snoozeville.   Its a really close thing between just right and not enough or too much.   Since I don't take them daily its been possible to adjust dose in small amounts to get it right.

I don't know enough about OCD meds to even have an opinion.  I'm kind of perfectionist which I afraid to tinker with because its one of my few useful traits.

Link to comment
Share on other sites

On 10/27/2016 at 4:50 AM, clinic said:

What do u think about gabapentin/pregabalin for anxiety ? Will they work for me ? I read that these drugs may cause cognitive impairment.

Trazodone has short half life, will it work if I take total dose at bedtime. Will it provide relief for daytime anxiety ?

1

Sorry it took me so darn long to get back to you... T_T

It's hard to say whether a medicine will work for someone or not. The best thing to do is to just try it and see if it works. I'll try and break up the meds in groups according to OCD and panic symptoms.

Panic disorder: (from Stahl's Essential Psychopharmacology)

  • 1st-line:
    • α2δ ligands like gabapentin (Neurontin)/pregabalin (Lyrica) can be effective
    • (along with SSRIs, SNRIs)
    • benzodiazepines
  • 2nd-line:
    • Tricyclic antidepressant
    • MAOI
    • Mirtazapine (Remeron)
    • Trazodone (Desyrel) (or nefazodone (Serzone))
  • Adjunctive:
    • Hypnotic
    • CBT
    • Atypical antipsychotic (which you're already on)

OCD (for some reason, Stahl doesn't lay out OCD treatments quite as nicely as he does for other anxiety disorders, so I'm just going to make some guesses here)

  • 1st-line:
    • (SSRIs, SNRIs)
    • Maybe α2δ ligands like gabapentin (Neurontin)/pregabalin (Lyrica) can be effective
    • (Benzodiazepines?) (My pdoc has used clonazepam (Klonopin) for my OCD before)
  • 2nd-line
    • Clomipramine (Anafranil) (a tricyclic antidepressant)
    • I don't think MAOIs are as effective for OCD but I could be totally wrong, someone please correct me if I'm wrong!
    • Trazodone/nefazodone
  • Adjunctive
    • CBT?
    • Atypical antipsychotic

If you'd like to try an antidepressant, why not try some of the second-line treatments? Like clomipramine (good anti-OCD properties) or imipramine (good anti-panic properties I hear).

As for taking the whole dose of trazodone at bedtime, it's not really safe to take more than a certain amount (I forget how much it is) all at once with the instant release trazodone. I think one dose shouldn't exceed more than 300 mg or something like that... I could be totally talking out my ass on that one though. It just seems I read that somewhere. If you want to take the whole dose of trazodone at bedtime, they make a brand of trazodone extended-release called "Oleptro." Unfortunately, there doesn't seem to be any copay coupons available for it, so you'd be paying full price for the brand-name.

On 8/26/2016 at 8:33 AM, clinic said:

viibryd(vilazodone) and clozapine both share 5HT-1A partial agonist property but viibryd still make me paranoid.

Not sure about 5-HT2A.

2

Yeah Viibryd doesn't have 5-HT2A antagonism, so I'm not surprised it made you paranoid. The downstream effects of the 5-HT1A partial agonism cause extra dopamine release, which could be contributing to your paranoia.

Most of the TCAs have a decent amount of 5-HT2A antagonism, mirtazapine has a good bit of 5-HT2A antagonism, as does trazodone and nefazodone. They *shouldn't* cause that same paranoia, but that's just my theory. Don't quote me on that, and if you decide to try any of those, please discuss it with your pdoc before doing so. Make sure s/he's okay with the idea of you taking one of those.

I hope this was helpful and didn't come across as me telling you how to manage your meds or anything... :) 

  • Like 1
Link to comment
Share on other sites

Seems like everyone goes SSRI > SNRI >  Antipsychotics   around here?   To me it seems like once you have tried a couple of SSRIs they are all very similar (just my experience) and it is debatable how much 'N' there is in the SNRIs as well.

Do doctors not try Tricyclics these days?  For example clomipramine for OCD is effective for some. 

Link to comment
Share on other sites

23 minutes ago, mikrw33 said:

If you'd like to try an antidepressant, why not try some of the second-line treatments? Like clomipramine (good anti-OCD properties) or imipramine (good anti-panic properties I hear).

As for taking the whole dose of trazodone at bedtime, it's not really safe to take more than a certain amount (I forget how much it is) all at once with the instant release trazodone. I think one dose shouldn't exceed more than 300 mg or something like that... I could be totally talking out my ass on that one though. It just seems I read that somewhere. If you want to take the whole dose of trazodone at bedtime, they make a brand of trazodone extended-release called "Oleptro." Unfortunately, there doesn't seem to be any copay coupons available for it, so you'd be paying full price for the brand-name.

Yeah Viibryd doesn't have 5-HT2A antagonism, so I'm not surprised it made you paranoid. The downstream effects of the 5-HT1A partial agonism cause extra dopamine release, which could be contributing to your paranoia.

Most of the TCAs have a decent amount of 5-HT2A antagonism, mirtazapine has a good bit of 5-HT2A antagonism, as does trazodone and nefazodone. They *shouldn't* cause that same paranoia, but that's just my theory. Don't quote me on that, and if you decide to try any of those, please discuss it with your pdoc before doing so. Make sure s/he's okay with the idea of you taking one of those.

I hope this was helpful and didn't come across as me telling you how to manage your meds or anything... :) 

I had my first panic attack and psychotic episode on clomipramine. So i cant take it.

I live india, we dont have trazodone extended release here. My pdoc told me to start trazodone 50mg at night. I will see how it goes. 

Yea, I also have that stephen stahl's essential psychopharmacology book. He indeed doesn't lay out OCD treatments quite as nicely as he does for other anxiety disorders. I have tried quetiapine for anxiety disorder - it was worsening my myoclonic jerks so I stopped it. I may try seroquel again with high anticonvulsant dose. I have tried benzo(klonopin) it worsened my cognition, I had memory and attention problems on it. Also I dont want to take benzos for life. SSRI/SNRIs were worsening paranoia as I said above. TCAs can have terrible side effects, so i dont want to try it. Nefazodone is not available here. Mirtazapine causes weight gain, so i dont wanna take that. My only options left for treating anxiety are - low dose seroquel with anticonvulsant, α2δ ligands like gabapentin/pregabalin and trazodone. Pdoc once prescribed tianeptine(stablon) to me, but i read somewhere that it increases dopamine too so i did not took it, and tianeptine being TCA can have other side effects.

Link to comment
Share on other sites

12 hours ago, clinic said:

I had my first panic attack and psychotic episode on clomipramine. So i cant take it.

Oh, I'm sorry to hear you had such a reaction from that medication. Indeed, you definitely can't take it! lol

12 hours ago, clinic said:

I live india, we dont have trazodone extended release here. My pdoc told me to start trazodone 50mg at night. I will see how it goes. 

Oh ok, I see. I hope the trazodone works well for you! :)

12 hours ago, clinic said:

Yea, I also have that stephen stahl's essential psychopharmacology book. He indeed doesn't lay out OCD treatments quite as nicely as he does for other anxiety disorders. I have tried quetiapine for anxiety disorder - it was worsening my myoclonic jerks so I stopped it. I may try seroquel again with high anticonvulsant dose. I have tried benzo(klonopin) it worsened my cognition, I had memory and attention problems on it. Also I dont want to take benzos for life. SSRI/SNRIs were worsening paranoia as I said above. TCAs can have terrible side effects, so i dont want to try it. Nefazodone is not available here. Mirtazapine causes weight gain, so i dont wanna take that. My only options left for treating anxiety are - low dose seroquel with anticonvulsant, α2δ ligands like gabapentin/pregabalin and trazodone. Pdoc once prescribed tianeptine(stablon) to me, but i read somewhere that it increases dopamine too so i did not took it, and tianeptine being TCA can have other side effects.

15

I wonder why he didn't bother to lay out treatments for OCD in that book like he did most other disorders? He also didn't really seem to outline treatment for depression very clearly, either (or at least it didn't seem so clear to me...).

Ooh, that doesn't sound good with the quetiapine worsening the myoclonic jerks... In my opinion, for what it's worth, I don't think you should have to increase your anticonvulsant and/or have an increased risk of seizure activity just to get your anxiety under control. I mean, yes, pretty much all antipsychotics lower the seizure threshold, but some probably more than others. There has to be alternatives that would work better that wouldn't cause the myoclonic jerks that would also help your anxiety.

If I might make a recommendation for a medication for anxiety... If you're not opposed to taking a typical antipsychotic/first-generation antipsychotic, at least short term anyway (i.e. up to 12 weeks), I had absolutely terrific results with low dose trifluoperazine (Stelazine in the US) with my anxiety when it got so bad I couldn't leave the house for simple things like going to the store no matter how badly I needed to buy something, or running simple errands, or even going to the pharmacy to pick up my meds. It had potent anxiolytic and even antidepressant properties for me, the latter of which was surprising to me for a first-gen antipsychotic. I still keep a supply of it just in case and take it every now and then as an as needed med. If you're concerned about weight gain, trifluoperazine can be weight-neutral or may cause a little weight gain (I gained weight the first time I took it, but I think that was because I was coming off a diet; however, the next few times I took it, I lost weight or stayed the same weight). It doesn't cause nearly as much weight gain as, say, chlorpromazine or even quetiapine for that matter. In fact, the amount of weight gain it causes is in the neighborhood of that of ziprasidone according to one study (don't have the link on hand), which is quite negligible. I started 1 mg twice daily, then went up to 1 mg 3x/day, then 2 mg 3x/day where I stayed for a few months before I discontinued the first time. Now I have some 1 mg and 2 mg tablets on hand just in case.

Otherwise, if you don't want to mess with first-gen antipsychotics, and if you haven't already taken it, and/or if it's available in your country, I'd also recommend Saphris (asenapine). I had pretty good results for a little while with that. It had a nice antidepressant effect too kinda like Stelazine but not as robust. I was on the 5 mg sublingual tablets (they taste awful! They're supposed to taste like "black cherry" but they just taste super medicinal and numb your mouth). I had to quit taking it though because it eventually started to make me feel kind of dysphoric.

Sorry to hear your experience with Klonopin wasn't good. I, too, have experienced the worsening of cognition from Klonopin, but that was when I first started taking benzos, like, for the first time ever. I guess I've built up such a tolerance to benzos that I just don't notice the cognitive effects anymore... XD 

Not all TCAs have terrible side effects. The secondary amine TCAs' (nortriptyline, protriptyline, desipramine) side effect profile is generally a lot milder than that of the tertiary amine TCAs'. I would be willing to make an exception for protriptyline, however, because of the sheer anticholinergic-ness of that medicine... (I had blurry vision, inability to focus close up, and some righteous urinary retention on that med after I had been on it for a few months.) YMMV though as everyone says around here. Nortriptyline is probably one of, if not the most benign TCAs. It had the least side effects of all the TCAs I've taken (which isn't many admittedly... lol).

I don't blame you for not wanting to take mirtazapine... it definitely makes me balloon up and put on the pounds... Miraculously, some people can take it without any problems. Generally the higher the dose, the lesser the problem is with weight gain, so I've heard, but that wasn't the case for me when I took it.

Yes, tianeptine is chemically a TCA, but it's absolutely nothing like any of the other TCAs in its mechanism of action. It works via glutamate activity (AMPA and NMDA receptors) and induces release of BDNF which affects neural plasticity. It may even have anticonvulsant activity via modulation of adenosine A1 receptors. It's also a low-affinity full agonist at the µ-opioid (which could be partially responsible for the dopamine effects you were talking about) and δ-opioid receptors (with negligible effects on the κ-opioid receptors). In order to induce euphoria as with most µ-opioid agonists, though, with tianeptine, you'd have to take well above the therapeutic dose. Also, it enhances release of dopamine in the mesolimbic pathway (bad for psychosis!), albeit modestly, and potentiates D2 and D3 receptors (but it's not clear how it does this). I dunno, maybe it sounds like you dodged a bullet with avoiding tianeptine what with it enhancing dopamine release in the mesolimbic pathway, which is the exact pathway antipsychotics target to antagonize dopamine receptors.

13 hours ago, clinic said:

Thats strange cuz my clozapine is also partial agnoism at 5ht-1A receptor but it doesn't worsen my paranoia.

https://en.wikipedia.org/wiki/Clozapine#Mechanism_of_action

 
 
 

You're absolutely right, I didn't think that through all the way when I wrote that. The dopamine release from the downstream effects of 5-HT1A partial agonism are in the striatum, which has (I don't think, anyway) nothing to do with the mesocorticolimbic projection (in which if dopamine were to be release, then I imagine it would provoke said paranoia).

  • Like 1
Link to comment
Share on other sites

Join the conversation

You can post now and register later. If you have an account, sign in now to post with your account.

Guest
Reply to this topic...

×   Pasted as rich text.   Paste as plain text instead

  Only 75 emoji are allowed.

×   Your link has been automatically embedded.   Display as a link instead

×   Your previous content has been restored.   Clear editor

×   You cannot paste images directly. Upload or insert images from URL.

 Share

×
×
  • Create New...