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tbs14

Severe psychosis and mixed mania

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For the past 3 weeks I've been in a mixed episode. Consisting of depressed, agitated, angry and sometimes giddy mood. I'm talking fast, cutting myself, sleep later than usual and waking up late. I'm sexually acting out and chain smoking which are better than my other unhealthy behaviors such as getting blackout drunk and huffing air duster and whippets which I am in recovery from addiction to. I'm hearing voices 24/7 and am paranoid and am developing delusions. My Latuda was increased from 120mg to 160mg but that isn't helping. I'll leave a list of of meds I've tried and what I'm currently on.

Failed meds

Luvox

Prozac

Lithium

Seroquel

Abilify

Trileptal

Gabapentin

I'm currently on 

Effexor XR 300mg OCD, PTSD, PD, SAD, GAD

Depakote ER 3000mg blood level 92 for mania and mixed states 

Latuda 160mg mood and schizo part of schizoaffective 

Prazosin 7mg PTSD

Trazodone 100-200mg sleep

I have a med appointment on the 20th so any med suggestions would be helpful. 

Also antipsychotic wise I didn't have a bad reaction to zyprexa but even at 5 mg it was very sedating and this was given to me in the height of agitation in the hospital so I don't think that's a long term option

Also benzodiapines arent an option for me because I'm in recovering from drug addiction and and alcohol and inhalants work very similarly in the brain to benzos so it would be very easy to get addicted and abuse

I was also wondering would clozapine be an option for me since I have failed to have substantial reduction in symptoms from 3 antipsychotics. And I have been on antipsychotic polypharmacy.

 

Edited by tbs14

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I can't answer your ultimate question about med recommendations because that's not my knowledge area, but I can tell you that latuda at that dose sent me completely manic and I believe it did the same to someone else I know.  So that might be the culprit, rather than the solution.  Are you willing to do even a small dose of zyprexa now to try to squash this thing?  Because it sounds desperately in need of squashing and zyprexa is a great one to do it.  It doesn't sound like a bit of sedation would necessarily be a bad thing.

I'd be concerned about taking Effexor while you're in mixed/psychotic hell. 

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@tbs14, I'll try to answer your question. I hope I can be of some help.

Firstly, let me just say I'm sorry you're dealing with this. I know exactly what it's like to be in that sort of hell. I don't have addiction problems, though, so I can't say I can empathize with that part, but I'm super sorry you're having to deal with that in addition to a mood disorder problem (they're very commonly comorbid).

5 hours ago, tbs14 said:

Failed meds

Luvox

Prozac

Lithium

Seroquel

Abilify

Trileptal

Gabapentin

I'm currently on 

Effexor XR 300mg OCD, PTSD, PD, SAD, GAD

Depakote ER 3000mg blood level 92 for mania and mixed states 

Latuda 160mg mood and schizo part of schizoaffective 

Prazosin 7mg PTSD

Trazodone 100-200mg sleep

You're on the highest dose of Latuda for schizophrenia. I'm assuming you're bipolar I based on the description of your symptoms, as that correct?

I agree with @dancesintherain partially insofar as it may not be the best medicine. I have never heard of that dose skyrocketing people into mania; however, I have heard of and personally been sent into hypomania/mania by the 20 mg dose. 40 mg was pretty innocuous but not very effective after a while.

I agree with @dancesintherain also with using Zyprexa to squash this. Either that or Haldol along with some Cogentin/Benadryl to help with any movement side effects for a short while. Haldol would be less sedating, but still could be sedating depending on how high the dose is. Also, less weight gain with Haldol, but that's the least of your concerns right now.

That's a mighty dose of Effexor to be on while mixed manic/psychotic. Perhaps if you came down on the Effexor, you could also come down on Depakote too (which is also a mighty heroic dose). Then you could be less sedated and not oversleep as much (hopefully).

If you're not getting enough antidepressant effect from Effexor at high doses, perhaps either switching antidepressants or switching antipsychotics would help. When you're bipolar, antidepressants are in the "backseat" while antipsychotics and mood stabilizers are in the "front seat." This is in an ideal picture though, of course. Have you tried a combination of Depakote + Lamictal? (Your Depakote dose would have to be seriously modified, probably halved.) Many people have great success with this combo, and are sometimes able to do away with antidepressants completely on this combo what with Lamictal having a slight antidepressant stabilizing effect (whereas the Depakote is the manic stabilizer). I personally haven't tried it so I can't vouch for it, but someone who has can probably speak up. There's also always Depakote + Lithium. Lithium has antisuiciodal properties (so long as "your head is still above the water;" if you're "drowning," it can actually worsen suicidality according to my pdoc).

That's also a mighty dose of trazodone for sleep (I say that, yet I'm on the same dose...) I think I suffer from the depressive side and you suffer more from the manic side from what I'm gathering—I may be sorely wrong and do correct me if I am. Seroquel didn't work for you, don't know what dose you tried it at. Low dose Seroquel is pretty good for sleep but if it didn't work, another possibility is Saphris. It's brand-name only right now, but it's soon to go generic. It has a copay coupon. It comes in 2.5 mg, 5 mg, and 10 mg sublingual tablets that taste like utter ass (really they taste like a "disappointing cherry liquor" to quote my friend @ByePolarCoordinates). The target dose is 10 mg twice daily, but you can just take 5 mg at bedtime for sleep, which is what I did. Sometimes I would take two for 10 mg if I felt I needed it. It's an excellent antipsychotic really and you could probably switch to it from Latuda. It is a sedating antipsychotic though, so you may wish to either divide the dose (as is recommended) 5-10 mg bid or 10-20 mg at bedtime if your pdoc says it's okay.

I'm terribly sorry you're dealing with PTSD. I have it too and I know how nightmarish it can be. Topamax is another med that can be used in low doses for PTSD, which may allow you to lower your prazosin dose which may lessen your sedation. It does have some cognitive effects and weight loss symptoms associated with it, just to let you know.

Other possibilities for antipsychotics that would be less sedating would be Rexulti (may be sedating to some, especially at lower doses), Vraylar, and Geodon (you have to make sure you eat 500 calories worth of food with both doses or it won't absorb and you'll go manic/psychotic again with this one!). They should also be weight- and metabolically friendly/neutral.

If you're still not getting enough antidepressant effect, there's Wellbutrin, which has a lower rate of inducing mania/switching than do the SSRIs and SNRIs, and there are also the eugeroics (wakefulness promoters) Provigil and Nuvigil (which are a pain in the ass to get approved with your insurance company for some reason... they both need a PA, and if you need to change your dose, you need another PA...).

5 hours ago, tbs14 said:

I was also wondering would clozapine be an option for me since I have failed to have substantial reduction in symptoms from 3 antipsychotics. And I have been on antipsychotic polypharmacy.

There are big guns, and then there are big-big guns. Clozapine is THE BIGGEST gun; i.e., a drug of "last resort." It is used when no other drug in its class works. Failure of 3 antipsychotics and antipsychotic polypharmacy may qualify you for being a candidate for clozapine, but in my uneducated opinion, I think you've still got some more meds to your disposal to try before resorting to clozapine. Keep in mind clozapine requires weekly blood work for a long period of time, then monthly after a long time of that, then I believe quarterly if I'm not mistaken (this is like years after being stabilized on it). It's a pain in the ass to take from what I understand. It can cause sialorrhea, which is excessive, thick drooling. Anticholinergics like glycopyrrolate can help counter it, but it can still be a problem even with that; however, sialorrhea pales in comparison to the risk of agranulocytosis and other blood dyscrasias it can cause. There are several people here who have taken or are on clozapine who can tell you about it. I can't for the life of me remember their names. My memory is fried because I had a pretty rough weekend of overdosing and seizures and whatnot. T_T 

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14 hours ago, mikl_pls said:

@tbs14, I'll try to answer your question. I hope I can be of some help.

Firstly, let me just say I'm sorry you're dealing with this. I know exactly what it's like to be in that sort of hell. I don't have addiction problems, though, so I can't say I can empathize with that part, but I'm super sorry you're having to deal with that in addition to a mood disorder problem (they're very commonly comorbid).

You're on the highest dose of Latuda for schizophrenia. I'm assuming you're bipolar I based on the description of your symptoms, as that correct?

I agree with @dancesintherain partially insofar as it may not be the best medicine. I have never heard of that dose skyrocketing people into mania; however, I have heard of and personally been sent into hypomania/mania by the 20 mg dose. 40 mg was pretty innocuous but not very effective after a while.

I agree with @dancesintherain also with using Zyprexa to squash this. Either that or Haldol along with some Cogentin/Benadryl to help with any movement side effects for a short while. Haldol would be less sedating, but still could be sedating depending on how high the dose is. Also, less weight gain with Haldol, but that's the least of your concerns right now.

That's a mighty dose of Effexor to be on while mixed manic/psychotic. Perhaps if you came down on the Effexor, you could also come down on Depakote too (which is also a mighty heroic dose). Then you could be less sedated and not oversleep as much (hopefully).

If you're not getting enough antidepressant effect from Effexor at high doses, perhaps either switching antidepressants or switching antipsychotics would help. When you're bipolar, antidepressants are in the "backseat" while antipsychotics and mood stabilizers are in the "front seat." This is in an ideal picture though, of course. Have you tried a combination of Depakote + Lamictal? (Your Depakote dose would have to be seriously modified, probably halved.) Many people have great success with this combo, and are sometimes able to do away with antidepressants completely on this combo what with Lamictal having a slight antidepressant stabilizing effect (whereas the Depakote is the manic stabilizer). I personally haven't tried it so I can't vouch for it, but someone who has can probably speak up. There's also always Depakote + Lithium. Lithium has antisuiciodal properties (so long as "your head is still above the water;" if you're "drowning," it can actually worsen suicidality according to my pdoc).

That's also a mighty dose of trazodone for sleep (I say that, yet I'm on the same dose...) I think I suffer from the depressive side and you suffer more from the manic side from what I'm gathering—I may be sorely wrong and do correct me if I am. Seroquel didn't work for you, don't know what dose you tried it at. Low dose Seroquel is pretty good for sleep but if it didn't work, another possibility is Saphris. It's brand-name only right now, but it's soon to go generic. It has a copay coupon. It comes in 2.5 mg, 5 mg, and 10 mg sublingual tablets that taste like utter ass (really they taste like a "disappointing cherry liquor" to quote my friend @ByePolarCoordinates). The target dose is 10 mg twice daily, but you can just take 5 mg at bedtime for sleep, which is what I did. Sometimes I would take two for 10 mg if I felt I needed it. It's an excellent antipsychotic really and you could probably switch to it from Latuda. It is a sedating antipsychotic though, so you may wish to either divide the dose (as is recommended) 5-10 mg bid or 10-20 mg at bedtime if your pdoc says it's okay.

I'm terribly sorry you're dealing with PTSD. I have it too and I know how nightmarish it can be. Topamax is another med that can be used in low doses for PTSD, which may allow you to lower your prazosin dose which may lessen your sedation. It does have some cognitive effects and weight loss symptoms associated with it, just to let you know.

Other possibilities for antipsychotics that would be less sedating would be Rexulti (may be sedating to some, especially at lower doses), Vraylar, and Geodon (you have to make sure you eat 500 calories worth of food with both doses or it won't absorb and you'll go manic/psychotic again with this one!). They should also be weight- and metabolically friendly/neutral.

If you're still not getting enough antidepressant effect, there's Wellbutrin, which has a lower rate of inducing mania/switching than do the SSRIs and SNRIs, and there are also the eugeroics (wakefulness promoters) Provigil and Nuvigil (which are a pain in the ass to get approved with your insurance company for some reason... they both need a PA, and if you need to change your dose, you need another PA...).

There are big guns, and then there are big-big guns. Clozapine is THE BIGGEST gun; i.e., a drug of "last resort." It is used when no other drug in its class works. Failure of 3 antipsychotics and antipsychotic polypharmacy may qualify you for being a candidate for clozapine, but in my uneducated opinion, I think you've still got some more meds to your disposal to try before resorting to clozapine. Keep in mind clozapine requires weekly blood work for a long period of time, then monthly after a long time of that, then I believe quarterly if I'm not mistaken (this is like years after being stabilized on it). It's a pain in the ass to take from what I understand. It can cause sialorrhea, which is excessive, thick drooling. Anticholinergics like glycopyrrolate can help counter it, but it can still be a problem even with that; however, sialorrhea pales in comparison to the risk of agranulocytosis and other blood dyscrasias it can cause. There are several people here who have taken or are on clozapine who can tell you about it. I can't for the life of me remember their names. My memory is fried because I had a pretty rough weekend of overdosing and seizures and whatnot. T_T 

I'm Schizoaffective bipolar type recently diagnosed. Previously was diagnosed Bipolar 1 w/psychotic features. Dx was mainly changed due the presence of catatonia, disorganization, voices and paranoia outside of mood and cognitive and negative symptoms. Sometimes I look more like a typical presentation of bipolar 1 hypersexuality, smoking, drinking talking fast, grandiose, reckless and other times I look more schizophrenic/ affective thought disorder, catatonia, mute and blank expression, homicidal ideation, paranoia, voices, delusions, mood incongruent psychosis. 

 

I don't think that the Latuda has enough of an antimanic effect on me. 

I'd be willing to try Seroquel XR again because it didn't make me as sleepy or hungry as the instant release version

Geodon is off the table because I already struggle to get a 350 Cal snack with latuda once a day. 500 Cal twice a day just for meds would be hard.

I like the idea of Vraylar but not so much rexulti because it failed phase 3 trials for bipolar mania and mixed states. I barely made a difference but my pdoc recently got samples of Vraylar so I might give that a shot. 

My PTSD is pretty much under control. The rage controlled by the depakote. Daytime symptoms controlled by CBD and effexor and nighttime by prazosin. The prazosin actually doesn't make me sleep which is why I'm on the trazodone still. 

Wellbutrin is also kinda off the table. I have very crippling anxiety. I have 5 anxiety disorders and Wellbutrin can make people kind of speedy. But I've also heard that it works well for bipolar folks because it quite stabilizing, I don't really understand how an antidepressant would be stabilizing for someone with my condition but I'm open to anything. It's also quite frequently as part of smoking/vaping cessation in combination with Nicotine Replacement Therapy

Talking about Clozaril I was wondering if a combination of Seroquel XR and Vraylar would be a good option for me because Seroquel helped me in the past(not fully) but I was lithium and not depakote. Lithium was like a sugar pill for me. So maybe this time a around things will be different since I will be taking all XR with depakote. Would D2 and D3 partial agonism of Vraylar along with Seroquel be synergystic like the popular combination of Abilify and Seroquel? 

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2 hours ago, tbs14 said:

I'm Schizoaffective bipolar type recently diagnosed. Previously was diagnosed Bipolar 1 w/psychotic features. Dx was mainly changed due the presence of catatonia, disorganization, voices and paranoia outside of mood and cognitive and negative symptoms. Sometimes I look more like a typical presentation of bipolar 1 hypersexuality, smoking, drinking talking fast, grandiose, reckless and other times I look more schizophrenic/ affective thought disorder, catatonia, mute and blank expression, homicidal ideation, paranoia, voices, delusions, mood incongruent psychosis. 

 

I don't think that the Latuda has enough of an antimanic effect on me. 

I'd be willing to try Seroquel XR again because it didn't make me as sleepy or hungry as the instant release version

Geodon is off the table because I already struggle to get a 350 Cal snack with latuda once a day. 500 Cal twice a day just for meds would be hard.

I like the idea of Vraylar but not so much rexulti because it failed phase 3 trials for bipolar mania and mixed states. I barely made a difference but my pdoc recently got samples of Vraylar so I might give that a shot. 

My PTSD is pretty much under control. The rage controlled by the depakote. Daytime symptoms controlled by CBD and effexor and nighttime by prazosin. The prazosin actually doesn't make me sleep which is why I'm on the trazodone still. 

Wellbutrin is also kinda off the table. I have very crippling anxiety. I have 5 anxiety disorders and Wellbutrin can make people kind of speedy. But I've also heard that it works well for bipolar folks because it quite stabilizing, I don't really understand how an antidepressant would be stabilizing for someone with my condition but I'm open to anything. It's also quite frequently as part of smoking/vaping cessation in combination with Nicotine Replacement Therapy

Talking about Clozaril I was wondering if a combination of Seroquel XR and Vraylar would be a good option for me because Seroquel helped me in the past(not fully) but I was lithium and not depakote. Lithium was like a sugar pill for me. So maybe this time a around things will be different since I will be taking all XR with depakote. Would D2 and D3 partial agonism of Vraylar along with Seroquel be synergystic like the popular combination of Abilify and Seroquel? 

Did anyone mention risperdal for the mixed/psychotic symptoms? That might be worth a shot too, good anti manic but often less sedating than zyprexa 

@mikl_pls the blood is weekly for 6 mo, then biweekly for 6 mo, then monthly forever 

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22 hours ago, tbs14 said:

 

I was also wondering could clozapine be an option for me since I have failed to have substantial reduction in symptoms from 3 antipsychotics. And I have been on antipsychotic polypharmacy.

 

I think if you've tried multiple antipsychotics and they have not worked, you should be a candidate for clozapine. However, I think you should try risperidone/invega, which also has a good track record, first.

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15 hours ago, tbs14 said:

Talking about Clozaril I was wondering if a combination of Seroquel XR and Vraylar would be a good option for me because Seroquel helped me in the past(not fully) but I was lithium and not depakote. Lithium was like a sugar pill for me. So maybe this time a around things will be different since I will be taking all XR with depakote. Would D2 and D3 partial agonism of Vraylar along with Seroquel be synergystic like the popular combination of Abilify and Seroquel?

It could be. The difference would be the preferential D3 partial agonism over D2 partial agonism of Vraylar with higher intrinsic activity at D3 than D2 as well. Seroquel/Seroquel XR and its active metabolite are relatively weak dopamine antagonists compared to the binding capacity of Vraylar. What might end up happening would be competitive antagonism between the two meds. I'm not exactly sure how that works, but I've read about it (not thoroughly enough to explain it obviously... lol).

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4 hours ago, Iceberg said:

@mikl_pls it might end up being fancy science speak for “crapshoot” lol 

That's a very distinctive possibility and probably the safest assumption! 😆 

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On 1/14/2020 at 3:33 PM, tbs14 said:

For the past 3 weeks I've been in a mixed episode. Consisting of depressed, agitated, angry and sometimes giddy mood. I'm talking fast, cutting myself, sleep later than usual and waking up late. I'm sexually acting out and chain smoking which are better than my other unhealthy behaviors such as getting blackout drunk and huffing air duster and whippets which I am in recovery from addiction to. I'm hearing voices 24/7 and am paranoid and am developing delusions. My Latuda was increased from 120mg to 160mg but that isn't helping. I'll leave a list of of meds I've tried and what I'm currently on.

Failed meds

Luvox

Prozac

Lithium

Seroquel

Abilify

Trileptal

Gabapentin

I'm currently on 

Effexor XR 300mg OCD, PTSD, PD, SAD, GAD

Depakote ER 3000mg blood level 92 for mania and mixed states 

Latuda 160mg mood and schizo part of schizoaffective 

Prazosin 7mg PTSD

Trazodone 100-200mg sleep

I have a med appointment on the 20th so any med suggestions would be helpful. 

Also antipsychotic wise I didn't have a bad reaction to zyprexa but even at 5 mg it was very sedating and this was given to me in the height of agitation in the hospital so I don't think that's a long term option

Also benzodiapines arent an option for me because I'm in recovering from drug addiction and and alcohol and inhalants work very similarly in the brain to benzos so it would be very easy to get addicted and abuse

I was also wondering would clozapine be an option for me since I have failed to have substantial reduction in symptoms from 3 antipsychotics. And I have been on antipsychotic polypharmacy.

 

I've never seen someone on such high doses of Depakote and Latuda and I've worked for a decade on an acute inpatient psych unit. 

The way things are right now, it's impossible to tell if meds simply aren't working or one (or more) are counteracting others and destabilizing you. 

I don't know how your doctor feels about it, but I'd probably back off either the Effexor or Latuda. SSRI's, SNRI's, etc. are pretty big no-no's in psychiatry for people with any flavor of bipolar disorder, especially at that high of a dose, without proper mood stabilizer coverage. A fair number of people also find Latuda activating, which can potentially be bad if it affects sleep or you experience akathisia/restlessness.

Are you taking Latuda with at least 350 calories? Because that's how you're supposed to take it — the same as Geodon — otherwise it can interfere with how the body metabolizes the medication. 

When you say you failed a trial of Lithium, what exactly does that mean? You didn't like how it made you feel or it caused medical problems for you? 

What does the "PD" stand for in the string of acronyms next to Effexor?

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1 hour ago, psychwardjesus said:

What does the "PD" stand for in the string of acronyms next to Effexor?

Probably panic disorder if I had to guess.

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8 hours ago, mikl_pls said:

Probably panic disorder if I had to guess.

Yep

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On 1/15/2020 at 3:33 PM, CeremonyNewOrder said:

I think if you've tried multiple antipsychotics and they have not worked, you should be a candidate for clozapine. However, I think you should try risperidone/invega, which also has a good track record, first.

I'm looking into trying invega sustenna because I've heard it's less sedating then risperdal has less sexual dysfunction and weight gain.

 

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14 hours ago, psychwardjesus said:

I've never seen someone on such high doses of Depakote and Latuda and I've worked for a decade on an acute inpatient psych unit. 

The way things are right now, it's impossible to tell if meds simply aren't working or one (or more) are counteracting others and destabilizing you. 

I don't know how your doctor feels about it, but I'd probably back off either the Effexor or Latuda. SSRI's, SNRI's, etc. are pretty big no-no's in psychiatry for people with any flavor of bipolar disorder, especially at that high of a dose, without proper mood stabilizer coverage. A fair number of people also find Latuda activating, which can potentially be bad if it affects sleep or you experience akathisia/restlessness.

Are you taking Latuda with at least 350 calories? Because that's how you're supposed to take it — the same as Geodon — otherwise it can interfere with how the body metabolizes the medication. 

When you say you failed a trial of Lithium, what exactly does that mean? You didn't like how it made you feel or it caused medical problems for you? 

What does the "PD" stand for in the string of acronyms next to Effexor?

I take the Latuda with food it's simply not doing its job. 

I'm on so much depakote because it has help a lot with my impulsivity and hostility. One of my favorite meds!

The high dose of effexor is mainly for crippling anxiety and OCD. Sadly OCD usually require the higher end of the AD doses.

If anything has to go it's the Latuda. 

I'm interested in trying either Vraylar, rexulti or invega sustenna

Question? How well does Rexulti work more mania because I haven't heard anything promising. Only for depression.

As for the Lithium. I simply just didn't respond.

Edited by tbs14

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1 hour ago, tbs14 said:

I'm looking into trying invega sustenna because I've heard it's less sedating then risperdal has less sexual dysfunction and weight gain.

 

It can really still cause your prolactin to skyrocket. My pdoc showed me blood test results of a patient without disclosing her identity the prolactin levels that Invega Sustenna can cause. It was astronomical and ridiculous. The reason she was put on it was because of the stupid pdoc at the local hospital who keeps putting that patient on Invega Sustenna after my pdoc as repeatedly written to him pleading with him not to use it with her again. But he is bullheaded and does whatever the fuck he wants.

It works well for some, but just be cautious with it. You may want to try oral Invega first before getting a depot shot version of it.

1 hour ago, tbs14 said:

The high dose of effexor is mainly for crippling anxiety and OCD. Sadly OCD usually require the higher end of the AD doses.

SSRIs tend to be better for OCD. I say tend to be. Everyone is different. Cymbalta works well for some people. Effexor works well for others. Etc... But Zoloft probably works the best for me. I have considered taking it above the max dose of 200 mg to try and treat my TR OCD.

1 hour ago, tbs14 said:

If anything has to go it's the Latuda. 

I'm interested in trying either Vraylar, rexulti or invega sustenna

Question? How well does Rexulti work more mania because I haven't heard anything promising. Only for depression.

As for the Lithium. I simply just didn't respond.

I'd say try Vraylar out of all of those. Rexulti has not demonstrated good anti-manic properties, and Invega Sustenna is long-acting and once you've got it in your system, you can't turn back after so long so if you have side effects, you will be with them for a long time. Again, I'd say try oral Invega before going to the depot shot.

I personally don't believe Rexulti it has a good antimanic effect. I believe in trials it failed to demonstrate antimanic effects but could be wrong. It has demonstrated antipsychotic effects for schizophrenia at 3-4 mg.

Lithium was a nightmare for me at just 300 mg.

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2 hours ago, mikl_pls said:

It can really still cause your prolactin to skyrocket. My pdoc showed me blood test results of a patient without disclosing her identity the prolactin levels that Invega Sustenna can cause. It was astronomical and ridiculous. The reason she was put on it was because of the stupid pdoc at the local hospital who keeps putting that patient on Invega Sustenna after my pdoc as repeatedly written to him pleading with him not to use it with her again. But he is bullheaded and does whatever the fuck he wants.

It works well for some, but just be cautious with it. You may want to try oral Invega first before getting a depot shot version of it.

SSRIs tend to be better for OCD. I say tend to be. Everyone is different. Cymbalta works well for some people. Effexor works well for others. Etc... But Zoloft probably works the best for me. I have considered taking it above the max dose of 200 mg to try and treat my TR OCD.

I'd say try Vraylar out of all of those. Rexulti has not demonstrated good anti-manic properties, and Invega Sustenna is long-acting and once you've got it in your system, you can't turn back after so long so if you have side effects, you will be with them for a long time. Again, I'd say try oral Invega before going to the depot shot.

I personally don't believe Rexulti it has a good antimanic effect. I believe in trials it failed to demonstrate antimanic effects but could be wrong. It has demonstrated antipsychotic effects for schizophrenia at 3-4 mg.

Lithium was a nightmare for me at just 300 mg.

As always, @mikl_pls offers some good advice. Strongly agree that you try the oral version first. If it doesn’t agree with you, you’re screwed when you get the long acting shot.

i would also pick Vraylar from those options 

and I also agree that Rexulti seems subpar in the antimania department  

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On 1/17/2020 at 2:08 PM, tbs14 said:

I take the Latuda with food it's simply not doing its job. 

I'm on so much depakote because it has help a lot with my impulsivity and hostility. One of my favorite meds!

The high dose of effexor is mainly for crippling anxiety and OCD. Sadly OCD usually require the higher end of the AD doses.

If anything has to go it's the Latuda. 

I'm interested in trying either Vraylar, rexulti or invega sustenna

Question? How well does Rexulti work more mania because I haven't heard anything promising. Only for depression.

As for the Lithium. I simply just didn't respond.

Professionally, I don't see a lot of Latuda usage in general. Not sure if that's more due to it being newer and perhaps less reliable in the psychiatrists' eyes or that it just hasn't seemed to work well for bipolar mania or psychosis. I've seen it used a handful of times as a primary or adjunct med for bipolar depression and major depression, but I don't remember it doing anything amazing. Plus, I imagine the calorie requirement plays a factor in people wanting to take it in that, whenever you take it, you really need to be at home to make yourself something to eat (or plan ahead for the day with a big enough meal or snack, but that can be a hassle) and since a lot of people take most meds at night, there's probably a lot of concern about weight gain when you're eating 350+ calories a night right before sleep. 

I couldn't say with Rexulti or Vraylar. They're too new and too expensive for most patients to afford before they go generic. If I had to guess though, I'd say Rexulti won't do great with mania as it's very similar to Abilify and in my experience hasn't worked for most people in that regard. I could possibly see it used as an adjunct, but not a primary antipsychotic. I've seen it used a lot more on units where I work that specialize more in straight depression, bipolar depression. Whether they actually work for those indications or it's just clever marketing though is another matter. 

I've seen a good amount of usage of Invega with some success, but it's primarily used for people that don't remember or stop taking their meds and it potentially has less undesirable side effects (at least of the parkinsonian/movement variety) as compared with the Haldol Dec shot. I also wouldn't expect it to be significantly more effective than Risperdal simply because paliperidone is the active metabolite of Risperdal, kinda like Pristiq and Effexor. 

On 1/17/2020 at 3:34 PM, mikl_pls said:

It can really still cause your prolactin to skyrocket. My pdoc showed me blood test results of a patient without disclosing her identity the prolactin levels that Invega Sustenna can cause. It was astronomical and ridiculous. The reason she was put on it was because of the stupid pdoc at the local hospital who keeps putting that patient on Invega Sustenna after my pdoc as repeatedly written to him pleading with him not to use it with her again. But he is bullheaded and does whatever the fuck he wants.

It works well for some, but just be cautious with it. You may want to try oral Invega first before getting a depot shot version of it.

SSRIs tend to be better for OCD. I say tend to be. Everyone is different. Cymbalta works well for some people. Effexor works well for others. Etc... But Zoloft probably works the best for me. I have considered taking it above the max dose of 200 mg to try and treat my TR OCD.

I'd say try Vraylar out of all of those. Rexulti has not demonstrated good anti-manic properties, and Invega Sustenna is long-acting and once you've got it in your system, you can't turn back after so long so if you have side effects, you will be with them for a long time. Again, I'd say try oral Invega before going to the depot shot.

I personally don't believe Rexulti it has a good antimanic effect. I believe in trials it failed to demonstrate antimanic effects but could be wrong. It has demonstrated antipsychotic effects for schizophrenia at 3-4 mg.

Lithium was a nightmare for me at just 300 mg.

Yes. I'm not as familiar with outpatient psychiatry, but I would imagine it's similar or the same — you're typically offered 1-2 test doses if you've never taken Invega before to test how you react to it (tolerability) before the one month or more IM injection. Because it would be a nightmare if they didn't do the test doses and then find out the hard way it gives you akathisia or something like that. Then you're stuck (as far as I know) until it wears off. 

And, yes, because it's an active metabolite of Risperdal, it can have a very similar side effect profile. I've only personally seen 4-5 people in 10 years develop any kind hyperprolactinemia on Risperdal or Invega and if your doctor worries that you might be at risk for it can easily order a blood test for your prolactin level. 

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