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Skeletor

What is the rationale behind prescribing antipsychotics for Depression, Panic, Anxiety and OCD?

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Posted (edited)

There is a growing trend for antidepressant + antipsychotic combos. One does regularly read that patients get prescribed an SSRI and in addition they get some atypical antipsychotic. What is the goal of prescribing an antipsychotic to a person with Depression, Panic, Anxiety or OCD? Shouldn't it be last resort?

https://psychotropical.com/psychotic-depression-and-tranylcypromine/

Edited by Skeletor
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Antipsychotics tend to have antidepressant capability. Some hit serotonin receptors quite significantly, as in Abilify.

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i'm by no means a doctor, so please excuse my layman's way of explaining this as i understand it. atypical antipsychotics are often used in low doses (usually well below the standard doses for treating psychosis) because they can amplify the effect of the antidepressant and make it more effective. or, when an antidepressant is partially helpful but there are still symptoms present, adding another medication to target the remaining symptoms can be faster than titrating off the AD, titrating on to a new one, and then waiting 6-8 weeks to judge if it's more effective than the last one.

it's also worth mentioning that AAPs are considered to be safer and cause less serious side effects than the older typical antipsychotics. at the doses used for anxiety, depression, OCD, etc, most people do not encounter serious side effects. lots of pdocs seem to prefer to try augmenting an AD with an AAP before even trying older antidepressants, like tricyclics and MAOIs. though these older ADs can be very effective, they are troublesome in some ways that SSRIs and AAPs are generally not. tricyclics can be more dangerous to overdose on, and generally come with a more severe side effect profile. MAOIs require dietary adjustments.

my experience when i was first prescribed an AAP was that i was seeing benefit from my AD (sertraline) but still had racing thoughts and intrusive thoughts. adding risperidone at a very low dose helped that. i eventually switched to venlafaxine as my AD, which was more calming for me than sertraline. in combination with the risperidone, my anxiety and intrusive thoughts were well controlled. later, when i came off risperidone, i found that the venlafaxine alone did not cover my symptoms effectively. i'm now trying a tricyclic antidepressant alone.

i hope this helps some. like i said, this is my understanding of it based on reading here and my own experiences.

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Some people just can’t tolerate a combo of 2 antidepressants, so it’s an alternative approach. I don’t think it should be a “last resort” necessarily, because some are FDA approved for the purpose... it’s not necessarily a “worse” side effect profile, but more like a different one that works better for some 

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Posted (edited)
10 hours ago, Skeletor said:

There is a growing trend for antidepressant + antipsychotic combos. One does regularly read that patients get prescribed an SSRI and in addition they get some atypical antipsychotic. What is the goal of prescribing an antipsychotic to a person with Depression, Panic, Anxiety or OCD? Shouldn't it be last resort?

I've seen this a lot also. I just wish that researchers could come up with a novel antidepressant, and do some longer clinical trials, instead of these "makeshift" combos where they start using stuff off-label, without knowing the longterm effects or interactions.

It all just feels like a shot in the dark, as if our brains are just a pinball game: start with this, for the side effect add this, oh tired, more anxious? then add this....until you don't even know which med is doing what, maybe a med pooped out, but how would you know if you add an A/P, then a benzo, then a mood stabilizer, etc etc. Then you taper off to switch, get withdrawals and the doc claims it's your "initial illness coming back"  🙄

Um no....We don't even know my baseline mood after spending 20 years experimenting with different combos etc, with no significant break...It takes time for your neurons to adjust & whatnot without a drug interfering. My body, brain and "baseline" is forever altered and dependent on drugs. Now my memory is shot, I have chronic fatigue, and I can't even poop now (daily), without stimulants! This is just wrong....!

Edited by Blahblah
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20 hours ago, notloki said:

Antipsychotics tend to have antidepressant capability. Some hit serotonin receptors quite significantly, as in Abilify.

Yes, but in that case wouldn't it be wiser to choose Mirtazapine, Buspirone or some trricyclic AD? They also (ant)agonize 5HT-receptors, but without the strong anti-dopamine effects...

It's just that I am unsure about the anti-dopamine effects. It seems to me that one does not want that when having run-of-the-mill-depression.

 

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Why are you asking? Has your pdoc prescribed this combination to you and you're trying to decide whether to take it?

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Also I disagree with the author of that article that psychotic depression isn't real psychosis or whatever it is he's saying. Abilify has been very helpful for my psychotic symptoms.

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There is a dopamine component to depression.

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11 hours ago, Skeletor said:

I agree with many of his main points, in regards to most A/Ds do not directly enhance DA transmission, which can actually worsen residual depressive symptoms such as: impaired motivation, concentration, and pleasure. I don't really see robust evidence for using A/Ps (typical or the "atypical', whatever that means) in depression either (unless there is a psychosis element)

"DA antagonists (neuroleptics), such as quetiapine, reduce signals in dopamine pathways. That strongly indicates it is ill-advised to use them to attempt to augment treatment response in serious melancholic-type depressions. Theory, and animal data, predict that action is the exact opposite of the increase in DA that strong evidence indicates is required.

The clinical evidence that quetiapine augmentation actually has any substantive benefits is weak — a couple of points on a rating scale does not an anti-depressant make — in my submission any minor benefits are quite insufficient to justify administration of a class of drugs with so many long-term side-effects. Any self-respecting Bayesian would want much stronger evidence of more substantial benefit.

DA antagonists such as quetiapine most certainly do not improve drive, motivation and energy — and that is what patients with severe depression need improved."

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8 hours ago, Blahblah said:

I agree with many of his main points, in regards to most A/Ds do not directly enhance DA transmission, which can actually worsen residual depressive symptoms such as: impaired motivation, concentration, and pleasure. I don't really see robust evidence for using A/Ps (typical or the "atypical', whatever that means) in depression either (unless there is a psychosis element)

"DA antagonists (neuroleptics), such as quetiapine, reduce signals in dopamine pathways. That strongly indicates it is ill-advised to use them to attempt to augment treatment response in serious melancholic-type depressions. Theory, and animal data, predict that action is the exact opposite of the increase in DA that strong evidence indicates is required.

The clinical evidence that quetiapine augmentation actually has any substantive benefits is weak — a couple of points on a rating scale does not an anti-depressant make — in my submission any minor benefits are quite insufficient to justify administration of a class of drugs with so many long-term side-effects. Any self-respecting Bayesian would want much stronger evidence of more substantial benefit.

DA antagonists such as quetiapine most certainly do not improve drive, motivation and energy — and that is what patients with severe depression need improved."

Today the antipsychotics used to add-on are commonly dopamine partial agonists like abilify and Rexulti, rather than straight antagonists 

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16 hours ago, Iceberg said:

Today the antipsychotics used to add-on are commonly dopamine partial agonists like abilify and Rexulti, rather than straight antagonists 

How do they work? Partial means only to some degree?

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Posted (edited)
34 minutes ago, Skeletor said:

How do they work? Partial means only to some degree?

Partial agonist have a ability to activate receptor,but only partially compared to natural ligand ie. dopamine.

image169.jpg

Stahl's Essential Psychopharmacology: Neuroscientific Basis and Practical Applications, 4th Ed.

Edited by morpheus
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Posted (edited)

I asked my Current Pdoc as to why all previous Pyschiatrists have perscribed Antipyschotics if OCD is best treated with high dose antidepressant..He said that sometimes with my ocd when its extreme it can spill over into what they call delusional..He explained it much better..My Main OCD "Theme" in my opinion is contamination yet there tends to be a Bizzare element to my thought process (Which i've wrote about on here) which on the surface may look delusional...The difference been i dont believe them 100%...I rememeber hitting a depression many years ago and i started getting really paranoid ideas...Thinking the terminator was looking for me ..Thinking i could feel presences etc ..Even though there was a part of me that did not believe this 100% the over whelming nature of it was terrifying..I was also told i was treatment resistant many years ago by a psyche...(Depression) In my mental health notes theres various terms like Acute Psychotic Feature,Self referential ideas and paranoid beliefs but i've never been diagnosed with any Pyschotic illness...My official diagnosis have been OCPD (one psyche said i could have cluster A traits which is paranoid etc) And OCD...I,ve been told my depression is reccurant ,Clinical and also Mixed..So i think in my case even though my diagnosis are all on the Obsessive/Anxious scale theres also other "features" that although dont warrant a pyschotic diagnosis, are troubling (and when at my worst) Severe enough to warrant similar treatment that someone which a Psychotic illness needs...Also OCD has a Insight Factor involved were a person can have a good degree of insight at one end and No insight at the other...I think when i get quite ill i fall somewere in the middle of the continuum...Thats just my guess i've never had a Pysche say that...I'm currently struggling at the moment taking my Antipsychotic..Although i'm not delusional the fear is very irrational and well out of proportion..This is all based Purely on my own  experience with mental health issues...I no everyone is different and different PDocs have Different reasons for perscribing Antipsychotics..Anyways Good question...I enjoy subjects like this..

Edited by GrannyG81
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In the realm of the experiential rather than the technical, as a bipolar person I’ve found that without a mood stabilizer AND an antipsychotic, I can’t take antidepressants. Things get really exciting really fast if I try.

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30 minutes ago, Gearhead said:

In the realm of the experiential rather than the technical, as a bipolar person I’ve found that without a mood stabilizer AND an antipsychotic, I can’t take antidepressants. Things get really exciting really fast if I try.

How so?

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Antidepressants can make bipolar people manic. If I don’t have other meds to counterbalance my AD, I go totally crazy.

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On 3/31/2020 at 2:01 AM, Juniper29 said:

Why are you asking? Has your pdoc prescribed this combination to you and you're trying to decide whether to take it?

Curiosity.

27 minutes ago, Gearhead said:

Antidepressants can make bipolar people manic. If I don’t have other meds to counterbalance my AD, I go totally crazy.

manic as in "reckless behavior, excessive money spending, doing drugs, feeling invincible?" ...

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1 hour ago, Skeletor said:

Curiosity.

manic as in "reckless behavior, excessive money spending, doing drugs, feeling invincible?" ...

Yes, that can happen. Happened to me once with an SSRI. But every persons reaction is different... it can also lead to a dysphoric type mania (which isn’t technically the term anymore but just for making the point) where people can become extremely irritable and have a hair trigger 

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