Skeletor Posted March 29, 2020 Share Posted March 29, 2020 (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 March 30, 2020 by Skeletor 2 1 Link to comment Share on other sites More sharing options...
notloki Posted March 30, 2020 Share Posted March 30, 2020 Antipsychotics tend to have antidepressant capability. Some hit serotonin receptors quite significantly, as in Abilify. 3 Link to comment Share on other sites More sharing options...
echolocation Posted March 30, 2020 Share Posted March 30, 2020 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. 3 Link to comment Share on other sites More sharing options...
Iceberg Posted March 30, 2020 Share Posted March 30, 2020 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 2 Link to comment Share on other sites More sharing options...
Blahblah Posted March 30, 2020 Share Posted March 30, 2020 (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 March 30, 2020 by Blahblah 3 2 Link to comment Share on other sites More sharing options...
Skeletor Posted March 30, 2020 Author Share Posted March 30, 2020 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. 2 1 Link to comment Share on other sites More sharing options...
Skeletor Posted March 30, 2020 Author Share Posted March 30, 2020 Here some articles I've been reading:https://psychotropical.com/dopamine-and-depression-part-1/ https://psychotropical.com/anti-psychotics/ https://psychotropical.com/quetiapine-the-miracle-of-seroquel/ https://psychotropical.com/risperdal-chicanery/ 2 Link to comment Share on other sites More sharing options...
Juniper29 Posted March 31, 2020 Share Posted March 31, 2020 Why are you asking? Has your pdoc prescribed this combination to you and you're trying to decide whether to take it? 1 1 Link to comment Share on other sites More sharing options...
Juniper29 Posted March 31, 2020 Share Posted March 31, 2020 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. 1 Link to comment Share on other sites More sharing options...
notloki Posted March 31, 2020 Share Posted March 31, 2020 There is a dopamine component to depression. 1 Link to comment Share on other sites More sharing options...
Blahblah Posted March 31, 2020 Share Posted March 31, 2020 11 hours ago, Skeletor said: Here some articles I've been reading:https://psychotropical.com/dopamine-and-depression-part-1/ https://psychotropical.com/anti-psychotics/ https://psychotropical.com/quetiapine-the-miracle-of-seroquel/ https://psychotropical.com/risperdal-chicanery/ 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." 2 2 Link to comment Share on other sites More sharing options...
Iceberg Posted March 31, 2020 Share Posted March 31, 2020 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 1 2 Link to comment Share on other sites More sharing options...
Skeletor Posted April 1, 2020 Author Share Posted April 1, 2020 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? 1 Link to comment Share on other sites More sharing options...
morpheus Posted April 1, 2020 Share Posted April 1, 2020 (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. Stahl's Essential Psychopharmacology: Neuroscientific Basis and Practical Applications, 4th Ed. Edited April 1, 2020 by morpheus 2 Link to comment Share on other sites More sharing options...
GrannyG81 Posted April 1, 2020 Share Posted April 1, 2020 (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 April 1, 2020 by GrannyG81 2 Link to comment Share on other sites More sharing options...
Gearhead Posted April 1, 2020 Share Posted April 1, 2020 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. 2 Link to comment Share on other sites More sharing options...
Skeletor Posted April 1, 2020 Author Share Posted April 1, 2020 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? 1 Link to comment Share on other sites More sharing options...
Gearhead Posted April 1, 2020 Share Posted April 1, 2020 Antidepressants can make bipolar people manic. If I don’t have other meds to counterbalance my AD, I go totally crazy. 2 Link to comment Share on other sites More sharing options...
Skeletor Posted April 1, 2020 Author Share Posted April 1, 2020 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?" ... 1 Link to comment Share on other sites More sharing options...
Iceberg Posted April 1, 2020 Share Posted April 1, 2020 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 2 Link to comment Share on other sites More sharing options...
Gearhead Posted April 1, 2020 Share Posted April 1, 2020 1 hour ago, Skeletor said: Curiosity. manic as in "reckless behavior, excessive money spending, doing drugs, feeling invincible?" ... Yup. Although, for me personally, really excessive spending has never been a huge issue. Or doing drugs. I’m more of a pressured speech, racing thoughts, magical thinking, hypersexuality, insomnia, forgetting to eat, whatdoyoumeanspeedlimit, kinda girl. 2 Link to comment Share on other sites More sharing options...
Skeletor Posted April 1, 2020 Author Share Posted April 1, 2020 5 minutes ago, Iceberg said: 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 This is interesting. Never heard of this before... so some kind of "masked mania"...? 2 minutes ago, Gearhead said: Yup. Although, for me personally, really excessive spending has never been a huge issue. Or doing drugs. I’m more of a pressured speech, racing thoughts, magical thinking, hypersexuality, insomnia, forgetting to eat, whatdoyoumeanspeedlimit, kinda girl. Interesting! How did you get diagnosed? It seems difficult do diagnose something like this, because many conditions share these kind of symptoms... 2 Link to comment Share on other sites More sharing options...
Gearhead Posted April 1, 2020 Share Posted April 1, 2020 4 minutes ago, Skeletor said: Interesting! How did you get diagnosed? It seems difficult do diagnose something like this, because many conditions share these kind of symptoms... I get the full manic-to-depressed cycle. When it comes to bipolar l, I’m a classic textbook case. https://www.webmd.com/bipolar-disorder/guide/bipolar-1-disorder#1 2 Link to comment Share on other sites More sharing options...
Iceberg Posted April 1, 2020 Share Posted April 1, 2020 @Skeletor the common term is “mixed mania” meaning that you get some elevated classic-mania symptoms but also get some symptoms that don’t exactly resemble classic mania, such as severe agitation among other things. It is often described as having mania and depressive symptoms at the same time, which is very dangerous because situations can result where a person can be suicidal and more likely to act on it because they have excess energy. In the latest DSM it is called “mania with mixed features” and it is horrible. I have been hospitalized for it before 2 Link to comment Share on other sites More sharing options...
Skeletor Posted April 1, 2020 Author Share Posted April 1, 2020 (edited) On 4/1/2020 at 11:00 PM, Iceberg said: @Skeletor the common term is “mixed mania” meaning that you get some elevated classic-mania symptoms but also get some symptoms that don’t exactly resemble classic mania, such as severe agitation among other things. It is often described as having mania and depressive symptoms at the same time, which is very dangerous because situations can result where a person can be suicidal and more likely to act on it because they have excess energy. In the latest DSM it is called “mania with mixed features” and it is horrible. I have been hospitalized for it before Thanks for clarifying it. I myself have been suspecting some form of "mixed states" affecting me. I have deeply dysphoric states, but they change from dysphoric to "okay" within the span of one day... sometimes many times in a day: In the morning I am dysphoric, depressive and ful of despair, in the afternoon I feel okay, but have my head full of thoughts and can't concentrate on a task, then in the evening it is somewhat worse... dysphoria, bad mood, and in late evening and night I feel good... not perfect, but good... clear mind, somewhat relaxed. (I have lots of psychomotor agitation: even as a child I was psychomotorically agitated.) I've never looked into Bipolar Disorder. I suspected maybe some form of ADHD, but am not sure. I am always tardy and have difficulties organizing myself and my day. Too much stuff in my head, too agitated. btw: How were your experiences with Remeron and Zoloft? How did they affect you and your BP? Edited April 3, 2020 by Skeletor Link to comment Share on other sites More sharing options...
Iceberg Posted April 1, 2020 Share Posted April 1, 2020 16 minutes ago, Skeletor said: Thanks for clarifying it. I myself have been suspecting some form of Cyclothymia affecting me. I have deeply dysphoric states, but they change from dysphoric to "okay" within the span of one day... sometimes many times in a day: In the morning I am dysphoric, depressive and ful of despair, in the afternoon I feel okay, but have my head full of thoughts and can't concentrate on a task, then in the evening it is somewhat worse... dysphoria, bad mood, and in late evening and night I feel good... not perfect, but good... clear mind, somewhat relaxed. (I have lots of psychomotor agitation: even as a child I was psychomotorically agitated.) I've never looked into Bipolar Disorder. I suspected maybe some form of ADHD, but am not sure. I am always tardy and have difficulties organizing myself and my day. Too much stuff in my head, too agitated. btw: How were your experiences with Remeron and Zoloft? How did they affect you and your BP? Remeron didn’t really do anything, Zoloft never got a chance to do anything cuz pdocs disagred about. Using it and it got pulled after only a few weeks. Only 1 of the 4 main docs I’ve had was a believer of using SSRIs with BP 1. The other three ranged from “bad idea” to “it won’t work (for me)” 2 Link to comment Share on other sites More sharing options...
Blahblah Posted April 1, 2020 Share Posted April 1, 2020 (edited) 14 minutes ago, Iceberg said: Remeron didn’t really do anything, Zoloft never got a chance to do anything cuz pdocs disagred about. Using it and it got pulled after only a few weeks. Only 1 of the 4 main docs I’ve had was a believer of using SSRIs with BP 1. The other three ranged from “bad idea” to “it won’t work (for me)” Hey @Iceberg were you on Lamictal before you started Lithium? I'm curious why you'd stay on both, since Lamictal is not a heavy-hitter as far as an anti-manic. I'm assuming your pdoc is ok with Adderall because its treating the ADHD...I always thought that was a huge no no for BP folks also. The whole BP/ cyclical spectrum thing is so complicated to treat. Interesting thread for sure. Edited April 1, 2020 by Blahblah 2 Link to comment Share on other sites More sharing options...
Iceberg Posted April 2, 2020 Share Posted April 2, 2020 1 hour ago, Blahblah said: Hey @Iceberg were you on Lamictal before you started Lithium? I'm curious why you'd stay on both, since Lamictal is not a heavy-hitter as far as an anti-manic. I'm assuming your pdoc is ok with Adderall because its treating the ADHD...I always thought that was a huge no no for BP folks also. The whole BP/ cyclical spectrum thing is so complicated to treat. Interesting thread for sure. Complicated it is. No, lamictal was later but it was a retry. I had been at a much lower lithium dose when I originally tried it, so we thought there might be more combined effectiveness when my lithium was significantly higher. It was added more to help maintain stability after an episode than to actually treat it. I don’t really get any side effects, so now it’s more of an “if it ain’t broke, don’t fix it” type of thing. Unfortunately Lithium as a lone mood stabilizer, even it super high doses, has proven to not be enough to keep things stable in either direction. the “possible ADHD in my sig was actually from a complete psych evaluation done years ago, I’ve never explicitly taken a med for it. The adderall is for a couple reasons. One; while I may not have ADHD, there are certain parts of my illness that make it hard for me to function cognitively in some settings, such as academically. Second, clozaril sedation is heavy, but apparently I get it even worse than most. Once it helped settle down the episode I was in, we used the adderall so I could function while things stabilized dose-wise, finally making the cost/benefit choice that cloz + adderall is better than no cloz at all... considering it’s been highly effective for me. Third, I have tried almost every strategy deemed safe to treat my depressive episodes. At the time, nothing had worked so we’re hoping to get some relief from depression as a side benefit. We did, it helps me feel driven and motivated through the day. You’re correct, it’s not a common option, but we were basically out of choices 2 Link to comment Share on other sites More sharing options...
Blahblah Posted April 2, 2020 Share Posted April 2, 2020 (edited) 8 hours ago, Iceberg said: Complicated it is. No, lamictal was later but it was a retry. I had been at a much lower lithium dose when I originally tried it, so we thought there might be more combined effectiveness when my lithium was significantly higher. It was added more to help maintain stability after an episode than to actually treat it. I don’t really get any side effects, so now it’s more of an “if it ain’t broke, don’t fix it” type of thing. Unfortunately Lithium as a lone mood stabilizer, even it super high doses, has proven to not be enough to keep things stable in either direction. the “possible ADHD in my sig was actually from a complete psych evaluation done years ago, I’ve never explicitly taken a med for it. The adderall is for a couple reasons. One; while I may not have ADHD, there are certain parts of my illness that make it hard for me to function cognitively in some settings, such as academically. Second, clozaril sedation is heavy, but apparently I get it even worse than most. Once it helped settle down the episode I was in, we used the adderall so I could function while things stabilized dose-wise, finally making the cost/benefit choice that cloz + adderall is better than no cloz at all... considering it’s been highly effective for me. Third, I have tried almost every strategy deemed safe to treat my depressive episodes. At the time, nothing had worked so we’re hoping to get some relief from depression as a side benefit. We did, it helps me feel driven and motivated through the day. You’re correct, it’s not a common option, but we were basically out of choices Makes sense! I hear you with the "ain't broke don't fix it" I'm not sure what Lamictal is doing, but it's been years, and I'm afraid to stop it. Especially as it has fewest side effects (at low doses). I recall Lithium being pretty strong/numbing (at the recommended doses) that's surprising that it isn't more effective. I also don't have diagnosed ADD, but the Ritalin really helps with cognitive function, focus, and drive, it helps mitigate brain fog side effects of other meds. Have you had to increase the dose very often or take breaks from it? I wish we didn't have to keep throwing different curveballs at our brains 😕 Edited April 2, 2020 by Blahblah 2 Link to comment Share on other sites More sharing options...
Iceberg Posted April 2, 2020 Share Posted April 2, 2020 10 hours ago, Blahblah said: Makes sense! I hear you with the "ain't broke don't fix it" I'm not sure what Lamictal is doing, but it's been years, and I'm afraid to stop it. Especially as it has fewest side effects (at low doses). I recall Lithium being pretty strong/numbing (at the recommended doses) that's surprising that it isn't more effective. I also don't have diagnosed ADD, but the Ritalin really helps with cognitive function, focus, and drive, it helps mitigate brain fog side effects of other meds. Have you had to increase the dose very often or take breaks from it? I wish we didn't have to keep throwing different curveballs at our brains 😕 I had my lithium level up to 1.5 at one point, which was knocking on the door of toxicity. it was good as a stabilizer for awhile, but once I got into an episode it couldn't get me out (on multiple occasions) I do back off on the Adderall when I'm not in focus-intensive situations or situations that require me to be alert (ex. driving), but not typically a full "break" and my pdoc gives me some discretion about when to back on the does depending on what my situation is 1 Link to comment Share on other sites More sharing options...
Adolf Posted April 7, 2020 Share Posted April 7, 2020 On 3/31/2020 at 10:34 AM, notloki said: There is a dopamine component to depression. Too much dopamine? Not enough dopamine? Link to comment Share on other sites More sharing options...
notloki Posted April 7, 2020 Share Posted April 7, 2020 2 hours ago, Adolf_H8 said: Too much dopamine? Not enough dopamine? Too simplistic a model. Link to comment Share on other sites More sharing options...
Adolf Posted April 7, 2020 Share Posted April 7, 2020 18 minutes ago, notloki said: Too simplistic a model. What is the right model? Link to comment Share on other sites More sharing options...
notloki Posted April 7, 2020 Share Posted April 7, 2020 Well is sure is not a simple hot/cold, more of this and less of that operation. Honestly don't you get it that we don't know for sure. 1 Link to comment Share on other sites More sharing options...
Skeletor Posted May 15, 2020 Author Share Posted May 15, 2020 On 4/8/2020 at 1:08 AM, notloki said: Honestly don't you get it that we don't know for sure. Nope. Link to comment Share on other sites More sharing options...
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