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So i had a phone appointment with the Pdoc today

I explained that i havent tried the abilify..He knows about my fear of meds...I explained i dont want to to take something with a risk of it been too activating/stimulating..Anyways he talked about quetiapine and that it would be his first choice for me... However at the time i'd not had a ECG which i've wrote about on these boards..Hes now happy to perscribe some quetiapine...Because of my fear of meds (Which is quite extreme) I've asked to start on the lowest possible dose which is 25mg..Hes ok with that..I have to collect the perscription tommorow afternoon from the mental health team..Hes doing me 2weeks worth which we will review and it can be increased etc if needed..I tried quetiapine many years ago and gave up after about 2 days because of how groggy i felt...Hes told me to stick with it and that the grogginess will ease..

I also take Mirtazapine 30mg (Been on that about 7 years) and my logical approach to this stupid fear of meds is that I take my Mirtazapine 30mg  at night which has some calming qualities to it and if i'm in a more calmer rational state then i'm at more chance of taking the quetiapine....He agreed it was a good way to look at it..

I know folks in here are on much higher amounts but from personal experiences what can i expect from such a small dose? Will it still be calming etc Will it have a spill over effect so that i'm calm less agitated the day after etc....I imagine if i get success from the med i will go up in dose as its not just anxiety i'm getting treated for i have depression/ocd and paranoid beliefs etc  but due to my irrational fear i'm starting at the lowest dose...Anyways thanks for listening and if anyone wants to chime in feel free...

Edited by GrannyG81
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Ymmv, but at 25 you’ll probably feel a calming/sedated feeling in the hours after taking the med, but the Overall persistent effect might take higher doses... I think the suggested range is 150-300 when on another anyjdepressant. I am NOT suggesting that you speed up the dosing schedule just cuz of the  theoretical doses that worked for others... with these types of things taking it slow is usually the best call. If sedation becomes an issue, there is an extended release version that seems to have less of the acute sedation for some people. In the meantime, you should be proud of yourself for getting on another med with an open mind, I know that’s tough for you

 

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Thanks @Iceberg

Yeah he says i'm too hard on myself..I told him i feel like a burden on the mental health services etc And he says thats not true at all..

I think its because taking meds i'd imagine for most people is something that not much thought goes into...I can imagine some mild apprehension when starting new meds for most people but this fear i have of them is well well out of context...It kind of makes you feel like a failure..Which is more the depression talking...

I feel like a broken record sometimes on here repeating the same thing in terms of this fear so your feedback is very much appreciated ...

 

 

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@GrannyG81

 

Good for you for trying the quetiapine! I think if you can push through the sedation it might just help you out! I know it helped me for many years! I’m just sharing my experience. I hope you have a good one too. Give it time and a good trial. Iceberg is right that the XR version is less sedating if you choose to ask your pdoc about that if you find the regular way too much sedation like you can’t handle it. I had to switch to the XR for this reason. But of course, YMMV. Best of luck to you with it and again good for you! I know it’s not easy at all for you to try a med. I hope you find a lot of relief! 

Edited by Wonderful.Cheese
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@Wonderful.Cheese

I dont know which type hes perscribed as i've not got the script yet..I've to collect it tommorow in the afternoon...

Hes gunna review me in 2weeks see how i'm getting on etc...He feels its the right med for me..I tend to have a lot of mood swings aswell as my OCD symptoms..When i get depressed (Which thankfully i've not had a major episode in a few years now) i get really paranoid and my thoughts tend to look delusional on the surface with the content..I just dont believe them 100% for them to be Psychotic..It does say in my notes evidence of  "Acute Psychotic features"..This was back when i had my last major episode..My depression is very mixed and although i'm not "Serverly Depressed" at the moment it does affect my day to day life...I think in very black/White Terms..If i'm not depressed like i was 5 years ago then i'm not depressed is how i think ..I dont look at it as continuum..Its either i'm depressed or i'm not..Its quite a blunt way of looking at things and is not a very helpfull way of looking at my problems..Its become such an ingrained way of my thinking style i dont know if i can change it?? I was diagnosed with a personality disorder OCPD and its a trait of that...Ohh the joys of mental health....Thanks for the feedback its very much welcomed...

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10 hours ago, Iceberg said:

@GrannyG81 I’d assume he gave you the instant release because as far as I know the lowest XR pill is 50 

Yes, I was fixing to say the same thing.

Also...

@GrannyG81, from what I have heard, quetiapine is... very odd... about its sedating effects, but generally stays calming across the dosage range. Especially with the instant release, low doses are extremely sedating (the lower, supposedly, the more sedating, but for some, the higher you go, the more sedating it can be, but it does reach a point where your H1 histamine receptors become "saturated," and it literally cannot become anymore sedating, at least via that mechanism of action...) You are already on mirtazapine, which is, I believe, the most potent H1 histamine antagonist (antihistamine) on the market (at least in the US), so your H1 histamine receptors will likely become "saturated" at a much lower dose of quetiapine than if you weren't on the mirtazapine. Regardless, this "low" dose range (typically 25-100 mg or simply <200-300 mg, depending on how you look at it), is also what is best for anxiety.

Usually his "saturation" effect occurs at or around 300 mg/day, which is when it supposedly starts to behave as an antidepressant, both for bipolar depression and for unipolar depression (although for the extended-release, they have approved the range of 150-300 mg/day for adjunct to an antidepressant, but 300 mg/day for both forms is really the better dose). It may even become ever so slightly stimulating (but not in a negative way), mostly on account of its active metabolite, norquetiapine, inhibiting reuptake of norepinephrine ever so slightly, but also other mechanisms of action. So this is the dose that would be optimal for your depression. Anxiolytic effects carry over into this dose range too. For the IR version, a max of 600 mg is indicated for depression, but you really don't want to go above 300 mg/day. For the extended-release version, 300 mg is the target and max dose for depression.

Now, for the OCD and paranoid beliefs, you're going to need a bit more dopamine D2 antagonism, so you will need the dose to be within the "antipsychotic range," which isn't really a range, put rather a target dose, which according to Stahl is 800 mg/day (both for IR and ER versions). For the IR version, the dose range for psychosis (and OCD is kinda understood even though the two aren't related, but OCD is improved with more D2 blockade) is 150-750 mg/day divided 2-3x/day (big hassle to take this way, not to mention super sedating during the day!!) with a max of 800 mg/day. For the ER version, it says the dose range for psychosis (and OCD) is 400-800 mg ER every evening. The titration is indicated to be rather rapid, but you can go as slow as you tolerate/need.

If I were in your shoes, this is how I would do it. I would stick with what you have, the 25 mg IR version, and just try it out and see how you do until the next visit. Increase as slowly as you need and are comfortable doing. At some point, in my opinion, there are two things you are going to want to do: (1) switch to the ER version is possible, and (2) consider discontinuing the mirtazapine, as the quetiapine will fill the role of mirtazapine as an antidepressant, as well as anxiolytic, and have an additional role as an antipsychotic/anti-obsessive agent. Both meds are very sedating on their own and promote weight gain quite a lot (especially IR quetiapine vs. ER quetiapine, but mirtazapine probably is even worse about weight gain than quetiapine...). I'd say probably by the time you get to 300 mg, if you're still on IR and if you make it to that dose, you might consider switching to the ER version if you can. It's way more convenient and has far less side effects, as well as being more effective with higher blood levels of the active metabolite, norquetiapine.

From 300 mg (going to assume ER version from hereon), try to go up, if you can, in 100 mg intervals, if not, 50 mg intervals (you may need multiple prescriptions for different strengths of the pill since the ER pills cannot be split or anything). 400 mg is the bare minimum that is indicated, but 600-800 mg is optimal, with 800 mg being the very most ideal dose if you're suffering from OCD and paranoia, since that's the dose with the optimal D2 binding occupancy for the most effective antipsychotic effects. Also, 5-HT2A antagonism will be at its highest, which also have anxiolytic effects, as well as 5-HT2C antagonism, which will have anxiolytic, antidepressant, and anti-OCD effects. 5-HT1A partial agonism will have anxiolytic, antidepressant, and I think antipsychotic effects (somewhat, indirect) as well. Also, the NRI of the active metabolite will contribute to some antidepressant and possible anxiolytic (though you wouldn't think it) effects.

But as has been said, take it at your own pace, don't feel the need to accelerate your titration. Just know that quetiapine is one of those antipsychotics that, due to its binding affinities to the dopamine receptors, it tends not to have any appreciable antipsychotic/anti-OCD effect until you get to the higher/highest dose possible, and the ER version is definitely, to my understanding, way more effective and has way less side effects than the IR version.

 

If quetiapine doesn't work for you (not trying to get ahead of you too far, just trying to give you some options to consider I guess for comfort's sake?), here are some alternatives that I would recommend (assuming they're available where you live). AAPs with antidepressant, anxiolytic, anti-OCD, and, well, antipsychotic properties:

  • ziprasidone (Geodon) 40 mg 2x/day with 500 calories of food per dose (needs to be taken with this much food or more or it will not be absorbed properly or at all) (low doses, 20-40 mg 2x/day, can be somewhat activating, but not nearly as much as aripiprazole can be... for you, 40-60 mg 2x/day would probably be ideal, with the max of 80 mg 2x/day being necessary only if you don't get an adequate response from the 40-60 mg 2x/day)
  • risperidone (Risperdal) or maybe paliperidone ER (Invega) (not familiar at all with dosing for these, but you want to watch your dose and try to keep it as low as effective because both of these meds can elevate prolactin quite substantially, which, in men especially but women too, can cause all sorts of things to go haywire...)
  • Brand-name only... (not sure if you'll be able to get all of these covered readily)
    • Latuda (lurasidone) 40 mg in the evening with at least 350 calories of food (similar to Geodon in this matter), lower doses (20-40 mg/day) are activating usually, with mid-range doses (60-80 mg) being neutral to somewhat sedating, and high doses (120 mg, max for bipolar, and 160 mg, max for psychosis/schizophrenia) being the most sedating. You'd likely wind up in the 60-80 mg dose range.
    • (Rexulti (brexpiprazole) not sure which dosing regimen to go by... it's only indicated for major depressive disorder, adjunct therapy, or schizophrenia...)
      • MDD, adjunct tx: Start: 0.5 mg (usually taken at bedtime as it is usually sedating, but may be stimulating for some, also may depend on dose), may increase dose each week (next would be 1 mg, then 2 mg, which is target dose for depression). Max: 3 mg/day (not usually more effective for depression, but may help more with anxiety, OCD, and definitely with paranoia)
      • Schizophrenia (likely more along the lines of treating the paranoia and OCD): Start: 1 mg x4 days, then increase dose to 2 mg x3 days, then increase dose to 4 mg (max). (May go to 3 mg in between 2 mg and 4 mg...)
    • Saphris (asenapine) (may take anywhere from 5 mg at bedtime to 10 mg 2x/day... This one is usually pretty sedating. It's also a sublingual tablet that is supposed to taste like black cherry, but it tastes quite nasty to most people, and some people simply cannot take this medicine because it is that nasty... but it's very calming for me and helps me sleep... the only problem is that the antidepressant effect wears of for me after a few weeks of taking it and then it starts to worsen my depression at just 5 mg at bedtime... I've never taken it at the indicated dose of 10 mg 2x/day.)
    • Vraylar (cariprazine)
      • bipolar I disorder, depressive
        Start: 1.5 mg (usually in the AM) x14 days (I'd say even longer, up to x4 weeks minimum), then may increase to 3 mg (max)
      • bipolar I disorder, manic/mixed
        Start: 1.5 mg AM x1 day, then increase to 3 mg in AM; Max: 6 mg/day; may adjust dose in 1.5 mg or 3 mg increments (better to do smaller dose adjustments with this medicine, usually at the least every x4 weeks minimum)
      • schizophrenia
        Start: 1.5 mg AM x1 day, then may increase to 3 mg in AM; Max: 6 mg/day (see bipolar, manic/mixed)
  • I did leave some out... like clozapine (Clozaril) as it's a drug of last resort, olanzapine (Zyprexa, Zyprexa Zydis) due to diabetes risk, Caplyta (lumateperone) which I take and while it's super good I don't know if its mechanisms of action would benefit you the best for all that you need it for, but you're welcome to give it a try if it's available to you, Secuado (basically transdermal patch version of Saphris) simply because I'm extremely unfamiliar with it, but if it's available to you, you're willing to put up with the trouble of wearing a patch, and Saphris was good to you but you couldn't stand the taste of the tablets, then I think it would be a good medicine, and Fanapt because it tends to have a much higher incidence of side effects and tends to be far less effective than the other AAPs. I also left out the long-acting injections, since those are usually reserved for people who are non-compliant with their medication.

 

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