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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 20 of 20. This is the beginning of the thread.
Posted by tensor on March 4, 2008, at 7:19:12
Of the newer antipsychotics, which is generally considered the best antidepressant? For unipolar/bipolarII depression. With 'best' I mean most antidepressant power but also a benign side effect profile. Not only as monotherapy but also as add-on.
Thanks/Mattias
Posted by Jamal Spelling on March 4, 2008, at 7:41:29
In reply to Which is the *Best*?, posted by tensor on March 4, 2008, at 7:19:12
I expressed an interest to my doctor to augment Cymbalta with a low dose of an AP. These were the options we discussed:
(i) flupenthixol (Fluanxol): a typical AP, it carries the risk of TD. It has motivating properties.
(ii) olanzapine (Zyprexa): very effective, but too expensive and weight gain is going to be a problem w.r.t. diabetes and hypertension.
(iii) amisulpride (Solian): an atypical AP, it is, like flupenthixol, motivating. However, she says there are cardiovascular concerns, so I would have to go for regular ECGs.
(iv) quetiapine (Seroquel): for the treatment of depression, this is currently her favourite. It is atypical, and has a reasonable risk profile. The main problem is that many find it sedating, and reading some posts on Psycho-Babble, I see many also complain that it flattens their mood.
As for an AP with a benign side-effect profile, it does - unfortunately - not exist. APs are amongst the big guns of psychiatry, and they all have their own problems. At the low doses that one would use for depression, side-effects are less likely and less severe, but they still exist. Nature did not intend for dopamine receptors to be blockaded.
Posted by Jamal Spelling on March 4, 2008, at 7:53:40
In reply to Which is the *Best*?, posted by tensor on March 4, 2008, at 7:19:12
The chart found at
http://meds.queensu.ca/~clpsych/orientation/Antipsychotics%20Comparison%20Chart.pdf
may also be useful to get an idea of what the peculiar issues are with some of the APs. I think the chart was drawn up more in the context of treatment for schizophrenia than treatment for depression, but it is still informative. For example, I doubt that you'd be using haloperidol for depression.
Posted by tensor on March 4, 2008, at 7:59:00
In reply to Re: Which is the *Best*? » tensor, posted by Jamal Spelling on March 4, 2008, at 7:41:29
Thanks for your post.
We don't have amisulpiride here, but we do have sulpiride. There also some other option like Abilify, which I have read has a strong antidepressant effect and risperdal and geodon. I don't think any pdoc here have much knowledge using APs as antidepressants./Mattias
Posted by tensor on March 4, 2008, at 10:09:35
In reply to Which is the *Best*?, posted by tensor on March 4, 2008, at 7:19:12
I'm meeting a pdoc tomorrow morning as I'm not capable of working right now, I was at job today but it was torture and I got absolutely nothing done. I need something strong and fast antidepressing. Currently taking 30mg Remeron, 2mg clon and 30mcg T3. Am looking at anticonvulsants and APs, have tried lithium and Lamictal with little or no success.
Any ideas?/Mattias
Posted by Phillipa on March 4, 2008, at 12:17:58
In reply to Re: Which is the *Best*?, posted by tensor on March 4, 2008, at 10:09:35
Klonopin or valium? Just a thought. Phillipa
Posted by tensor on March 4, 2008, at 12:21:26
In reply to Re: Which is the *Best*? » tensor, posted by Phillipa on March 4, 2008, at 12:17:58
> Klonopin or valium? Just a thought. Phillipa
I don't really class the benzos as antipsychotics(do you?).
Posted by Quintal on March 4, 2008, at 12:39:38
In reply to Which is the *Best*?, posted by tensor on March 4, 2008, at 7:19:12
I'd say go for the sulpiride. I haven't personally taken it but I'm very familiar with amisulpride by now and it is a good drug for depression. It usually works quickly too (at least for me). I've taken Seroquel, Zyprexa and Abilify and didn't have the kind of response I got with amisulpride, not by a long shot.
Q
Posted by tensor on March 4, 2008, at 12:53:32
In reply to Re: Which is the *Best*? » tensor, posted by Quintal on March 4, 2008, at 12:39:38
Thank you for the tip. Is there anything you can tell me about its(ami-/sulpiride) side effects, do you think elevated prolactin or tremor will be a problem in the dosing range of 50-150mg?
/Mattias
> I'd say go for the sulpiride. I haven't personally taken it but I'm very familiar with amisulpride by now and it is a good drug for depression. It usually works quickly too (at least for me). I've taken Seroquel, Zyprexa and Abilify and didn't have the kind of response I got with amisulpride, not by a long shot.
>
> Q
Posted by Quintal on March 4, 2008, at 13:21:41
In reply to Re: Which is the *Best*? » Quintal, posted by tensor on March 4, 2008, at 12:53:32
The most common side effect of amisulpride is insomnia (my own experience and according to my medical book). Apart from that I haven't had any side effects as such other than feeling 'hyper' and agitated at 200mg, but I put that down to excess dose. Amisulpride is as bad as risperidone elevating prolactin, which is pretty bad. Sulprirde may be diffrent though. I haven't had any problems from excess prolactin levels (if I did have elevated prolactin), but I know one poster had severe sexual dysfunction at 50mg. I was quite surprised by that because I find it to have a pro-sexual effect. I was still very much 'sexually active' even when I was in hospital on 200mg. I'm very sensitive to that side effect, so there's no doubt I would pick up on it if I were experiencing any sexual dysfunction - I couldn't tolerate SSRIs for that reason. It seems to enhance orgasm a great deal, a bit like Mirapex did. I've never noticed any sign of hand tremor.
I also take Agnus Castus, which is a dopamine agonist and lowers prolactin levels. It might be an idea for limiting/treating elevated prolactin if it were to be a problem? I wasn't taking Agnus Castus in hospital, or the first time I took it, and I had no sexual/breast growth/milk problems then.
Q
Posted by tensor on March 4, 2008, at 14:05:00
In reply to Re: Which is the *Best*? » tensor, posted by Quintal on March 4, 2008, at 12:39:38
How was Abilify? Did you have any antidepressant response at all? If, was it stronger that the other 2nd gen. APs?
/Mattias
Posted by Jamal Spelling on March 4, 2008, at 14:49:57
In reply to Which is the *Best*?, posted by tensor on March 4, 2008, at 7:19:12
You might find the following posts informative:
Posted by tensor on March 4, 2008, at 15:31:16
In reply to Re: Which is the *Best*? » tensor, posted by Jamal Spelling on March 4, 2008, at 14:49:57
Thanks,
do you know if Sulpiride can be taken with Remeron?
/Mattias
Posted by Jamal Spelling on March 4, 2008, at 15:37:38
In reply to Re: Which is the *Best*?, posted by tensor on March 4, 2008, at 15:31:16
> Thanks,
>
> do you know if Sulpiride can be taken with Remeron?
>
> /MattiasI don't, sorry.
Posted by bleauberry on March 4, 2008, at 16:37:15
In reply to Which is the *Best*?, posted by tensor on March 4, 2008, at 7:19:12
Sulpride or amisulpride would be my first choices. Low dose risperdal second. Zyprexa any dose third. I've tried all those, but not abilify or ziprasidone. I also tried the popular seroquel and thought it was more appropriate for turning violent prison inmates into zombies. Just opinions.
Posted by Quintal on March 4, 2008, at 17:31:31
In reply to Re: Which is the *Best*? » Quintal, posted by tensor on March 4, 2008, at 14:05:00
I had no antidepressant response from Abilify - it made me very ill. I only managed to take it for three days at 5mg, and had to stop for my own safety. There were many side effects, but severe heartburn/excess acid, dizziness, akathisia and insomnia were the worst. It was the first time I'd experienced akathisia and it is a truly hellish experience... it's one reason why risperidone is out of the question for me. I think I had a very mild akathisia-like reaction with amisulpride at 200mg, but the doctor gave me some procyclidine p.r.n and it seemed to help. They deleted it from my chart when amisulpride was lowered to 100mg and I managed okay from that point on. I think amisulpride and sulpiride have the most antidepressant potential out of all the antipsychotics, combined with a fast onset of action.
As an afterthought, I once took a combined preparation of melictracen and flupentixol called Deanxit, and that produced a very fast antidepressant response too. Completely took away my sucicidal thoughts within a few hours. Obviously I can't say which drug was doing what, but it is a very effective combo.
Q
Posted by Phillipa on March 4, 2008, at 19:06:31
In reply to Which is the *Best*?, posted by tensor on March 4, 2008, at 7:19:12
If only atypical antipsychotics isn't seroquel sometimes used as an antidepressant. Have you tried benzos? Love Phillipa
Posted by Emme on March 4, 2008, at 19:45:19
In reply to Which is the *Best*?, posted by tensor on March 4, 2008, at 7:19:12
My vote is for Abilify. Relatively rapid response (within about 4-5 days) and relatively low side effect profile at the 2.5 mg dose I take. Your mileage may vary of course.
I found Zyprexa to have a quick, strong AD effect, but it was too sedating and I rapidly gained weight on it. So that was that.
I have no experience with amisulpride or sulpiride.
Good luck,
emme> Of the newer antipsychotics, which is generally considered the best antidepressant? For unipolar/bipolarII depression. With 'best' I mean most antidepressant power but also a benign side effect profile. Not only as monotherapy but also as add-on.
>
> Thanks/Mattias
Posted by yxibow on March 8, 2008, at 2:48:46
In reply to Re: Which is the *Best*?, posted by bleauberry on March 4, 2008, at 16:37:15
> Sulpride or amisulpride would be my first choices. Low dose risperdal second. Zyprexa any dose third. I've tried all those, but not abilify or ziprasidone. I also tried the popular seroquel and thought it was more appropriate for turning violent prison inmates into zombies. Just opinions.
Opinions are fine -- I can tell you I'm not a prison inmate and I am so used to it that it doesn't have a lot of sedation.
Posted by yxibow on March 8, 2008, at 3:13:27
In reply to Re: Which is the *Best*? » tensor, posted by Jamal Spelling on March 4, 2008, at 7:41:29
> I expressed an interest to my doctor to augment Cymbalta with a low dose of an AP. These were the options we discussed:
>
> (i) flupenthixol (Fluanxol): a typical AP, it carries the risk of TD. It has motivating properties.
>
> (ii) olanzapine (Zyprexa): very effective, but too expensive and weight gain is going to be a problem w.r.t. diabetes and hypertension.For some, and this can be monitored with excercise and diet if this is a needed choice
> (iii) amisulpride (Solian): an atypical AP, it is, like flupenthixol, motivating. However, she says there are cardiovascular concerns, so I would have to go for regular ECGs.
QTc and torsades de pointes have occurred with Mellaril also. Its a hit and miss and varies with the individual, but prudency would say that getting tested every so often for a drug with that profile is probably a good thing.
> (iv) quetiapine (Seroquel): for the treatment of depression, this is currently her favourite. It is atypical, and has a reasonable risk profile. The main problem is that many find it sedating, and reading some posts on Psycho-Babble, I see many also complain that it flattens their mood.
>
> As for an AP with a benign side-effect profile, it does - unfortunately - not exist. APs are amongst the big guns of psychiatry, and they all have their own problems. At the low doses that one would use for depression, side-effects are less likely and less severe, but they still exist. Nature did not intend for dopamine receptors to be blockaded.
We are not born 100% perfect. But I can't have a nature vs. nurture argument. I know that there is some dopaminergic component of my current disorder, most likely, and certainly serotonergic. -- from being born with a disposition towards biological ilnesses, which most all mental illnesses are.
The risks of TD are now assesed about 5% per year in total for all typicals up to about a maximum of 25% over an unknown amount of time. With atypicals, Seroquel (and Zyprexa) are the safest agents at 0.1%Amisulpride and Sulpiride are not technically atypicals. Amisulpride acts more as an atypical with its side effect profile. Sulpiride has a very high affinity for D2 but not the same affinities for 5HT as atypicals usually do.
I would say the safest augmenting agents for SSRIs would be Seroquel first and Zyprexa possibly, at a low but clinical dose (100-200mg). As for Cymbalta, I took Seroquel along with it when I was using it, but that was for an unusual disorder and not so much for augmentation. But still Cymbalta having as much as a 6:1 SE to NE affinity, I would imagine it would function somewhat like an SSRI augmentation.
-- tidings
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