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Dr. Bob is Robert Hsiung, MD,
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Posted by Lamdage22 on January 26, 2015, at 9:33:16
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by ed_uk2010 on January 26, 2015, at 9:21:00
No insomnia unless i try to reduce Zyprexa.
No voices, nothing.
Depression though. Particularly seasonal affective i suspect.
The low potency AP was my idea. I think it doesnt carry a risk of diabetes and i have tolerated it well in the past!
Posted by Lamdage22 on January 26, 2015, at 10:58:56
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 26, 2015, at 9:33:16
What would you recommend for my insomnia, ed?
Posted by ed_uk2010 on January 26, 2015, at 11:48:03
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 26, 2015, at 10:58:56
>What would you recommend for my insomnia, ed?
Initially, I'd suggest that you try taking more Seroquel in the evening and less during the day, rather than adding more medication. I'm unsure of the value or safety of adding a third antipsychotic acting on some of the same receptors which are already blocked by your current high dose antipsychotic treatment.
The thing is about adding pipamperone.... low dose mainly block 5-HT2a receptors, high doses block D2 receptors as well. I imagine your 5-HT2a receptors are substantially blocked already by Seroquel and Zyprexa. I don't think the TD risk or the diabetes risk of pipamperone are well known. Pipamperone is usually classified as a typical antipsychotic but its receptor binding profile is slightly atypical, despite its chemical similarity to haloperidol (Haldol).
How bad is your insomnia? Perhaps it would improve on treating your depression.
Have you struggled to find a suitable treatment for depression? You seem to be on a very small dose of venlafaxine. Do you have a history of symptoms being worsened by antidepressants eg. a manic episode being induced?
Posted by Lamdage22 on January 26, 2015, at 13:16:30
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by ed_uk2010 on January 26, 2015, at 11:48:03
> >What would you recommend for my insomnia, ed?
>
> Initially, I'd suggest that you try taking more Seroquel in the evening and less during the day, rather than adding more medication. I'm unsure of the value or safety of adding a third antipsychotic acting on some of the same receptors which are already blocked by your current high dose antipsychotic treatment.
>
> The thing is about adding pipamperone.... low dose mainly block 5-HT2a receptors, high doses block D2 receptors as well. I imagine your 5-HT2a receptors are substantially blocked already by Seroquel and Zyprexa. I don't think the TD risk or the diabetes risk of pipamperone are well known. Pipamperone is usually classified as a typical antipsychotic but its receptor binding profile is slightly atypical, despite its chemical similarity to haloperidol (Haldol).
>
> How bad is your insomnia? Perhaps it would improve on treating your depression.
>
> Have you struggled to find a suitable treatment for depression? You seem to be on a very small dose of venlafaxine. Do you have a history of symptoms being worsened by antidepressants eg. a manic episode being induced?I take the low dose of venlafaxine to be able to orgasm.
Higher doses werent more effective.
I havent struggled, i didnt find anything for depression
Posted by ed_uk2010 on January 26, 2015, at 13:23:13
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 26, 2015, at 13:16:30
OK, so how bad is your depression now? And how bad is the insomnia? I mean, do you feel very distressed by it? Or not so bad?
Perhaps lithium carbonate might help the depression, rather than lithium orotate.
Posted by Lamdage22 on January 27, 2015, at 3:00:09
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by ed_uk2010 on January 26, 2015, at 13:23:13
My mood is like a 4 out of 10.
I could sleep yesterday with 40 mg pipamperone and 12.5 Zyprexa (instead of 15).
Lithium at 300 led to humongous weight gain so i dont even want to know about, say 900.
Posted by ed_uk2010 on January 27, 2015, at 5:56:40
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 3:00:09
Morning.
> My mood is like a 4 out of 10.
It does sound like you need further treatment for this. Which antidepressants have you tried and how do you respond? It looks like you don't tolerate high doses of serotonergic drugs like venlafaxine.
>I could sleep yesterday with 40 mg pipamperone and 12.5 Zyprexa (instead of 15).
Excellent that you could sleep!
I suppose what I'm wondering is..... taking pipamperone may allow you to reduce Zyprexa to some extent by blocking some of the same receptors, but do you think things will be better by taking three antipsychotics instead of two? What do you plan here? The incidence of side effects with pipamperone does not seem very well established but sexual dysfunction/libido loss is often reported so I assume it elevates prolactin.
Regarding Seroquel, do you find you need the daytime doses to relieve agitation?
>Lithium at 300 led to humongous weight gain so i dont even want to know about, say 900.
You may need to be cautious about valproic acid (valproate) since it causes weight gain so frequently. It's generally more effective against manic symptoms than depression. Do you have a history of mania or mixed states? I'm wondering if this is why your doctor mentioned it.
Posted by Lamdage22 on January 27, 2015, at 7:10:50
In reply to Re: Multiple mechanism with Zyprexa and some atyp » Lamdage22, posted by ed_uk2010 on January 27, 2015, at 5:56:40
Hi Ed,
it is clear that i need depression tteatment, but this treatment is not on the market yet. Trust me we tried all that could be tried or all that is worth trying.
Im not taking the valproic acid.
Its not worth the risk.
So do you think trazodone could be better for me? The "non-addicting" sleep meds arent too many.
Posted by Lamdage22 on January 27, 2015, at 7:14:06
In reply to Re: Multiple mechanism with Zyprexa and some atyp » Lamdage22, posted by ed_uk2010 on January 27, 2015, at 5:56:40
i took like 900 seroquel all at night the other day, i still couldnt sleep. I just took like 300mgs ontop of the 500 i take at night.
No sleep until 15mg of Zyprexa.
Pipamperone is more sedating than zyprexa but it is way less potent than zyprexa.
Thats what im ttying to do. Replace the high potency stuff with lower potency.
Im still for trazodone.
Posted by Lamdage22 on January 27, 2015, at 7:20:37
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 7:14:06
Or not trazodone.
Idk seriously and im not going to worry sick about all this.
Posted by ed_uk2010 on January 27, 2015, at 8:52:09
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 7:14:06
> i took like 900 seroquel all at night the other day, i still couldnt sleep. I just took like 300mgs ontop of the 500 i take at night.
Oh right, I guess that's not going to work then.
>Pipamperone is more sedating than zyprexa but it is way less potent than zyprexa.
Less potent just means fewer milligrams though, it doesn't mean better. In general, highly potent antipsychotics like haloperidol cause less weight gain than low potency neuroleptics, but there are many exceptions (as you know!). I doubt pipamperone causes as much weight gain as Zyprexa, for example.
>I'm still for trazodone.Trazodone is probably worth a try, as a non-antipsychotic alternative to pipamperone which might allow you to sleep on a lower total antipsychotic dose. Trazodone is one of the more weight neutral options and doesn't elevate prolactin. It doesn't normally cause sexual dysfunction either. I don't know whether it would help your depression - it might. Would your doctor be up for trying it?
Posted by Lamdage22 on January 27, 2015, at 9:16:11
In reply to Re: Multiple mechanism with Zyprexa and some atyp » Lamdage22, posted by ed_uk2010 on January 27, 2015, at 8:52:09
I dont know. He might be.
But trazodone can cause arrythmias as well as Seroquel and Zyprexa.
Its hard to tell which is the better alternative for me.
Posted by ed_uk2010 on January 27, 2015, at 9:34:14
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 9:16:11
>But trazodone can cause arrhythmias as well as Seroquel and Zyprexa.
It's possible, but the same risk applies when adding another antipsychotic. Either way, you should be having an ECG to check your QTc interval.
>Its hard to tell which is the better alternative for me.
You'd really have to try trazodone to see if it helps, and to find out whether it allows you to sleep on a lower antipsychotic dose.
Posted by Lamdage22 on January 27, 2015, at 11:21:23
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by ed_uk2010 on January 27, 2015, at 9:34:14
> >But trazodone can cause arrhythmias as well as Seroquel and Zyprexa.
>
> It's possible, but the same risk applies when adding another antipsychotic. Either way, you should be having an ECG to check your QTc interval.
>
> >Its hard to tell which is the better alternative for me.
>
> You'd really have to try trazodone to see if it helps, and to find out whether it allows you to sleep on a lower antipsychotic dose.Hey ed. I had an ecg yesterday. Its totally fine.
I will think about trazodone until my next appointment.
Posted by ed_uk2010 on January 27, 2015, at 12:37:53
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 11:21:23
>I had an ecg yesterday. Its totally fine.
Good to hear.
Have you ever been stable on Seroquel without Zyprexa, apart from insomnia?
Posted by Lamdage22 on January 27, 2015, at 12:40:06
In reply to Re: Multiple mechanism with Zyprexa and some atyp » Lamdage22, posted by ed_uk2010 on January 27, 2015, at 12:37:53
Ed, i once was stable on 200mg Seroquel. (No psychosis)
A ludicrous trial with Parnate, a trial with tianeptine and a "therapeutic" session with an parents=antichrists therapist have led to the dosages i am on now.
Posted by ed_uk2010 on January 27, 2015, at 13:04:40
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 12:40:06
> Ed, i once was stable on 200mg Seroquel. (No psychosis)
OK. Was this recently, and how long were you stable for?
I was wondering really, whether your use of multiple antipsychotics was required for psychosis, or whether the doses had been increased to their current level for insomnia or other reasons?
What was your psychosis like? Schizoaffective disorder is quite variable so I'm unsure.
Posted by Lamdage22 on January 27, 2015, at 13:08:11
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by ed_uk2010 on January 27, 2015, at 13:04:40
> > Ed, i once was stable on 200mg Seroquel. (No psychosis)
>
> OK. Was this recently, and how long were you stable for?No it was 2013. For as long as i didnt try Parnate. Ok i was on 300 then after some time but i could have been on 200 as well.
> I was wondering really, whether your use of multiple antipsychotics was required for psychosis, or whether the doses had been increased to their current level for insomnia or other reasons?
Im not sure if it is psychosis. It does go away with meds though. We call it "pre-psychotic"
> What was your psychosis like? Schizoaffective disorder is quite variable so I'm unsure.
Loss of control.
Posted by Lamdage22 on January 27, 2015, at 13:09:38
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 13:08:11
And yes, after the Parnate trial, after the tianeptine trial and after this ridiculous session with the therapist i was full blown psychotic and thus increased the dosages.
Posted by ed_uk2010 on January 27, 2015, at 13:39:52
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 13:09:38
>i was full blown psychotic and thus increased the dosages...
Delusions and hallucinations?
Posted by Lamdage22 on January 27, 2015, at 13:42:14
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by ed_uk2010 on January 27, 2015, at 13:39:52
delusions.
Posted by Lamdage22 on January 27, 2015, at 14:04:16
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 13:42:14
Its like my mind takes on a life of its own.
It just goes and goes and goes.
If it wasnt psychosis but something else, would it be treated any different?
Posted by ed_uk2010 on January 27, 2015, at 16:38:36
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 14:04:16
>It just goes and goes and goes.
Like rapid thoughts? Were you depressed at the time? Or more manic/overactive/excited? What were the delusions like?
>If it wasn't psychosis but something else, would it be treated any different?Delusions are a form of psychosis, but they can occur as part of mood disorders, as well as primary psychotic illnesses like schizophrenia.
In schizoaffective disorder, delusions occur *mainly* during depressive, manic, or mixed episodes, but also occur when mood is relatively normal *on occasion*. If delusions or hallucinations *never* occur except in the setting of highly abnormal mood, the diagnosis of schizoaffective disorder is not normally applied, and a mood disorder with psychotic features is diagnosed instead eg. major depression with psychotic features ie. 'psychotic depression', or bipolar disorder with psychotic features. Some doctors may diagnose schizoaffective disorder even when delusions only occur during mood episodes, if the delusions are highly bizarre and resemble schizophrenia.
>would it be treated any different?
Schizoaffective disorder is virtually always treated with antipsychotics, other meds can be used as well but not in the absence of antipsychoics.
Treating psychotic depression, and bipolar disorder with psychotic features usually involves antipsychotics, but not absolutely always.
If you don't mind, it would be useful to know something about the delusions. And in what way did you lose control?
Delusions which occur in mood disorders are most commonly related to the mood state eg. during severe depression, someone may have the delusion that they are actually dead.... during mania, someone may believe they are the president. Delusions in schizoaffective disorder are less likely to be clearly related to the mood state, but they can be... they also tend to be more bizarre eg. someone might believe that they can read everyone else's mind, or that people can read their mind... or that their thoughts are being sent to people by the radio, for example. This type of bizarre delusion unrelated to mood is typical of schizoaffective disorder and is uncommon or exists only very briefly in primary mood disorders. The presence of bizarre delusions is strongly suggestive that antipsychotics are needed. Constant or at least very frequent hallucinations, most often voices, are much more typical of schizoaffective disorder than mood disorders - and normally respond only to antipsychotics.
.............
People with a history of psychosis should avoid dopaminergic drugs eg. amphetamines, cocaine, methylphenidate, Parnate, dopamine agonists (eg. Requip, Mirapex) and possibly bupropion. These drugs may induce psychosis. Large amounts of alcohol are also a very bad idea. Cannabis should be avoided. I'm sure you already know all this but I thought I'd write it anyway!
By the way, how do you respond to Lamictal?
Posted by ed_uk2010 on January 27, 2015, at 17:57:16
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 14:04:16
Essentially...
I'm trying to understand you better, rather than making too many suggestions based on inadequate evidence. There is often a tendency for people to make A LOT (of sometimes inappropriate) suggestions on forums like this without really knowing much/anything about the person they're making suggestions to. I'm keen to avoid this type of thing. It can be harmful.
This is the impression I get....
You have a long history of depressive illness, and some anxiety. Various trials of medication did not provide relief. You then had an episode in which you became delusional and rather out of control while taking Parnate. This episode has been difficult for you to recover from. You are currently not psychotic but feel depressed most of the time and have trouble sleeping.
Is that about right?
I don't need to know exactly, but how old are you now and how old were you when your mental health problems began? Have you ever had a psychotic or manic episode when NOT taking an antidepressant? The Parnate episode sounds like drug-induced psychosis.
About trazodone....
Have you ever taken it before?
It seems that Seroquel has been beneficial to you over quite a long period of time. You mentioned being stable on Seroquel alone at one point. Seroquel is known to have antidepressant, antimanic and antipsychotic properties. I can't really say whether you would develop psychotic symptoms again if you reduced Zyprexa too much. I think the risk depends partly on whether your psychotic symptoms occur only in response to certain antidepressants (eg. Parnate), or whether they occur spontaneously. Obviously, if you have a history of delusions, psychosis or loss of control in the *absence* of triggering medication, you are more likely to experience psychosis on reducing Zyprexa than if you experience such symptoms only when triggered by meds. Consideration of this issue is important because it could help you, and your doctor, decide whether they is any chance of reducing your antipsychotic meds in the presence of a sedating drug such as trazodone for sleep.... or whether this would be unwise. The major purpose of reducing Zyprexa would be to reduce your weight or improve your physical health, I assume? So, it would only really be of value to reduce Zyprexa if, a) you are currently needing to lose more weight even in the presence of metformin and b) if you were able to find a replacement for Zyprexa which would treat your insomnia and maintain your stability without causing weight gain itself.
Posted by ed_uk2010 on January 27, 2015, at 18:01:07
In reply to Re: Multiple mechanism with Zyprexa and some atyp, posted by Lamdage22 on January 27, 2015, at 9:16:11
And, what are your height and weight at the moment?
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