antipsychotics

Antipsychotics Should Be Used for Non-Psychotic Depression Treatment

→ February 6, 2017 - 11 Comments

Antipsychotics Should Be Used for Non-Psychotic Depression Treatment

While some disagree, it’s important that people understand that antipsychotics need to be used for non-psychotic depression treatment, when appropriate.

At any one time, 14 million people suffer from depression but only 60-70% of these people respond to antidepressant treatment. Of those who do not respond, 10-30% exhibit treatment-resistant symptoms including “difficulties in social and occupational function, decline of physical health, suicidal thoughts, and increased health care utilization.” Treating these people presents a huge issue for healthcare practitioners and one of the options they consider is the use of a medication class known as antipsychotics.

Recently, a group called the Therapeutics Initiative wrote a letter entitled Antipsychotics should not be used for non-psychotic depression. Their conclusions are as the title suggests: this body found little evidence to support the use of antipsychotics in the treatment of non-psychotic major depressive disorder.

And while I respect the work of this body and while they have considered some evidence (in the case of quetiapine [Seroquel], an antipsychotic), there is more to consider on the issue.

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I Have Bipolar Depression – Should I Take an Antidepressant?

→ March 24, 2014 - 49 Comments

I Have Bipolar Depression – Should I Take an Antidepressant?

Would you like the short answer or the long answer? In short, if you have bipolar disorder, no, you shouldn’t be taking an antidepressant – even if you’re depressed – in many, if not most, cases.

The long answer is, naturally, more complicated.

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Antipsychotic Warning, Saffron for Depression, Polypharmacy – 3 New Things

→ September 8, 2011 - 2 Comments

It’s a bit of a short week what with the holiday and all, but still, there is time for three new things about mental health. Today’s three new things are:

  • A safety warning on the atypical antipsychotic drug asenapine maleate (Saphris)
  • Saffron and depression
  • Multi-drug (polypharmacy) treatment of mental illness

Serious Allergic Reactions Reported with Asenapine Maleate (Saphris)

Asenapine maleate (Saphris) is an atypical antipsychotic drug recently approved for use in the treatment of bipolar type 1 mania and mixed episodes (as well as schizophrenia).

In slightly less than two years of approval, about 87,000 people have been prescribed asenapine maleate. The FDA’s Adverse Event Reporting System (AERS) has had a significant number of serious allergic (hypersensitivity) reactions reported. These serious allergic reactions were reported in 52 cases and are considered Type 1 hypersensitivity. From the FDA:

“Signs and symptoms of Type I hypersensitivity reactions may include anaphylaxis (a life-threatening allergic reaction), angioedema (swelling of the deeper layers of the skin), low blood pressure, rapid heart rate, swollen tongue, difficulty breathing, wheezing, or rash . . . Several cases reported multiple hypersensitivity reactions occurring at the same time, with some of these reactions occurring after the first dose of Saphris.”

Any such reactions require immediate medical attention.

You can report serious allergic reactions to the FDA’s MedWatch program here.

FYI, asenapine maleate’s label has been changed and updated with this new information.

Saffron used to treat depressionCan Saffron Help with Depression?

Saffron (crocus sativus) is the most expensive spice by weight and is integral in French bouillabaisse. And someone asked me this week, “Can saffron help with depression?” Initially, I did a search on the Alternative Medicine Index at the University of Maryland Medical Center and turned up nothing. This alternative index lists most everything so my immediate answer to “can saffron help with depression,” was no.

However, I may have spoken slightly too soon.

Upon closer inspection I did find one study that asserts, in treating mild-to-moderate depression:

“Saffron petal was significantly more effective than placebo and was found to be equally efficacious compared to fluoxetine and saffron stigma.”

Now, hold on a minute. This is not a good, particularly scientific, study. This is just a review of studies, some of which are very questionable in nature. The above statement is premature at best. All that can really be said (in my opinion) is that saffron deserves further study and that some formulation of it might work.

Prescribing More Than One Drug for Mental IllnessWhy Are People Treated With Many Drugs At Once?

Good question. This is called polypharmacy and most doctors agree it’s a bad thing. The reason polypharmacy is bad is because it greatly increases the chance, and severity, of side effects. (There are other reasons too.) People who have been through rounds of polypharmacy will tell you this is true.

However, doctors continue to prescribe many drugs simultaneously for a condition. This article explores why polypharmacy is so common.

The article may make you take a look at your drug regimen and talk to your doctor about reducing some of your medication. This isn’t always possible, but a good idea if you can get away with it.

Note on Polypharmacy

It’s worth noting some conditions do warrant polypharmacy.

According to the Psychiatric Times article, the best indications for polypharmacy are few and well established:

  1. Bipolar depression
  2. Psychotic or agitated depression
  3. Co-morbid conditions that require independent medications (e.g., ADD and major depression)
  4. When partial response to the first medication requires adding another adjunctively
  5. When there is a combination of psychiatric and pain problems

OK all. Until next week when I will learn more and try to do better.

Saffron pictures provided by Wikipedia.

Linky-Madness, Drugging Children and Anxious Hat Makers – 3 New Things

→ August 25, 2011 - 4 Comments

In my line of work I come across the most obscure information, which is why I love sharing it with you. This week’s three new things about mental illness include:

  • A weekly mental health link-party
  • How scientists want to drug children who might get a mental illness
  • How hat makers used to experience social phobia

How could you not want to know the details about that?

1. What I Like – Madness Mental Health Linky

I’ve been participating for a few weeks in the Monday Madness Mental Health Linky over at the WordsinSynch blog by Shah Wharton. As the name implies, there are fresh links every Monday.

[push]Anyone can contribute a useful mental health link. Shah features her own work or the work of others and then lists useful links.[/push]

(No offence to Shah, but the layout is awful and kind of hard to understand.  Here’s how it works: Simply read the Monday Linky article and at the bottom there are featured links. Below that is the “blog hop” where the reader-submitted useful mental health links are posted and below that you can enter your own link.)

Click. Read. Enjoy.

2. What I Don’t Like – Drugging Children (or anyone unnecessarily)

Drugging Children with AntipsychoticsI could just leave it there but what I especially don’t like is the drugging of children who might get a mental illness. This is one of the troubles with that fad diagnosis I mentioned last weekpsychosis risk syndrome. While we do, honestly, know what puts a person at risk for psychosis, that’s a far cry from actually being able to accurately predict who is going to get a psychotic disorder.

For example, I know smoking puts you at risk for lung cancer, but you still might not get it. (Although smoking’s a lot more clear cut than psychosis. Don’t smoke. Seriously.)

In this study, people age 15-40 were to be given an antipsychotic (quetiapine) to see if it would delay or prevent the onset of a psychotic disorder like schizophrenia. And – here’s the kicker – up to 80% may never get the disorder anyway.

So I ask you, is it worth exposing a 15-year-old to a powerful antipsychotic associated with an increased mortality rate on a guess? I think not. (More next week.)

3. What is Just Bizarre – Hat Makers, Mercury  and Anxiety

Think you have social phobia? Do you make hats?

Excessive shyness, embarrassment, self-consciousness, timidity, social-phobia and lack of self-confidence are components of erethism, which is a symptom complex that appears in cases of mercury poisoning. Mercury poisoning was common among hat makers in England in the 18th and 19th centuries, as they used mercury to stabilize wool into felt fabric.

(From Wikipedia, where else?)

See you all next week for an attempt at a smarter and better me.

PS: Have you entered to win yet?

Mixed Bipolar Disorder – How to Treat Mixed Mood Episodes

→ August 23, 2011 - 23 Comments

In the final installation of my mixed moods series, I talk about how to treat mixed moods in bipolar disorder. If you need a refresher on mixed moods in bipolar 1 or bipolar 2, see the first three articles in this series:

Treating Mixed Moods in Bipolar 1 – Mixed Mania

We know most about treating mixed moods in bipolar type 1 as that’s what has been classically defined as a mixed mood in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Because mixed moods in bipolar disorder type 1 are considered a type of mania, one could think of treating them in the same way bipolar mania is treated. Typical mania treatments include:

  • Lithium
  • Some anticonvulsants
  • Antipsychotics (normally atypical)
  • Benzodiazepines (for acute anxiety, commonly seen in mania and mixed moods)

Often a combination of an anticonvulsant and an antipsychotic is used.

FDA-Approved Drugs for Treating Mixed Moods in Bipolar 1

Since mixed moods are defined in the DSM, there are specific medications approved by the Food and Drug Administration (FDA) to treat mixed mania. FDA-approved drugs for treating mixed moods in bipolar disorder type 1:

  • Carbamazepine extended release (Equetro)
  • Aripiprazole (Abilify)
  • Ziprasidone (Geodon)
  • Risperidone (Risperdal)
  • Asenapine (Saphris)
  • Olanzapine (Zyprexa)

Bipolar Type 1 and Mixed Mood TreatmentWhy lithium didn’t make the list I’m not entirely sure;* because, as I’ve mentioned, mixed moods and acute anxiety carry a significant risk of suicide and lithium seems to have a particularly strong anti-suicide effect.

Electroconvulsive therapy (ECT) is also indicated for the treatment of bipolar disorder mixed moods.

Treating Mixed Moods in Bipolar 2

As I mentioned in the article on mixed moods in bipolar disorder type 2, mixed moods can either have hypomania or depression as the primary mood. This primary mood then, dictates the type of treatment chosen.

Treating Mixed Hypomania

According to this two-part Psychiatric Times article by Steven C. Dilsaver, MD, mixed hypomania in bipolar type 2 can be treated similarly to treating a mixed mood in bipolar type 1.

Specifically noted is the concern of acute anxiety during mixed hypomania and the fact not all patients readily admit to psychological and physical symptoms of anxiety. However, this is critical information to your doctor and should always be offered, even if not specifically asked.

Other mixed hypomania treatment tips include:

  • Comorbid (co-occurring) anxiety may decrease the effectiveness of mood-stabilizing agents, so benzodiazepines may be a better choice.
  • Not treating anxiety aggressively can reduce overall long-term treatment outcomes.

Treating Mixed Depression

Mixed depression is particularly hard to treat as mixed moods often predict a lack of response to antidepressants, not to mention the fact that antidepressants can make hypomanic or manic symptoms worse.

A suggested treatment strategy for mixed moods in bipolar 2 with the primary mood of depression is the following:

  • Begin by suppressing hypomanic symptoms by using an mood stabilizer or antipsychotic (antipsychotics may work in 1-2 weeks)
  • Start medication at low doses and titrate (raise the dose) quickly – this is generally necessary due to the severity of mood symptoms
  • If depressive symptoms persist after response to the above medication, add a selective serotonin reuptake inhibitor (SSRI) antidepressant very slowly while watching for signs of hypomania – this requires very close monitoring and likely weekly doctor visits (impossible for some, obviously)

This is very similar to what many doctors are now recommending for bipolar disorder type 2 in general. First, stop the cycling (or hypomania) and see if that also corrects the depression. Avoid the use of antidepressants whenever possible.

Preventing Mixed Depression in Bipolar Type 2

How To Prevent Bipolar Disorder Mixed Moods

Obviously, no one can guarantee prevention of any mood, but there are some recommendations given in the article, as people with mixed depression are known to be at high risk for reoccurrence.

Tips on preventing mixed depression in bipolar 2 include:

  • Lamotrigine is the favorite prophylactic medication as it seems to prevent depression without being an antidepressant
  • Ongoing scheduled benzodiazepine doses can help prevent panic attacks^
  • A combination of an antipsychotic, plus lamotrigine, plus a benzodiazepine is often “highly effective” (words Dr. Dilsaver’s)
  • Lithium is known to be a highly preventative agent; however, in many cases divalproex (Depakote) is superior and has fewer side effects

Series on Mixed Moods in Bipolar Disorder

Whew. OK, there turned out to be a lot to know about mixed moods in bipolar disorder. I hope you learned something reading it as I certainly did writing it.

For your convenience, here are the links to the other three parts in the series:

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Notes

* I suspect there wasn’t enough money to be made on a generic drug to fund the studies, especially when doctors are going to use it anyways.
^ Yes, I know, long-term (sometimes any term) benzodiazepine use is controversial. Personally, I’m not against them and neither are many doctors – when used responsibly.

Reference

Psychiatric Times, Mixed States in Their Manifold Forms. Part one and part two.

Why Aren’t Doctors More Honest With Patients in the Hospital?

→ July 1, 2011 - 33 Comments

Inpatient Prescriptions of Antipsychotics

Yesterday I received this comment from Leah,

. . . At the mental health clinic [where] I stayed, they were really into prescribing low doses of Seroquel [quetiapine] for unipolar depression . . . after reading up on this stuff I became somewhat angry for the widely prescribed off-label use of these antipsychotics since side effects can be strong. Especially since I was not told. Do you maybe have any thoughts on this practice?

Thoughts? Yes. Far too many. Ask anyone.

I have, over and over, lamented about the lack of honesty and transparency in the doctor-patient relationship. Specifically, why is it doctors prescribe antipsychotics, often off label, without disclosing their risks? It’s happened to me many times. In the hospital may be a special case, however.

Prescribing Antipsychotics

Antipsychotics (by which I mean atypical antipsychotics) are being prescribed for all sorts of things these days. Traditionally schizophrenia, but now frequently bipolar disorder and major depressive disorder (MDD) too. There is considerable evidence for atypical antipsychotic treatment in all three disorders.

Antipsychotics and Risk

Antipsychotics are not pleasant medications. Antipsychotics turn down the dopamine and serotonin in your brain, those neurotransmitters typically considered to be “happy chemicals.” Why does that help depression? That is extraordinarily fuzzy, but we know they work for some people.*

Trouble is antipsychotics carry very serious risks. Risks like permanent movement disorders, weight gain and diabetes. I have had fits about such things.

Antipsychotics FDA-Approved for Treatment of Depression (Unipolar)

  • Aripiprazole (Abilify) is an antipsychotic “indicated for use as an adjunctive therapy to antidepressants for the treatment of major depressive disorder (MDD).”
  • Olanzapine (Zyprexa, antipsychotic) and fluoxetine (Prozac, antidepressant) come combined in one medication called Symbax. Olanzapine and fluoxetine, when used in combination is “indicated for the treatment of treatment resistant depression.” **
  • Quetiapine Fumarate Extended-Release (Seroquel XR) is an antipsychotic “indicated for use as adjunctive therapy to antidepressants for the treatment of MDD.” *** (Study of quetiapine monotherapy for MDD)

Prescribing of Antipsychotics

[push]Antipsychotics do work quite well for many.[/push]

Often when multiple antidepressants fail for depression, antipsychotics are up next, typically as an adjunct (like aripiprazole, above). And in all honesty, in a case of severe or treatment-resistant depression, in my opinion this practice is quite reasonable.

Antipsychotics in the Hospital

One of the places people are often introduced to antipsychotics is in the hospital. There are generally three reasons for this:

  1. Patients in the hospital are there because treatment has failed thus far
  2. Patients are in the hospital because they are in crisis
  3. Patients need something that will stabilize them so they can leave the hospital

Those are the realities of being in the hospital. Under these circumstances it’s quite reasonable to prescribe powerful, more risky medication as the person is in more danger. This doesn’t mean it’s pleasant. As I remarked after having been given quetiapine in the hospital:

Seroquel [quetiapine] is the new med . . . 50 fucking milligrams a day. That’s ridiculous. He had to know that would kill me. And yet, somehow he doesn’t care.

I will say though, he looked like I had punched him in the stomach when I saw him today. I don’t know what he was expecting but I did look pretty bad. His medication made me that way for fuck’s sake, where’s the surprise there?

Doctors and Honesty in a CrisisHospital Prescribing

Here’s the thing about hospital prescribing – doctors really, really want you to take the medication. No, they can’t make you (bearing legal exceptions) but they do want you to. And this is not for some dark, sinister reason, it’s because they want you to get better.

You’re sick. You don’t have the mental capacity to be considering antipsychotic study data comparisons. You don’t have cognitive ability to make good choices and assess risk. You’re already overwhelmed. You’re in a psych ward. It’s not the place to be discussing the nuances of treatment.

Skip the Messy Medication Details

So doctors often overlook things like telling patients a drug is being prescribed off label (if it is) and there may be serious side effects. They choose the treatment they feel gives you the best chance at recovery. (By the way, doctors do this all the time, not just in psychiatric cases.)

Because if you don’t accept treatment, how will you get better? And if you don’t get better how will you leave the hospital? And if you don’t leave the hospital, how will you get back to your life?

Doctors Have a Tough Call When Prescribing in a Hospital

That’s the choice. Do you tell the patient more information and run the risk of them refusing treatment and not getting better? Or do you tell the patient less information to increase the chance they will accept treatment?

Antipsychotic Prescription in the HospitalI feel for doctors in this scenario. From personal experience I can tell you, being in a psych ward is seriously unfun. And when I was there I was incapable of making good decisions. He could have given me heroin and I probably would have taken it. But that’s the game folks. Your brain isn’t working. Your brain is in crisis. That’s why you’re in the hospital. You can’t expect your brain to make good choices at that moment.

I understand the conundrum. I understand why doctors do it and I understand why patients get made about it. But what the heck else is the doctor supposed to do? ****

Antipsychotic Prescriptions after the Hospital

But, of course, then there’s the problem of what happens once you leave the hospital. You should be more stable and more able to make good decisions. So it’s time for the doctor to cough up whatever it is they skipped over while you were busy being crazy.

I find doctors tend not to do this. I can’t really say why. They don’t want to rock the boat if you’re doing well? They’re lazy? Who knows? I’m not a doctor and really couldn’t say. I consider it to be unprofessional, unethical and bad practice, but that’s me.

Honesty and Doctors

I’m sorry to say doctors are often only as honest as we make them. We have to question them. We have to get the information even if they don’t offer it. It’s our responsibility. Not because it should be but simply because we’re the ones with the most invested. Like I said, the time to do this isn’t likely going to be in a hospital ward, but at some point, the unpleasant information has to be dealt with. And it may only happen if you force the issue.

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Notes of the Foot

* I actually have a pet theory on this regarding depression and mild psychosis, but that’ll have to be another day.

** Treatment resistant depression is defined as “major depressive disorder in patients who do not respond to 2 separate trials of different antidepressants of adequate dose and duration in the current episode.”

*** Quetiapine fumarate (the non-extended-release form) is not FDA-approved for unipolar depression (making that information extremely hard to find).

**** An answer, by the way, might be to have a patient’s proxy or advocate make the decision, as they are not ill at the time. However, as time is an issue, and decisions have to be made extremely quickly, it’s unlikely a proxy could get up to speed on the treatment fast enough. Not to mention, many of us don’t have such people.

 

Are Psych Meds Addictive? – Antipsychotics (Part 2)

→ June 28, 2011 - 14 Comments

Are Psych Meds Addictive? – Antipsychotics (Part 2)

In the first of this series I discussed antidepressants and addiction. Some people contend antidepressants are addictive; however, not only is the term “addiction” not defined medically, the use of antidepressants does not generally match the symptoms of any defined substance use disorder either. (More information on substance abuse and substance dependence.)

This time antipsychotics are up to bat. Are antipsychotics addictive? Are people dependent on antipsychotics? Do antipsychotics cause withdrawal?

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Caffeine and Mental Illness and Caffeine Disorders

→ February 21, 2010 - 13 Comments

Caffeine and Mental Illness and Caffeine Disorders

Caffeine is the world’s most popular psychoactive substance. So many of us love it a la Starbucks, Tim Hortons or just out or our home coffee machine. Me, I love coffee and I’m a fan of caffeine too. Coffee’s the nectar of the gods and nothing will convince me otherwise.

It seems though, caffeine can actually hurt you. I know, I never thought my beloved coffee could harm me, but I suppose anything that you abuse, will abuse you back. So, here is everything you ever needed to know about caffeine, caffeine disorders and caffeine and mental illness but were afraid to ask.

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