Posted by Elizabeth on April 4, 2002, at 4:41:47
In reply to Zyprexa progress report, posted by KB on April 2, 2002, at 20:55:56
Hi. Boy this is a controversial topic -- dopamine antagonists for depression, that is.
It is true that some people become more depressed on antipsychotic drugs. This is a risk, so if you're considering taking them, you should proceed with caution, especially if you're already depressed.
Paradoxically, though, some people with depression (esp. agitated depression) find that low or modest doses of Zyprexa and other atypical APs (dunno about the older DA antagonists) relieve suicidal obsessions. They also sometimes improve other depressive symptoms, perhaps because of a connection to the "negative symptoms" of schizophrenia (which bear some resemblance to some of the symptoms of depression). They can improve mental clarity and help with "brain fog." They can also be helpful for people who have symptoms associated with the amorphous entity known as "borderline personality disorder," notably the extreme mood shifts (such as "anger attacks") which can sometimes lead to dissociative episodes and/or self-injury or other self-destructive impulses. This general stabilizing effect can be put to good use in bipolar disorders as well, of course. Their stabilizing and calming effect may reduce the hyperreactivity and obsessive thoughts/replays often seen in PTSD, and the "negative symptoms" here may be alleviated as well (loss of interest in life, affective blunting, inability to feel close to other people). Finally, some people with OCD benefit from these drugs, in low doses. So as we can see, they have many positive effects that make them worth a try in a lot of situations. This is a benefit of the atypicals in particular: their improved side effect profiles make it worthwhile to try them (especially in low doses) for nonpsychotic conditions. Notice that when APs are used in nonpsychotic conditions, they're usually symptom-directed: they relieve particular symptoms, they don't treat the disorder as a whole (as they often do in psychotic disorders, or as ADs often do in depression, e.g.).
I do think that pdocs are too quick to whip out the antipsychotics if someone doesn't respond completely to an antidepressant. I think there are better strategies that they should probably try first in most cases, strategies that are very unlikely to make things worse. I believe that some of the reasons for this are the fear of using "addictive" drugs (e.g., stimulants), ignorance about the many alternatives (older or newer ADs, augmentation, AD combinations), and excessive concern about occult bipolar disorders (this also leads to overuse of anticonvulsants, IMO).
Another mistake that some pdocs make is assuming that antipsychotic drugs will help with anxiety. This might be in part because antipsychotics are typically sedating and can be calming for people suffering from agitation; the desire to avoid benzodiazepines undoubtedly plays a role as well. I've even heard of doctors trying to force patients to discontinue benzodiazepines, insisting that an antipsychotic will relieve the withdrawal symptoms (it won't) and treat the anxiety disorder (it probably won't do that either). This is cruel and potentially dangerous. In general it's not appropriate to use antipsychotics for your average anxiety disorder, except for some cases of OCD and perhaps severe PTSD. APs are not effective in panic disorder, social or specific phobias, or generalized anxiety.
I might as well throw in my own experience with APs, though it's generally a negative one. I wasn't helped by the addition of antipsychotics to antidepressants (I tried Zyprexa up to 10 mg/day, Seroquel up to 100 mg/day, don't recall the doses of Risperdal or Mellaril, and amoxapine up to 75 mg/day [serum level was probably high though]). IMO, if you have a difficult-to-treat depression, atypical APs are probably worth a try as augmentors even if you don't have any psychotic features. [There actually was, at one time, some speculation between my doctors that I might be having "mood-congruent delusions," but although I'd been agitated, they decided that I most likely wasn't delusional. I'm still not really clear on what constitutes a depressive delusion -- I mean, we've all had some really dark and irrational thoughts while depressed, right? -- so I don't really have an opinion as to what was happening with me back then.
I didn't have any dramatic bad reactions to Zyprexa or Seroquel -- no increased suicidal thoughts or anything like that -- but I did feel sluggish and generally crappy ("malaise" is the technical term for this state, I think) when I tried these two drugs. The only drug of any type that I'd say made me more depressed in any serious way was Risperdal: I took it at bedtime, had a night of horrifying vivid dreams/RBD episodes/frequent awakenings, and woke up feeling agitated and suicidal (this was while I was on one of the MAOIs, too, so most of these problems had been fairly well under control until I took the risperidone). The other DA-blockers I've taken were amoxapine and a very low dose of thioridazine (Mellaril). Neither of these caused any mood problems, although all the TCAs I've taken (amoxapine, desipramine, nortriptyline) seem to have brought on vivid dreams, even when used along with MAOIs (amoxapine + Parnate, nortriptyline + Marplan), which are supposed to suppress REM sleep pretty thoroughly. TCAs have some similarities, both chemical and pharmacological, to phenothiazine antipsychotics -- dunno if that's relevant or what, tho'.
Anyway, the moral of the story is that everybody's different. Don't make a decision about whether to try something based on what happened to somebody else. Take the risks into account (and be prepared to deal with the possible bad effects), but don't be paralyzed into total inaction by them. APs can cause problems for some people, but for many they turn out to be extremely helpful. Unfortunately, it's very hard to predict how any particular person will react to them.
-elizabeth
P.S. A note about extrapyramidal symptoms and their prevention and treatment: I really do think that the atypical APs have made a tremendous difference in terms of side effects and tolerability. I've heard (from reliable sources) that psych hospitals used to be filled with people with all sorts of movement disorders (e.g., "the Thorazine shuffle"). A couple years ago I was visiting someone I knew from group therapy who was hospitalized in the psychotic disorders unit at McLean. I met some of the other patients there, and one of the residents. I didn't see anyone with any visible case of EPS, although the resident said that just about all the patients on that unit were on some sort of antipsychotic drug. There are still a lot of problems in the treatments available for psychiatric illness, but I am impressed with the progress that has been made.
poster:Elizabeth
thread:100817
URL: http://www.dr-bob.org/babble/20020402/msgs/101763.html