![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 11 of 11. This is the beginning of the thread.
Posted by JohnL on September 9, 2001, at 7:21:25
Hi all,
This is kind of long, but has some really good info. I like it when a doctor shares what has been working, and why. The question and answer format has some excellent info on Zyprexa and Lamictal. Of note, he also speaks highly of Neurontin, however the writer of this stuff spelled it wrong and called it Neurotone.I praise Zyprexa all the time. I probably don't praise Lamictal enough. But this doctor says it all better than I could....
Depression: The Invisible IllnessThe following is the question and answer session from the Depression: The Invisible Illness meeting in Atlanta. The
presenter was Jay D. Fawver, M.D.Q: With perimenopausal women would your recommend estrogen as a means of treatment?
Dr. Fawver: If they have perimenopausal depression, I would certainly recommend an antidepressant. I always defer to my
gynecologists or my primary care colleagues in terms of using estrogen. But I'll tell you this about estrogen. With menopausal
women, estrogen and an antidepressant can work very synergistically. Women who have a degree of depression during their
menopause will feel psychologically better when they get the estrogen. Estrogen by itself will not help with menopausal major
depression, but it can help with the overall well being. Estrogen is good for the bones, it's good for the heart, but it's also good
for the brain because it helps with memory and mood. So if the woman is having a lot of hot flashes and feeling pretty miserable,
as a psychiatrist, I would recommend the vegetable analog of estrogen. I would recommend at least 20 grams of soy products a
day because that can give you a little bit of relief. But really if the primary care physician or gynecologist is recommending
estrogen, I'm all for it. Obviously, you have to get around the risk of the thrombophlebitis, the cervical cancer and the breast
cancer. That's why I don't mess with that as a psychiatrist. I leave that to them because they're the ones doing the Pap smears.
They're the ones doing the breast examinations, so I leave that to them.Q: Is there any problem with combining the following MAOI's?
Dr. Fawver: Depakote would be no problem. Lamictal I wouldn't combine with a monoamine oxidase inhibitor because
Lamictal does have a selective serotonin reuptake inhibitor built into it. That's why Lamictal, also known as lamotrigine, it's an
anticonvulsant, that's why it's very good for bipolar depression. The key with Lamictal is you have to be very careful on your
dosing. Gradually increase the dosage so you stay away from the rash and hopefully the Stevens-Johnson syndrome (ck this),
but I wouldn't combine Lamictal with an MAOI. Topamax, I believe that you could combine that with a MAOI. Topamax also
being an anticonvulsant, but that does not appear to have any inherent antidepressant features in it. Finally Neurotone.
Neurotone would indeed be safe to combine with a monoamine oxidase inhibitor. Neurotone primarily affects GABA-A
receptors, and does not appear to have an inherent antidepressant effect.Q: Is Lamictal an effective antidepressant?
Dr. Fawver: Yes, I use Lamictal for bipolar depression. The nice thing about Lamictal is that it does not cause weight gain.
And if people have these recurrent, depressive bouts maybe with a manic episode here and there, but predominantly their
bipolar disorder is of a depressive nature, Lamictal can be a very nice medication. Go very easy on your dosage for Lamictal.
Twenty-five mgs at bedtime for the first two weeks, then 50 mgs at bedtime for a week, 100 mgs for a week. You're shooting
for a dose of 200 mgs at bedtime, and you're going to slowly get up there at about five or six weeks. Go very slow on the
dosage because the faster the dosage is kicked up for Lamictal, the more likely you're going to see the rash and the more likely
you're going to have the liver failure that's associated with it.Q: Does double depression exist?
Dr. Fawver: I think it does. Double depression is major depression with dysthymic disorder. These people have been
depressed since they were kids. They had a low degree of depression that might not have met the criteria for major depression,
but they're always depressed. Even when they get well, they don't seem to all the way recover from the major depression.
That's always hanging over their heads to some degree. The key with double depression is that it's difficult to treat. They don't
respond as well to the antidepressants. They are always kind of negativistic, and pessimistic and grouchy and irritable.
Sometimes you need to be a little bit more aggressive with the medication. For these people, depression has become a way of
life for them. Some therapists have referred to them as being depressive personality disorders. So the therapy can be helpful,
but it's not uncommon that they might need a combination of antidepressants. You need to be a little more aggressive in how
you treat them.Q: Comment on whether antidepressants or anticonvulsants have an adjunctive role with antidepressants help with
treatment-resistant depression.Dr. Fawver: If somebody does have a mixed bipolar disorder, by all means, they often need the combination of an
anticonvulsant or mood stabilizer with an antidepressant. If somebody has unipolar major depression without evidence of
bipolar disorder, an anticonvulsant will probably not help them that much. The exception can be Neurotone. Neurotone I will
use for generalized anxiety disorder. I use Neurotone nowadays where I used to use Ativan. Previously, I would use Ativan to
help somebody with generalized anxiety to take the edge off things. I'm finding Neurotone to be a great medication for anxiety.
One hundred to 300 mgs, three times a day, takes the edge off of things, but it doesn't dope them up and it does not seem to
hinder their cognition, like you might see with Ativan. Obviously, Neurotone is not likely to be abused like Ativan can. I'll use
Neurotone if I'm going to use something for anxiety if I'm going to use an anticonvulsant for unipolar depression.We're getting a lot of benefit from using the atypical antipsychotic medications for augmentation for unipolar depression.
Zyprexa, for instance, increases the norepinephrine and dopamine in the prefrontal cortex. By doing that, you can add on
Zyprexa with an SSRI at 10 mgs at bedtime and sometimes get an augmentation to your antidepressant effect. Risperdal, at
doses as small as 1 mg at bedtime, can augment an antidepressant because Risperdal is indirectly affecting the serotonin
transmission by blocking serotonin two-way receptors. So, yes, the atypical antidepressant medications can certainly be used
for augmentation with the antidepressants. Even if a person does not have psychotic depression and even if a person does not
have bipolar depression.Q: Please comment on the role of antidepressants in schizoaffective disorder, depression in schizophrenic patients, depression in
borderline personality disorder and depression in bipolar disorder.Dr. Fawver: Depression is schizoaffective disorder, the antidepressants certainly do play a role. I'm hopeful that as we use the
atypical antipsychotic medications for the treatment of schizoaffective disorder, we're going to find that antidepressants are less
necessary. In my experience, specifically with Zyprexa, I'm finding that Zyprexa can be helpful for the patient with
schizoaffective disorder by itself. Again, because Zyprexa can help with the highs, it can help with the lows and it's also an
effective antipsychotic medication. So as these newer atypical antipsychotics come out, I'm more hopeful that the
antidepressants will be less necessary to use with them.With depression in-patients with schizophrenia, 80% of patients with schizophrenia have a clinically significant degree of
depression at some time in their lives. Antidepressants help to some degree, but the key with your patients with schizophrenia is
to be very careful what antipsychotic medication you're using. If you're using the older antipsychotics -- Haldol, Stelazine,
Prolixin. They cause depression. Try to stay away from them. Use exclusively the newer medications if you can get away with
doing that, and hopefully you wouldn't have to use your antidepressants.Depression in borderline personality disorder. It's always there with these borderline patients, and antidepressants can help to
some degree, but again, I'm using a lot of atypicals with my patients with borderline personality disorder.And finally, depression with bipolar disorder, if you use an antidepressant medication on somebody with bipolar disorder, be
very careful they don't swing into the highs. You always want to use a mood stabilizer if you know somebody has bipolar
disorder and they slip into a depression. You're going to use your antidepressant, perhaps, but always have a mood stabilizer on
board--lithium, Lamictal, Depakote or Zyprexa, of the newer ones.Q: Lilly is said to be coming out with a new form of Prozac in the next few years. Do you have any information on it?
Dr. Fawver: I'm a consultant with Eli Lilly. I'm not an employee with Eli Lilly. But what I can tell you, is that the answer is yes.
They're tweaking an antidepressant that will, essentially, have fewer side effects and their hope is that it will have a faster onset
of action.Q: With PMS symptoms, can you use the Prozac only the week of the symptoms?
Dr. Fawver: I've been doing that for 10 years now. I noticed back in 1990, if I had women who were good Wellbutrin
responders, but they still had the PMS there, I'd put them on the Prozac, 20 mgs a day just on the PMS days, maybe five days
a month, and it did great. I've had other women who were referred to me by primary care doctors only for their PMS, which
we would now call premenstrual dysphoric disorder. It was severe PMS that was incapacitating for five to seven days before
their periods. You can use Prozac, 20 mgs a day or Zoloft, 50 mgs a day. They tend to do very well with that. It's called luteal
phase dosing, also known as intermittent dosing, also known as pulse dosing. It's been compared directly with continuous
dosing. Works just as well. So there's a lot of validity to that. Now you might think, how can an antidepressant work with just
five or six days of treatment? Keep in mind that PMS is not a true clinical depression. Major depression or a clinical depression
is the type of depression that causes significant receptor changes in the brain. It takes you four to six weeks to reverse those
receptor changes with a major depression. PMS you don't have those type of receptor changes. So with PMS, you take the
Prozac within 20 minutes and you can feel better. If any of us in this room right now took 20 mgs of Prozac, in about 20 to 30
minutes our serotonin levels in our brain would increase. Would we notice it? Only if we were a little bit low on serotonin to
begin with. For instance, if you were two or three days before your period, and you took a Prozac 20 mg capsule, you would
feel better in 20 or 30 minutes. And it's not placebo effect, you actually feel better. So there's a lot of validity to that. Once the
woman begins her menstrual flow for that month, that's when she stops the medication. I've found that to be very effective.Q: Can you repeat the drugs that inhibit cytochrome P450 3A34?
Dr. Fawver: If you use Serzone in conjunction with Propulsid, it's contraindicated. Propulsid could cause you to have a
potentially fatal cardiac arrhythmia. So do not use Propulsid with Serzone and Luvox. So Luvox and Serzone are the two
antidepressants that we have to be very careful in using Propulsid. That's what you always ask them about. Fortunately, Seldane
is now off the market, so we don't have to worry about that any more.Q: In elderly patients and dropouts, was there a difference between the older and the newer medications?
Dr. Fawver: With the elderly patients, specifically, there was not a difference in dropouts. Curious effect. But in the general
overall population, more people dropped out on the older medications compared to the newer populations. But for the elderly
population, specifically, in the study I showed you, there was no difference.Q: Briefly compare and contrast the various treatment modalities in late-life depression.
Dr. Fawver: A lot of people who are old-old, those being people over 80 years of age, they often respond very nicely to very
small amounts of medication. Those are your Prozac 5 mg patients. Those are your Paxil, 10 mgs a day patients, or maybe even
your Zoloft, 25 mgs a day patients. They are often exquisitely sensitive to very small amounts of medication. I will often combine
a small amount of these newer medications for depression with just a pinch of Ritalin or Dexedrine, and it will perk them up very
nicely, especially if they've given up on life, especially if they're medically ill, if they have cancer, if they have heart disease, I
watch their blood pressure and heart rate pretty closely. You can add 5 mgs of Ritalin twice a day, start at 2.5 mgs twice a day,
but often 5 mgs of Ritalin in the morning and 5 mgs at noon in combination with your SSRI can give them a nice energizing
effect. They don't tend to increase the dosage and escalate that, they often do very nicely with a nice, small dosage. But the key
with these newer medications is that a small amount goes a long way. I showed you the study with the geriatric patients with
citalopram or Selexa. But really any of the newer agents can be beneficial.Q: Atypical antipsychotics?
Dr. Fawver: Absolutely. The atypical antipsychotic medications are good for the elderly patients that have psychotic
depression. By itself, Zyprexa does not appear to be a good medication for unipolar depression. So if you have some patient
with major depression and you only give them Zyprexa, it's probably not going to work that well. But you give that patient
Prozac and they partially respond, and then add Zyprexa 5 to 10 mgs to it, they can get a dramatic improvement in their
response. For some reason, Zyprexa needs a little bit of an antidepressant to help squeeze out that extra dopamine and
norepinephrine from the frontal lobes. Zyprexa you going to find in terms of a new indication that Lilly's going to come out with,
and this is very public, you're going to see a bipolar indication for Zyprexa. They've already gotten a written letter of approval
from the FDA. You're going to find that in the future, Zyprexa will be a very nice mood stabilizer and we're going to be treating
a lot of patients with it monotherapy for bipolar disorder. I've been using Zyprexa now for two years for my patients with
bipolar disorder, and more often than not, I'm able to get by on using Zyprexa as monotherapy. I don't have to add
antidepressants or benzodiazepines to it. So it will be a fun treatment to watch.
Posted by bob on September 9, 2001, at 15:14:03
In reply to Doc's Experience with Zyprexa, Lamictal, more., posted by JohnL on September 9, 2001, at 7:21:25
> Hi all,
> This is kind of long, but has some really good info. I like it when a doctor shares what has been working, and why. The question and answer format has some excellent info on Zyprexa and Lamictal. Of note, he also speaks highly of Neurontin, however the writer of this stuff spelled it wrong and called it Neurotone.
>
> I praise Zyprexa all the time. I probably don't praise Lamictal enough. But this doctor says it all better than I could....
>
>
> Depression: The Invisible Illness
>
>
>
> The following is the question and answer session from the Depression: The Invisible Illness meeting in Atlanta. The
> presenter was Jay D. Fawver, M.D.
>
> Q: With perimenopausal women would your recommend estrogen as a means of treatment?
>
> Dr. Fawver: If they have perimenopausal depression, I would certainly recommend an antidepressant. I always defer to my
> gynecologists or my primary care colleagues in terms of using estrogen. But I'll tell you this about estrogen. With menopausal
> women, estrogen and an antidepressant can work very synergistically. Women who have a degree of depression during their
> menopause will feel psychologically better when they get the estrogen. Estrogen by itself will not help with menopausal major
> depression, but it can help with the overall well being. Estrogen is good for the bones, it's good for the heart, but it's also good
> for the brain because it helps with memory and mood. So if the woman is having a lot of hot flashes and feeling pretty miserable,
> as a psychiatrist, I would recommend the vegetable analog of estrogen. I would recommend at least 20 grams of soy products a
> day because that can give you a little bit of relief. But really if the primary care physician or gynecologist is recommending
> estrogen, I'm all for it. Obviously, you have to get around the risk of the thrombophlebitis, the cervical cancer and the breast
> cancer. That's why I don't mess with that as a psychiatrist. I leave that to them because they're the ones doing the Pap smears.
> They're the ones doing the breast examinations, so I leave that to them.
>
> Q: Is there any problem with combining the following MAOI's?
>
> Dr. Fawver: Depakote would be no problem. Lamictal I wouldn't combine with a monoamine oxidase inhibitor because
> Lamictal does have a selective serotonin reuptake inhibitor built into it. That's why Lamictal, also known as lamotrigine, it's an
> anticonvulsant, that's why it's very good for bipolar depression. The key with Lamictal is you have to be very careful on your
> dosing. Gradually increase the dosage so you stay away from the rash and hopefully the Stevens-Johnson syndrome (ck this),
> but I wouldn't combine Lamictal with an MAOI. Topamax, I believe that you could combine that with a MAOI. Topamax also
> being an anticonvulsant, but that does not appear to have any inherent antidepressant features in it. Finally Neurotone.
> Neurotone would indeed be safe to combine with a monoamine oxidase inhibitor. Neurotone primarily affects GABA-A
> receptors, and does not appear to have an inherent antidepressant effect.
>
> Q: Is Lamictal an effective antidepressant?
>
> Dr. Fawver: Yes, I use Lamictal for bipolar depression. The nice thing about Lamictal is that it does not cause weight gain.
> And if people have these recurrent, depressive bouts maybe with a manic episode here and there, but predominantly their
> bipolar disorder is of a depressive nature, Lamictal can be a very nice medication. Go very easy on your dosage for Lamictal.
> Twenty-five mgs at bedtime for the first two weeks, then 50 mgs at bedtime for a week, 100 mgs for a week. You're shooting
> for a dose of 200 mgs at bedtime, and you're going to slowly get up there at about five or six weeks. Go very slow on the
> dosage because the faster the dosage is kicked up for Lamictal, the more likely you're going to see the rash and the more likely
> you're going to have the liver failure that's associated with it.
>
> Q: Does double depression exist?
>
> Dr. Fawver: I think it does. Double depression is major depression with dysthymic disorder. These people have been
> depressed since they were kids. They had a low degree of depression that might not have met the criteria for major depression,
> but they're always depressed. Even when they get well, they don't seem to all the way recover from the major depression.
> That's always hanging over their heads to some degree. The key with double depression is that it's difficult to treat. They don't
> respond as well to the antidepressants. They are always kind of negativistic, and pessimistic and grouchy and irritable.
> Sometimes you need to be a little bit more aggressive with the medication. For these people, depression has become a way of
> life for them. Some therapists have referred to them as being depressive personality disorders. So the therapy can be helpful,
> but it's not uncommon that they might need a combination of antidepressants. You need to be a little more aggressive in how
> you treat them.
>
> Q: Comment on whether antidepressants or anticonvulsants have an adjunctive role with antidepressants help with
> treatment-resistant depression.
>
> Dr. Fawver: If somebody does have a mixed bipolar disorder, by all means, they often need the combination of an
> anticonvulsant or mood stabilizer with an antidepressant. If somebody has unipolar major depression without evidence of
> bipolar disorder, an anticonvulsant will probably not help them that much. The exception can be Neurotone. Neurotone I will
> use for generalized anxiety disorder. I use Neurotone nowadays where I used to use Ativan. Previously, I would use Ativan to
> help somebody with generalized anxiety to take the edge off things. I'm finding Neurotone to be a great medication for anxiety.
> One hundred to 300 mgs, three times a day, takes the edge off of things, but it doesn't dope them up and it does not seem to
> hinder their cognition, like you might see with Ativan. Obviously, Neurotone is not likely to be abused like Ativan can. I'll use
> Neurotone if I'm going to use something for anxiety if I'm going to use an anticonvulsant for unipolar depression.
>
> We're getting a lot of benefit from using the atypical antipsychotic medications for augmentation for unipolar depression.
> Zyprexa, for instance, increases the norepinephrine and dopamine in the prefrontal cortex. By doing that, you can add on
> Zyprexa with an SSRI at 10 mgs at bedtime and sometimes get an augmentation to your antidepressant effect. Risperdal, at
> doses as small as 1 mg at bedtime, can augment an antidepressant because Risperdal is indirectly affecting the serotonin
> transmission by blocking serotonin two-way receptors. So, yes, the atypical antidepressant medications can certainly be used
> for augmentation with the antidepressants. Even if a person does not have psychotic depression and even if a person does not
> have bipolar depression.
>
> Q: Please comment on the role of antidepressants in schizoaffective disorder, depression in schizophrenic patients, depression in
> borderline personality disorder and depression in bipolar disorder.
>
> Dr. Fawver: Depression is schizoaffective disorder, the antidepressants certainly do play a role. I'm hopeful that as we use the
> atypical antipsychotic medications for the treatment of schizoaffective disorder, we're going to find that antidepressants are less
> necessary. In my experience, specifically with Zyprexa, I'm finding that Zyprexa can be helpful for the patient with
> schizoaffective disorder by itself. Again, because Zyprexa can help with the highs, it can help with the lows and it's also an
> effective antipsychotic medication. So as these newer atypical antipsychotics come out, I'm more hopeful that the
> antidepressants will be less necessary to use with them.
>
> With depression in-patients with schizophrenia, 80% of patients with schizophrenia have a clinically significant degree of
> depression at some time in their lives. Antidepressants help to some degree, but the key with your patients with schizophrenia is
> to be very careful what antipsychotic medication you're using. If you're using the older antipsychotics -- Haldol, Stelazine,
> Prolixin. They cause depression. Try to stay away from them. Use exclusively the newer medications if you can get away with
> doing that, and hopefully you wouldn't have to use your antidepressants.
>
> Depression in borderline personality disorder. It's always there with these borderline patients, and antidepressants can help to
> some degree, but again, I'm using a lot of atypicals with my patients with borderline personality disorder.
>
> And finally, depression with bipolar disorder, if you use an antidepressant medication on somebody with bipolar disorder, be
> very careful they don't swing into the highs. You always want to use a mood stabilizer if you know somebody has bipolar
> disorder and they slip into a depression. You're going to use your antidepressant, perhaps, but always have a mood stabilizer on
> board--lithium, Lamictal, Depakote or Zyprexa, of the newer ones.
>
> Q: Lilly is said to be coming out with a new form of Prozac in the next few years. Do you have any information on it?
>
> Dr. Fawver: I'm a consultant with Eli Lilly. I'm not an employee with Eli Lilly. But what I can tell you, is that the answer is yes.
> They're tweaking an antidepressant that will, essentially, have fewer side effects and their hope is that it will have a faster onset
> of action.
>
> Q: With PMS symptoms, can you use the Prozac only the week of the symptoms?
>
> Dr. Fawver: I've been doing that for 10 years now. I noticed back in 1990, if I had women who were good Wellbutrin
> responders, but they still had the PMS there, I'd put them on the Prozac, 20 mgs a day just on the PMS days, maybe five days
> a month, and it did great. I've had other women who were referred to me by primary care doctors only for their PMS, which
> we would now call premenstrual dysphoric disorder. It was severe PMS that was incapacitating for five to seven days before
> their periods. You can use Prozac, 20 mgs a day or Zoloft, 50 mgs a day. They tend to do very well with that. It's called luteal
> phase dosing, also known as intermittent dosing, also known as pulse dosing. It's been compared directly with continuous
> dosing. Works just as well. So there's a lot of validity to that. Now you might think, how can an antidepressant work with just
> five or six days of treatment? Keep in mind that PMS is not a true clinical depression. Major depression or a clinical depression
> is the type of depression that causes significant receptor changes in the brain. It takes you four to six weeks to reverse those
> receptor changes with a major depression. PMS you don't have those type of receptor changes. So with PMS, you take the
> Prozac within 20 minutes and you can feel better. If any of us in this room right now took 20 mgs of Prozac, in about 20 to 30
> minutes our serotonin levels in our brain would increase. Would we notice it? Only if we were a little bit low on serotonin to
> begin with. For instance, if you were two or three days before your period, and you took a Prozac 20 mg capsule, you would
> feel better in 20 or 30 minutes. And it's not placebo effect, you actually feel better. So there's a lot of validity to that. Once the
> woman begins her menstrual flow for that month, that's when she stops the medication. I've found that to be very effective.
>
> Q: Can you repeat the drugs that inhibit cytochrome P450 3A34?
>
> Dr. Fawver: If you use Serzone in conjunction with Propulsid, it's contraindicated. Propulsid could cause you to have a
> potentially fatal cardiac arrhythmia. So do not use Propulsid with Serzone and Luvox. So Luvox and Serzone are the two
> antidepressants that we have to be very careful in using Propulsid. That's what you always ask them about. Fortunately, Seldane
> is now off the market, so we don't have to worry about that any more.
>
> Q: In elderly patients and dropouts, was there a difference between the older and the newer medications?
>
> Dr. Fawver: With the elderly patients, specifically, there was not a difference in dropouts. Curious effect. But in the general
> overall population, more people dropped out on the older medications compared to the newer populations. But for the elderly
> population, specifically, in the study I showed you, there was no difference.
>
> Q: Briefly compare and contrast the various treatment modalities in late-life depression.
>
> Dr. Fawver: A lot of people who are old-old, those being people over 80 years of age, they often respond very nicely to very
> small amounts of medication. Those are your Prozac 5 mg patients. Those are your Paxil, 10 mgs a day patients, or maybe even
> your Zoloft, 25 mgs a day patients. They are often exquisitely sensitive to very small amounts of medication. I will often combine
> a small amount of these newer medications for depression with just a pinch of Ritalin or Dexedrine, and it will perk them up very
> nicely, especially if they've given up on life, especially if they're medically ill, if they have cancer, if they have heart disease, I
> watch their blood pressure and heart rate pretty closely. You can add 5 mgs of Ritalin twice a day, start at 2.5 mgs twice a day,
> but often 5 mgs of Ritalin in the morning and 5 mgs at noon in combination with your SSRI can give them a nice energizing
> effect. They don't tend to increase the dosage and escalate that, they often do very nicely with a nice, small dosage. But the key
> with these newer medications is that a small amount goes a long way. I showed you the study with the geriatric patients with
> citalopram or Selexa. But really any of the newer agents can be beneficial.
>
> Q: Atypical antipsychotics?
>
> Dr. Fawver: Absolutely. The atypical antipsychotic medications are good for the elderly patients that have psychotic
> depression. By itself, Zyprexa does not appear to be a good medication for unipolar depression. So if you have some patient
> with major depression and you only give them Zyprexa, it's probably not going to work that well. But you give that patient
> Prozac and they partially respond, and then add Zyprexa 5 to 10 mgs to it, they can get a dramatic improvement in their
> response. For some reason, Zyprexa needs a little bit of an antidepressant to help squeeze out that extra dopamine and
> norepinephrine from the frontal lobes. Zyprexa you going to find in terms of a new indication that Lilly's going to come out with,
> and this is very public, you're going to see a bipolar indication for Zyprexa. They've already gotten a written letter of approval
> from the FDA. You're going to find that in the future, Zyprexa will be a very nice mood stabilizer and we're going to be treating
> a lot of patients with it monotherapy for bipolar disorder. I've been using Zyprexa now for two years for my patients with
> bipolar disorder, and more often than not, I'm able to get by on using Zyprexa as monotherapy. I don't have to add
> antidepressants or benzodiazepines to it. So it will be a fun treatment to watch.*************************************************
John:
Are you the same John that has been promoting Adrafanil and Amisulpride on this board? If you are, then as I read this, do I detect a shift in your strategies? It seems that you now are promoting the atypical APs, along with Lamictal, and possibly concomitan treatment with an SSRI? What happened to the Adrafanil and Amisulpride, just out of curiosity?
BTW, the science and logic behind the Zyprexa addition seems very sound. My concern is the often reported significant weight gain on Zyprexa. Also, I took Lamicatal for awhile last year, and developed a rash. I don't think I went as slowly as some... but I followed the package insert instructions. Do you think it would be worth another try with an extremely slow dosage titration?
Bob
Posted by JohnL on September 10, 2001, at 3:08:30
In reply to Re: Doc's Experience with Zyprexa, Lamictal, more., posted by bob on September 9, 2001, at 15:14:03
> John:
>
> Are you the same John that has been promoting Adrafanil and Amisulpride on this board? If you are, then as I read this, do I detect a shift in your strategies? It seems that you now are promoting the atypical APs, along with Lamictal, and possibly concomitan treatment with an SSRI? What happened to the Adrafanil and Amisulpride, just out of curiosity?
>
> BTW, the science and logic behind the Zyprexa addition seems very sound. My concern is the often reported significant weight gain on Zyprexa. Also, I took Lamicatal for awhile last year, and developed a rash. I don't think I went as slowly as some... but I followed the package insert instructions. Do you think it would be worth another try with an extremely slow dosage titration?
>
> BobBob,
Yes, I am the same John who likes to suggest Adrafinil and Amisulpride as alternatives for people who have been disappointed with other more common meds. They are still two of my favorites for a lot of reasons. It's just that Zyprexa and Lamictal are proving to be unusually good medicines, so I don't want to ignore them. I tend to go more with what works a lot in the real world, regardless of what literature says. With that in mind, some of the all time top drugs have to be Adrafinil, Amisulpride, Zyprexa, Lamictal, and good ole Prozac, in my opinion. Obviously the doc in this thread seems to really like Zyprexa, and he seems to like Lamictal and Neurontin too. Zyprexa has been a wonderful medicine for me. Lamictal helped me some, but not a whole lot, but then again I never got higher than 100mg dose. The doc in this thread thinks 200mg is the target to shoot for, so if that is true then I fell short and didn't give it a good enough trial. At least one thing is for sure, that is, I did not get worse on Lamictal. So many other meds actually made me worse instead of better. Lamictal was one of the good ones that did not do that to me.Mileage varies of course. But in this trial and error game, I like to go with things that have the highest odds for success. These meds fit that description. Just my opinion though.
If you were to try Lamictal again, it might be a good idea to start at 12.5mg and work your way up. Increase the dose by 12.5mg every four days or so. The rash would be unlikely at that pace.
Weight gain on Zyprexa is indeed a common problem. It can be dealt with however. Careful snacking habits and such can make a difference. I gained weight when I first started Zyprexa, but have now lost it all simply by cutting back on snacks and not eating so much at meal time.
John
Posted by bob on September 10, 2001, at 10:53:11
In reply to Re: Doc's Experience with Zyprexa, Lamictal, more., posted by JohnL on September 10, 2001, at 3:08:30
>
> > John:
> >
> > Are you the same John that has been promoting Adrafanil and Amisulpride on this board? If you are, then as I read this, do I detect a shift in your strategies? It seems that you now are promoting the atypical APs, along with Lamictal, and possibly concomitan treatment with an SSRI? What happened to the Adrafanil and Amisulpride, just out of curiosity?
> >
> > BTW, the science and logic behind the Zyprexa addition seems very sound. My concern is the often reported significant weight gain on Zyprexa. Also, I took Lamicatal for awhile last year, and developed a rash. I don't think I went as slowly as some... but I followed the package insert instructions. Do you think it would be worth another try with an extremely slow dosage titration?
> >
> > Bob
>
> Bob,
> Yes, I am the same John who likes to suggest Adrafinil and Amisulpride as alternatives for people who have been disappointed with other more common meds. They are still two of my favorites for a lot of reasons. It's just that Zyprexa and Lamictal are proving to be unusually good medicines, so I don't want to ignore them. I tend to go more with what works a lot in the real world, regardless of what literature says. With that in mind, some of the all time top drugs have to be Adrafinil, Amisulpride, Zyprexa, Lamictal, and good ole Prozac, in my opinion. Obviously the doc in this thread seems to really like Zyprexa, and he seems to like Lamictal and Neurontin too. Zyprexa has been a wonderful medicine for me. Lamictal helped me some, but not a whole lot, but then again I never got higher than 100mg dose. The doc in this thread thinks 200mg is the target to shoot for, so if that is true then I fell short and didn't give it a good enough trial. At least one thing is for sure, that is, I did not get worse on Lamictal. So many other meds actually made me worse instead of better. Lamictal was one of the good ones that did not do that to me.
>
> Mileage varies of course. But in this trial and error game, I like to go with things that have the highest odds for success. These meds fit that description. Just my opinion though.
>
> If you were to try Lamictal again, it might be a good idea to start at 12.5mg and work your way up. Increase the dose by 12.5mg every four days or so. The rash would be unlikely at that pace.
>
> Weight gain on Zyprexa is indeed a common problem. It can be dealt with however. Careful snacking habits and such can make a difference. I gained weight when I first started Zyprexa, but have now lost it all simply by cutting back on snacks and not eating so much at meal time.
> John****************************************
A few more questions John, if you don't mind:
What, exactly is your med regimen currently?
Are you still taking Lamictal? If not, why not?
Why did you only get to 100mg on Lamictal - what stopped you?
I personally would be worried about using drugs not available in the U.S., as it would seem to me that the supply source is quite precarious! What if one's supply of Amisulpride or Adrafanil dried up and more could not be obtained in a timely manner, if at all? Then a nasty, nasty withdrawl might be faced - no?
You response to my previous queries was very helpful - thank you.
Bob
Posted by JohnL on September 10, 2001, at 17:34:25
In reply to Re: Doc's Experience with Zyprexa, Lamictal, more., posted by bob on September 10, 2001, at 10:53:11
> ****************************************
>
> A few more questions John, if you don't mind:
>
> What, exactly is your med regimen currently?
>
> Are you still taking Lamictal? If not, why not?
>
> Why did you only get to 100mg on Lamictal - what stopped you?
>
> I personally would be worried about using drugs not available in the U.S., as it would seem to me that the supply source is quite precarious! What if one's supply of Amisulpride or Adrafanil dried up and more could not be obtained in a timely manner, if at all? Then a nasty, nasty withdrawl might be faced - no?
>
> You response to my previous queries was very helpful - thank you.
>
> BobHi Bob,
My current regimen is 20mg Prozac, 300mg Adrafinil, 5mg Zyprexa. Maybe once every month or every two months I sometimes experience a sinking spell. When that happens, I have discovered that taking just 50mg of Amisulpride completely fixes it in one day and lasts for weeks. So I take Amisulpride on an as needed basis, which is not very often. It is what I consider to be my life raft. The only reason I don't take it continuously is because it also makes me somewhat impotent. I don't like that. So my bread and butter medicines are Prozac, Adrafinil, and Zyprexa. If I ever need an extra boost, Amisulpride is on standby.The reason I quit Lamictal was because it just didn't seem to be doing much. The only side effect I had was insomnia, which got really bad when I hit 100mg. Not even Remeron could do a good job of overcoming that insomnia. I slept horrible. With the benefit of hindsight however, I can see that Lamictal did indeed smooth out my days and prevent any mood swings. It was helping. I couldn't really tell at the time though. At that time I was more focused on fixing my anhedonia, and not so much concerned about mood swings. I think the culprit at the time that I should have gotten rid of was the Remeron, not the Lamictal. If I ever run into trouble again, Lamictal is high on my list of drugs to revisit.
I do worry about the exact thing you mentioned, that is, not being able to get a refill from overseas for one reason or another. I try to make sure and stock up well in advance, so that if anything does happen, at least I will have a few months supply on hand while I figure out what to do. I hope that never happens. But if it does, at least I will have plenty of time to deal with it and find another source or whatever.
I have stopped both Adrafinil and Amisulpride before, and when I did I experienced no withdrawals at all. So I'm not worried about that part of it. The part that scares me is that anhedonic dark dungeon that begins to close in around me at about day 3 of not taking my meds. That's very scary. The scariest part though is that there is not any drug in the USA that can do for me what Adrafinil does. That's scary. We tend to think of the USA as all there is, but that's just not the case.
John
Posted by Zo on September 10, 2001, at 21:42:56
In reply to Re: Doc's Experience with Zyprexa, Lamictal, more., posted by JohnL on September 10, 2001, at 3:08:30
> Careful snacking habits and such can make a >difference. I gained weight when I first started Zyprexa, >but have now lost it all simply by cutting back on snacks >and not eating so much at meal time.
John, John, John. What am I going to do with you.:)
Zo
Posted by Jane D on September 11, 2001, at 0:34:22
In reply to Doc's Experience with Zyprexa, Lamictal, more., posted by JohnL on September 9, 2001, at 7:21:25
John,
I agree. This is very interesting. There are a few more things I'm curious about. Do you know who he was speaking to here? Was it patients (seems unlikely from the content), students, general practitioners, psychiatrists or some other group entirely? When was this meeting? And lastly, do you know anything more about this presenter?I don't want to nitpick too much but I do think it is important to keep a couple of things in mind while reading the transcript. This seems to be an unproofed transcript. For example I suspect that "Depression is schizoaffective disorder, the antidepressants certainly do play a role." should really read "Depression in schizoaffective ..." I mention that because I know that one doctor previously complained about being misquoted on the board. I also worry that there may be other transcription errors that are less obvious to me. One other thing that jumped out at me is that he says he is a consultant for Eli Lilly who makes both Prozac and Zyprexa which he refers to frequently and favorably. Consultant can mean many things and this may or may not matter but it's something I like to know. I'm glad he mentioned it.
Thanks for posting this.
Jane
Posted by JohnL on September 11, 2001, at 2:41:17
In reply to Re: Doc's Experience with Zyprexa, Lamictal, more. » JohnL, posted by Zo on September 10, 2001, at 21:42:56
> > Careful snacking habits and such can make a >difference. I gained weight when I first started Zyprexa, >but have now lost it all simply by cutting back on snacks >and not eating so much at meal time.
>
>
> John, John, John. What am I going to do with you.
>
> :)
>
> ZoZo, how about sending me a couple dozen extra glazed donuts? :-)
Seriously, the weight gain thing bothers me greatly. I like to grow rose plants. One thing I've noticed is that the most beautiful and the most aromatic ones are also the ones with the nastiest thorns. I guess Zyprexa is kind of like that.
John
Posted by JohnL on September 11, 2001, at 2:52:27
In reply to Re: Doc's Experience with Zyprexa, Lamictal, more. » JohnL, posted by Jane D on September 11, 2001, at 0:34:22
Hi Jane,
You bring up some good points. I don't know the answers to your good questions. I think you are right about it being kind of informally proofed, because the writer spelled Neurontin as Neurotone. Regardless of its possible flaws and shortcomings, I think it holds some interesting points of views to consider. I definitely did not intend for it to be interpreted as some kind of bible or some kind of stringent research. Based on my own casual observations, I believe most of everything said is closer to being true than false. I just thought it brought up some interesting points that I wish were more common place in other literature. This piece came from MhSource, which is a pretty credible source overall. You do bring up some good points though, which I think should definitely be considered to keep the whole thing in context.
John> John,
> I agree. This is very interesting. There are a few more things I'm curious about. Do you know who he was speaking to here? Was it patients (seems unlikely from the content), students, general practitioners, psychiatrists or some other group entirely? When was this meeting? And lastly, do you know anything more about this presenter?
>
> I don't want to nitpick too much but I do think it is important to keep a couple of things in mind while reading the transcript. This seems to be an unproofed transcript. For example I suspect that "Depression is schizoaffective disorder, the antidepressants certainly do play a role." should really read "Depression in schizoaffective ..." I mention that because I know that one doctor previously complained about being misquoted on the board. I also worry that there may be other transcription errors that are less obvious to me. One other thing that jumped out at me is that he says he is a consultant for Eli Lilly who makes both Prozac and Zyprexa which he refers to frequently and favorably. Consultant can mean many things and this may or may not matter but it's something I like to know. I'm glad he mentioned it.
>
> Thanks for posting this.
>
> Jane
Posted by Elizabeth on September 12, 2001, at 5:29:47
In reply to Doc's Experience with Zyprexa, Lamictal, more., posted by JohnL on September 9, 2001, at 7:21:25
> Dr. Fawver: Depakote would be no problem. Lamictal I wouldn't combine with a monoamine oxidase inhibitor because
> Lamictal does have a selective serotonin reuptake inhibitor built into it.(This is a confusing way of saying that Lamictal is a serotonin reuptake inhibitor, right?)
FWIW, I took Lamictal, up to 500 mg/day, with Nardil for several months without problems.
> Q: Is Lamictal an effective antidepressant?
I didn't get any AD effect out of it. Actually I didn't notice any effect, period.
> Q: Does double depression exist?
>
> Dr. Fawver: I think it does. Double depression is major depression with dysthymic disorder. These people have been
> depressed since they were kids.That could be me (that, or subsyndromal ADD).
> Even when they get well, they don't seem to all the way recover from the major depression.
This is definitely me, since the onset of major depression (in childhood, around age 10). Depression changed me irreversibly.
> We're getting a lot of benefit from using the atypical antipsychotic medications for augmentation for unipolar depression.
This is true -- atypical antipsychotics seem to help some people, at least in low doses -- but they also often make depressives feel worse rather than better. Also, 10 mg seems a bit high for people with nonpsychotic depression. I would probably want to start at 2.5, the lowest available pill size.
> Dr. Fawver: Depression is schizoaffective disorder, the antidepressants certainly do play a role.
I think that should be "depression IN schizoaffective disorder..." ?
> With depression in-patients with schizophrenia, 80% of patients with schizophrenia have a clinically significant degree of
> depression at some time in their lives.Especially following major psychotic episodes.
> If you're using the older antipsychotics -- Haldol, Stelazine,
> Prolixin. They cause depression.They do. But the newer ones often do too. The newer ones, though, can help with negative symptoms and do seem to carry less risk of EPS.
> Depression in borderline personality disorder. It's always there with these borderline patients, and antidepressants can help to
> some degree, but again, I'm using a lot of atypicals with my patients with borderline personality disorder.Note: tricyclics should not be used in BPD. They can potentially make it worse.
Re part-time ADs for PMDD:
> You can use Prozac, 20 mgs a day or Zoloft, 50 mgs a day. They tend to do very well with that.I know a woman who used Paxil for this, to good effect. Luvox and Celexa are probably effective too. It doesn't work for women with irregular periods, for obvious reasons.
> If any of us in this room right now took 20 mgs of Prozac, in about 20 to 30
> minutes our serotonin levels in our brain would increase.This is important in that it shows that "serotonin deficiency" is not a cause of clinical depression simply because serotonergic drugs often relieve depression.
Re depression in old age:
> I will often combine
> a small amount of these newer medications for depression with just a pinch of Ritalin or Dexedrine, and it will perk them up very
> nicely, especially if they've given up on life, especially if they're medically ill, ...Yes, stimulants can be of great help to people who have "given up" or who feel resigned. I've been trying to get a friend who is like that to get some stimulants.
BTW, I think that some of the weight gain from antipsychotics such as Zyprexa can be traced to lethargy and sluggishness.
> Seriously, the weight gain thing bothers me greatly. I like to grow rose plants. One thing I've noticed is that the most beautiful and the most aromatic ones are also the ones with the nastiest thorns. I guess Zyprexa is kind of like that.
I think that's certainly true of buprenorphine. The side effects can be very hard to tolerate, and you have to be really motivated to get will if you're going to be able to put in the extra effort it takes to manage them.
-elizabeth
Posted by Elizabeth on September 12, 2001, at 13:37:45
In reply to Re: Doc's Experience with Zyprexa, Lamictal, more. » JohnL, posted by Elizabeth on September 12, 2001, at 5:29:47
> Yes, stimulants can be of great help to people who have "given up" or who feel resigned. I've been trying to get a friend who is like that to get some stimulants.
Err, that sounded bad. < g > I meant that I'm trying to get him to talk to his pdoc about stimulants and try to get a script. :-}
-elizabeth
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