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Mood Disorder Community
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Administrator
Administrator
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 Posted - 05/09/2005 : 22:14:22
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CNS Spectr. 2004 Sep;9(9 Suppl 9):11-8.
Rethinking the treatment paradigm for bipolar depression: the importance of long-term management.
Baldassano CF, Ballas CA, O'Reardon JP.
Department of Psychiatry, University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA. cfb@mail.med.upenn.edu
The need for long-term management of bipolar disorder is evident. Bipolar patients spend more time depressed than manic; however, few agents used for maintenance therapy of bipolar disorder have demonstrated good efficacy in delaying relapse into depression. This article provides a comprehensive review of open-label and randomized, controlled studies examining prophylactic efficacy in bipolar disorder, especially bipolar depression.
Lithium, considered the gold standard for bipolar disorder maintenance therapy may be more effective in delaying manic relapse than in delaying depressive relapse.
Evidence for the efficacy of divalproex and carbamazepine in delaying depressive relapse is yet to be fully elucidated.
Lamotrigine has demonstrated efficacy in delaying time to depressive relapse.
Unpublished studies show olanzapine's efficacy in preventing manic recurrence, while its efficacy in preventing depressive recurrence is yet to be proven.
As patients with bipolar disorder are prone to experiencing depressive episodes, more attention needs to be focused on preventing depressive relapse. To date, three agents--lithium, lamotrigine, and olanzapine--have been shown to have prophylactic benefits in treating this highly recurrent disorder.
[PubMed PMID: 15361807]
[RELATED ARTICLES http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Display&dopt=pubmed_pubmed&from_uid=15361807]
Comment
Lamotrigine Is The Only Anticonvulsant That Prevents Depression
It appears that no anticonvulsant is a good treatment for both acute mania and the prevention of depressive relapse. Divalproex and carbamazepine are good treatments for acute mania, but often fail to prevent depressive relapse. Lamotrigine prevents depressive relapse, but isn't a good treatment for acute mania.
Lithium And Olanzapine Also Prevent Depression
Lithium is licenced for the treatment of acute mania, and the prevention of manic and depressive relapses. However, lithium may be more effective in preventing manic relapse than in preventing depressive relapse. Thus it is important to know that olanzapine is also licenced as a maintenance treatment to prevent depressive relapse. Unfortunately, the significant weight gain caused by olanzapine often limits its use.
What do you think?
Phil Long M.D.
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| BlueAngel
New Member
89 Posts |
Posted - 05/14/2005 : 09:20:47
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Thanks for the information, Dr. Long. As a bipolar with more than 30 years on mood stabilizers, including lithium and most of the anticonvulsant meds, I'd have to say that none of them prevent recurring depressions. In fact, all of them caused me to relapse into depression unless teamed with a potent antidepressant. My experience tells me that its a delicate balancing act trying to keep the antidepressant and the mood stabilizer in perfect proportion so I'm neither pushed into mania or dragged down to depression. It took more than a year to fix the dosages of my current drug combo at levels that give me stability most of the year with only minor swings into depression or hypomania. I'm not free of symptoms, by any means; but I am functional and I call that real progress. 
BlueAngel, balancing on the head of a pin. |
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| KarenBP
Starting Member
8 Posts |
Posted - 05/14/2005 : 16:27:51
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What I think is that this is an acutely frustrating subject. I flatly refuse to take olanzapine for this very reason, and can't take lamictal because I get the dreaded rash.
I'm left with off-label choices which I hope will work--in my case, topamax with effexor.
I'd like to know what you think, actually. |
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| aquamarine
Amazing Member (1000+ posts)
1238 Posts
Gratitude: 300
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Posted - 05/14/2005 : 16:48:27
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While my "official" diagnosis is MDD, I have more in common with BP mood experiences than the pure depressive experiences. I rapid cycle between major depression and just below hypomania (I question that I do not have full hypomanic episodes). To me my experiences mirror the experiences of people I see on the BP Discussion board...I believe there is a continuum or spectrum of types/levels of BP beyond the "official" types. That said, my biggest problem is treatment resistent depression...I love my "highs".
My depression has remained totally untreatable by every anti-depressant, antipsychotic, anti-convulsant I tried. In fact, I believe much of the rapid cycling I encountered was triggered by some of them. Finally, 24 meds, 7 ECT treatments and twice weekly therapy for 3.5 years later I seemed to be having some success with Epival (Depakote)...it has calmed my anxiety, moodswings and irritability and I finally can sleep. Some days it seems to help with my depression...but not consistently.
Problem is I was having cognitive problems, depersonalization problems and extreme fatigue on 1000 and 750mgs. So my pdoc has suggested I take it down to 500mgs and maybe augment with olanzapine. I have had bad experiences with risperdal and seroquel...could barely move on either and am really afraid of gaining weight as I have worked so hard to lose what I did gain before. I would rather try something else.
I tried Lamotrigine and loved its side effect profile for me...but it only seemed to help my depression a tiny bit, for a very short while. I am wondering 2 things:
Do you think I might have more success with Lamotrigine and my depression now that the Epival is helping me with some of my other symptoms?
Do you think I could use Lamotrigine to maintain my mood if I ever get it up to the level I want it to be.
Thanks
...Aquamarine |
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| nan (inactive)
Starting Member
11 Posts
Gratitude: 1
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Posted - 05/14/2005 : 18:31:44
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What do I think?
Suffering with this illness for over 30yrs, I am taking Eskalith which is a slow release form of lithium. I was taking Lithium for 30yrs. If I do not take it I can not function so this medication is very important to me. I am also taking lexapro for anxiety and klonopin.
Hugs,
Nan |
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| autumn2night
Full Member (100+ posts)
175 Posts
Gratitude: 4
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Posted - 05/15/2005 : 11:20:14
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It would be nice if there was just one medication to "cure all" and send us on our merry way. But often when a patient finally comes to a psychiatrist for the first time displaying the BP disorder, he/she has also added a host of other "self coping stratigies" to his/her plate so to speak. So he is also coping with perhaps an anxiety issue on top of the BP disorder and will also need to be treated for that. I was treated for BP and years later was showing signs of resisting the newer meds for BP. It was then that I was dx.ed with D.I.D. which of course explained why another round of meds. had to be added to my BP. meds.
Also, how are these studies being done? I've always been interested in the Omish community.
Also as we age, hormonal changes occur - are the studies generalized to all ages and races? Lot of questions back at you.
autumn2night |
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| KeriRae
Starting Member
13 Posts |
Posted - 05/17/2005 : 09:31:00
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I dont have the mania as bad as others. I have been on Lamictal for almost 2 months now (up to 150mg). I thought it was helping with my depressed agitation and irritability. Although, I found myself crying Saturday when I watched "Grumpy old Men". That was pretty weird. But, it went away a few hours later. I dont think I am up to the right dose yet. I have been happy lately and I've noticed people talk to me again. So, I think I'm not so irritating to others (from the hyper stuff like interupting people, monopolizing conversations and feeling obligated to show the dumb people exactly how stupid they are). I feel that I'm a little better while still needing a higher dose. The depression has been better than before the Lamictal. I have been grouchy for about 2-3 days each time I increase it. But, I can control it knowing it's the med adjusting.
I may need an SSRI too just to get that extra boost, but I am scared the mania may hit me hard. I love the highs too but I just can't afford it anymore. *Trying to be good and get better.
To finally make my point, I think in some less extreme cases of depression it may help. I mean, do the people with the very severe depression really have the energy to participate in studies? Are they on so many meds or self medicating they are kicked out of the study? Are they really bipolar to begin with? I take it all with a huge handfull of salt. I've learned to do that now. We all know that they spin it the way they need to to keep funding high. Who else is going to pay for all the new research and free drug pens?
I think the best place to get any info is from forums like this. I hope doctors take the time to listen to us for once. And, this is the best place to start.
Nice bonus to Lamictal...
After self medicating with opiates like Vicodin for a few years..I am now dealing with an addiction problem (Suboxone treatment and online NA forums). For the psychological part of addiction, the Lamictal has helped me there too. Maybe because the depression is not as bad now. I dont know.
Thanks to the forum gods,
KeriRae |
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| BlueAngel
New Member
89 Posts |
Posted - 05/17/2005 : 10:33:24
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Hi, KeriRae. I don't thing we know one another, but I'm guessing that you're the KeriRae who sent me an email shortly after I retired from the BDWC/YABB board. I was known as DeeCee over there. From what I learned about you in your first post, I think we have lots in common  Welcome to the new group!
BlueAngel |
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| Jana
Full Member (100+ posts)
177 Posts
Gratitude: 1
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Posted - 05/17/2005 : 13:15:54
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For me, Lamictal was a Godsend! I never got the rash or any side effects.. and i could see SO much clearer. The only time i noticed it not helping my depression much was when i was PMSing(sorry guys.. lol) and it made my PMS worse.. much worse. It also put me into hypomania for the first time.. so i had to add Seroquel or i wouldnt sleep. I was awake for 48 hours when i first went on Lamictal and was so agitated and depressed that i fell back into old SI habits. After calling my pdoc.. they added Seroquel and it was a great combo for me. However.. when i lost my job and insurance.. i had to go off my Lamictal. I went off Cold Turkey and instantly went into my first big hypomanic stage. I also started to rapid cycle and that hasnt changed in me at all. I have never had full blown mania (although i wonder if it wasnt full blown when i went off the Lamictal) When i get my insurance in September.. you bet that i will be asking for Lamictal again!
Jana
"Cast your cares on the Lord and He will sustain you. He will never let the righteous fall" Psalms 55:22 |
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| KeriRae
Starting Member
13 Posts |
Posted - 05/18/2005 : 07:58:15
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Hey DeeCee. Yes, I remember you.. Of course I do! We talked about how hot we are, right? It's nice to see you again.
After I think about it Jana, I think it has helped my mania more than I thought before.
I think it's the best option for people that cycle hourly, like me. I definately know that part is long gone. Since I have only been on it for a few months, I was thinking it really wasnt long enough to really say if it helps the big spells (weeks of mania). I know there may be a big one lurking around. I wonder if this type of treatment also stops the progression of bipolar. I'm not sure what this is but I started working out again too. It just seems so much easier to push myself, ya know? It's like I can see good things are going to happen to me again. I never expected that. Jana, I wish I could share mine or get you some samples. I wonder if they have an assistance program at Glaxo.
I wish you all the best.
- KeriRae
KeriRae |
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| KeriRae
Starting Member
13 Posts |
Posted - 05/18/2005 : 08:02:16
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| I probably can get you samples, Jana. I dont know how to send you a private message on here. Let me know. I am in Texas but can mail you a few samples. |
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| smoky jo
Starting Member
2 Posts |
Posted - 05/22/2005 : 06:21:57
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| Hi dont know if im in the right thread or not!! Can some one be kind enough to tell me the difference between bipolarI,II and cyclothmia (sorry dont know if thats spelt right) I cant really understand it on the info pages could someone narrow it down!! thanx |
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| Jana
Full Member (100+ posts)
177 Posts
Gratitude: 1
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Posted - 05/22/2005 : 08:38:50
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Smoky Jo.. \
I dont know about Cyclomythis (or however its spelled..( but i do know that to be dxed as Bipolar 1.. you have to have had a manic episode. If youve never had a full blown manic episode.. then you are classified as BP2. I hope this helps.
Love,
Jana
"Cast your cares on the Lord and He will sustain you. He will never let the righteous fall" Psalms 55:22 |
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| Pepper
Starting Member
9 Posts
Gratitude: 1
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Posted - 05/23/2005 : 21:06:55
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[quote]Originally posted by smoky jo
Hi dont know if im in the right thread or not!! Can some one be kind enough to tell me the difference between bipolarI,II and cyclothmia (sorry dont know if thats spelt right) I cant really understand it on the info pages could someone narrow it down!! thanx
[/quote
Hi Smoky Jo,
Here are some definitions that differentiate the three BP's:
Bipolar I - when a patient suffers from one or more manic or mixed episodes, whether or not there have been any episodes of major depression
Bipolar II - when a hypomanic episode occurs after one or more major depressive episodes
Cyclothymic - chronic, fluctuating mood disturbance over 2yrs, involving periods of hypomanic and depressive symptoms that are not sufficient to warrant classification as full manic or major depressive episodes.
Also, FYI:
manic - increased energy, restlessness, racing thoughts, rapid speech, excessive highs, extreme irritability/distractability, decreased need for sleep, uncharacteristically poor judgement, impulsive, reckless, bizarre behaviour, increased sexual drive, violent agitation and delusions and visual & auditory hallucinations.
hypomanic - all of the above symptoms (sometimes milder), and take away the violent agitation, as well as the delusions and hallucinations.
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| Pepper
Starting Member
9 Posts
Gratitude: 1
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Posted - 05/23/2005 : 21:18:04
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In response to the 'rethinking the treatment paradigm for bipolar.' It seems there are so many things we have to take into consideration. My understanding is that there is new research that suggests that about one third of patients who suffer from Major Depressive Disorder and are resistant to their treatment regimens, may infact, be misdiagnosed bipolar patients.
Furthermore, I have heard specialists in Bipolar Disorder and Refractory Depression talk about the 'window of opportunity' in which patients must be caught or treated effectively.
I know personally, I am one of these statistics. I was first diagnosed as depressed....and then, treatment failure after treatment failure (or partial response), I was diagnosed at Bipolar II. Now looking back, I know I had the symptoms, but I had no clue as to what Bipolar Disorder was or that it even existed.
I guess my point is that the screening process for bipolar disorder at the general practicioner level should be perhaps enhanced. There are likely one or two key questions that would automatically set off the radar to detect whether or not he/she was dealing with a potential Bipolar patient. If they are, then I think that treatment regimens should be aggressive. There is data with olanzapine as maintenance therapy in bipolar, but many psychiatrists are using other atypical antipsychotics to do the same trick (ie: seroquel and risperdal...both which do not cause half as much weight gain as olanzapine). So, the options are beginning to surface more and more.
I don't know about the US, because the healthcare system is so different that Canada's. However, here it is very difficult for GP's to screen for Bipolar Disorder or other difficult to treat and high maintenance illnesses because there is such a shortage of physicians here. So, there are always these problems that we have to deal with. It should be interested to see what research surfaces over the next couple of years that will help us Bipolars. Unfortunately, monotherapy doesn't look like it has a bright future in our lives. |
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| Administrator
Administrator
14912 Posts
Gratitude: 593
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Posted - 06/18/2005 : 23:16:53
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Dear Members,
Please permit me to partially resubmit a previous posting. I agree with our other members that, if possible, psychiatrists must limit the use of olanzapine (Zyprexia) because all too often it causes unacceptible weight gain.
To be honest, I haven't had sufficient clinical experience yet with lamotrigine (Lamactal) to form an opinion. It definitely works as an antidepressant for some individuals with Bipolar Disorder, but it doesn't seem to have the high success rate as lithium (or lithium + antidepressant medication).
In my practice, when lithium +/- antidepressant medication fails, I have often found that previously refractory Bipolar patients recover from their depression on a combination of lithium/anticonvulsant + antipsychotic + antidepressant medication.
Recently, an individual who had suffered for years with bipolar I disorder depression dramatically responded to this "triple combination", namely:
- Divalproex sodium (Epival, Depakote) 1000 mg / day (500 mg po BID PC) [an anticonvulsant]
- Flupenthixol (Fluanxol) 4.5 mg / day (4.5 mg po HS) [an antipsychotic medication]
- Venlafaxine (XR, Effexor) 150 mg / day (75 mg po BID) [an antidepressant]
The advantage of flupenthixol is that this older ("typical") antipsychotic medication usually has little weight gain or hand tremor. In addition, flupenthixol costs a fraction of what the newer ("atypical") antipsychotics cost. I'm not aware of this medication being available in the United States, but it is available in Canada and Europe.
European research has documented the benefit of flupenthixol in the treatment of Major Depressive Disorder.
Curr Med Res Opin. 1990;12(1):51-7.
A double-blind comparison of oral amitriptyline and low-dose intramuscular flupenthixol decanoate in depressive illness.
Maragakis BP.
Department of Psychological Medicine, Billinge Hospital, Wigan, England.
Fifty-seven hospital out-patients with depressive symptoms were studied in a double-blind manner for up to 4 weeks, 30 whilst being treated with intramuscular flupenthixol decanoate (5 to 10 mg/fortnight) and 27 with oral amitriptyline (75 to 150 mg/day). The results of assessment using the Hamilton Rating Scale for Depression, the Leeds Self-Rating Scale for Depression and the Clinical Global Impressions severity scale showed that both therapies were effective in resolving depression in the patients studied. The two treatments were well tolerated and side-effect profiles were similar, dry mouth, faintness/dizziness and drowsiness being the most frequently reported adverse events. Extrapyramidal signs were seen in similar numbers of patients in each treatment group. One patient from each of the two groups was withdrawn from therapy before the end of the study because of adverse events.
PMID: 2188797
Curr Med Res Opin. 1989;11(9):593-9.
Primary care treatment of depression in the elderly: a double-blind, multi-centre study of flupenthixol ('Fluanxol') and sustained-release amitriptyline.
Hostmaelingen HJ, Asskilt O, Austad SG, Fjellheim J, Hostmaelingen EA, Kristiansen PH, Olsen TI, Skotte T, Ofsti E.
A multi-centre general practice study was carried out to compare flupenthixol and a sustained-release preparation of amitriptyline in the primary care treatment of depression in the elderly. Fifty-one clinically depressed patients, aged 65 years or over, were allocated at random to one of the two treatment groups in this 4-week double-blind, double-dummy study. On entry, patients received either a 0.5 mg flupenthixol tablet in the morning and a placebo capsule at night (25 patients) or a 25 mg sustained-release amitriptyline capsule at night and a placebo tablet in the morning (26 patients), but at the end of the first or second weeks the dosage could be doubled according to the assessed clinical need. Fourteen patients in each treatment group had their dosages doubled. Patient assessment was undertaken on study entry and after 1, 2 and 4 weeks of treatment using a 0 to 3 scale global assessment and the Montgomery Asberg Depression Rating Scale; side-effects were recorded on the UKU Scale. After 4-weeks' treatment, over 80% of patients in each group had improved and in the flupenthixol group there was additionally a noticeable and highly significant reduction in symptom severity after only 1 week of treatment. Patients treated with flupenthixol had fewer and milder side-effects.
PMID: 2692973
Pharmatherapeutica. 1989;5(5):292-7.
Flupenthixol and fluvoxamine in mild to moderate depression: a comparison in general practice.
Hamilton BA, Jones PG, Hoda AN, Keane PM, Majid I, Zaidi SI.
Seventy-two depressed patients attending general practices were randomly allocated to treatment with either flupenthixol dihydrochloride (1 to 2 mg/day) or fluvoxamine maleate (100 to 200 mg/day) to assess efficacy and side-effects over a 4-week period. Clinical assessments were carried out before medication (Day 1) and on Days 8, 15 and 29 of treatment using the Hamilton Rating Scale for Depression, Clinical Global Impressions (CGI) and a patient self-assessment visual analogue scale for depression. Unwanted symptoms were also recorded. Reduction in mean total scores on the Hamilton scale at each assessment and therapeutic effect improvement on the CGI were greater for patients treated with flupenthixol (p less than 0.05). Reduction in unwanted symptoms was progressive in both groups, but more pronounced in patients receiving flupenthixol. Twice as many new symptoms arose in the fluvoxamine group compared to the flupenthixol group. Four patients were withdrawn in the fluvoxamine group due to untoward drug effects compared with none in the flupenthixol group.
PMID: 2501801
Pharmatherapeutica. 1986;4(9):561-70.
Neurotic depression accompanied by somatic symptoms: a double-blind comparison of flupenthixol and diazepam in general practice.
Grillage M.
A total of 192 patients suffering from mild to moderate depression, with or without anxiety, accompanied by one or more specific somatic symptoms, was entered into a double-blind, multi-centre trial to compare flupenthixol and diazepam as treatments for psychosomatic syndromes in general practice. Each patient was treated for 4 weeks and assessed after 1, 2 and 4 weeks on the Hamilton Depression Scale, with visual analogue scales of depression and somatic symptoms, by global assessments (psychological and somatic symptoms) and on a side-effects scale. The principal somatic symptoms were tension headache (69 patients), epigastric discomfort (59 patients), chest pain (39 patients) and backache (25 patients). There were 9 drop-outs (2 on flupenthixol and 7 on diazepam), of whom 5 (2 on flupenthixol and 3 on diazepam) who were treated for at least 2 weeks were included in the analysis of results. All patients received 1 tablet a day (0.5 mg flupenthixol or 2.5 mg diazepam) for the first week. Thereafter, all except 5 patients (3 on flupenthixol and 2 on diazepam) had their dose doubled for the remaining 3 weeks of study. Both drugs were effective in producing consistent improvement in all four somatic symptom groups in terms of both depression and somatic symptoms over the 4 weeks of study. There was a trend throughout in favour of flupenthixol as the more therapeutically effective. Flupenthixol was significantly more effective in relieving depressive symptoms and somatic symptoms in all four somatic symptom groups considered together. It was also superior to diazepam as measured by its effect on the depression sub-scales, anxiety, agitated depression, retarded depression and melancholia. Both drugs were well tolerated, although diazepam-treated patients showed a moderate increase in side-effects scores initially, while the scores in patients treated with flupenthixol decreased consistently over all 4 weeks of the trial. It is concluded from this study that flupenthixol has an important place in the management of patients with psychosomatic illness.
PMID: 3763651
Neuropsychobiology. 1983;10(2-3):131-6.
Depression-inducing and antidepressive effects of neuroleptics. Experiences with flupenthixol and flupenthixol decanoate.
Poldinger W, Sieberns S.
The antidepressive and anxiolytic efficacy of flupenthixol has been investigated in numerous controlled and open trials involving patients with endogenous, reactive as well as senile depressions. When administered at a mean daily single or multiple dose of 1-2 mg, flupenthixol proved to be a very effective and well-tolerated antidepressant. As opposed to some of the currently available antidepressants, flupenthixol has a rapid onset of action which is often displayed within the first 2-3 days following its application. Flupenthixol decanoate has also a pronounced antidepressive and anxiolytic effect which appears to be adequate enough for treating mild to moderately severe syndromes of depression. This depot neuroleptic has been given at a fortnightly dosage ranging between 2.5 and 30 mg. However, if the aspect of efficacy in relation to tolerance has to be taken in to consideration, then 5 mg are apt to be an appropriate dose. Patients with an agitated depression and/or suicide ideation should, however, be excluded from therapy with this drug. Extrapyramidal movement disorders which may appear during treatment are a disadvantage of this medication. Apparently such disorders are rarely encountered if the dose is kept below 10 mg. Other untoward effects are very seldom indeed. A final and conclusive judgement on the possible application of flupenthixol decanoate in the prophylaxis of phases in patients with bipolar and periodical depressions is as yet not feasible. Further clinical trials are necessary before flupenthixol decanoate can be classified as a possible 'depot antidepressant'.
PMID: 6674820 [
Br J Psychiatry. 1982 Mar;140:287-91.
A controlled comparison of flupenthixol decanoate injections and oral amitriptyline in depressed out-patients.
Tam W, Young JP, John G, Lader MH.
Sixty-eight depressed out-patients were allocated to treatment with either oral amitriptyline (75-225 mg/day) or intramuscular flupenthixol decanoate (10-30 mg every 14 days) in flexible dosage for 12 weeks under double-blind procedures. Various observer- and self-rating scales were applied before and after 2, 4, 8 and 12 weeks of treatment. Twenty-four patients completed the course of amitriptyline and 20 the course of flupenthixol. All variables improved over time, but there were no significant differences between the two drugs. The Newcastle scores pre-treatment were not related to drug response suggesting that both drugs were similarly effective across a wide spectrum of depressive disorders. Patients on amitriptyline tended to complain of dry mouth; those on flupenthixol had a higher incidence of extrapyramidal signs, the majority receiving anti-parkinsonian drugs at some time during the treatment. Flupenthixol decanoate in low dose is a useful anti-depressant, but should be restricted to short courses of treatment, to patients refractory to other treatments, and to patients suspected of poor compliance.
PMID: 7093597
In summary, my experience is that refractory depression in Bipolar I Disorder usually requires this "triple combination" treatment.
Although North America is currently having a love-affair with the newer ("atypical") antipsychotic medications, I find that they offer little clinical benefit over our older, much safer and less costly "typical" antipsychotic medications. Specifically, the weight gain caused by most of our newer ("atypical") antipsychotic medications is totally unacceptible (and about to cause an epidemic of diabetes mellitus in our patients).
My patients have had very little weight gain (or other adverse effects) on an old antipsychotic medication, flupenthixol. Thus it is now my first choice (in combination with lithium or other mood-stabilizer) when an antipsychotic medication is required for the maintenance phase of Bipolar I Disorder.
Since flupenthixol is not sedating, I am usually forced to use the very sedating olanzapine (or other sedating atypical antipsychotic medication) as my emergency treatment for acute mania.
Phil Long M.D.
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Preventing The Return Of Depression
