Buproprion vs. SSRIs for Cluster Bees

[fiatslug]

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In my admittedly limited, new PGY-3 experience in outpatient, I find that I'm inheriting some borderline/narcissistic patients who are on buproprion, and it's not doing much for their mood. Furthermore, several of them report good mood improvement efficacy with the SSRIs (unsurprisingly, we're doing some cross tapers, and at least 2 are reporting mood improvement with initiation of SSRI within 1-2 weeks...). Haven't been able to dig up any data on pubmed about txing Cluster Bees with buproprion vs. SSRIs, though there is good evidence for txing borderline pts with SSRIs:

http://www.ncbi.nlm.nih.gov/entrez/..._uids=12450955&query_hl=7&itool=pubmed_docsum

In fact, I've not found any studies looking at buproprion as solo tx for borderline PD or other Cluster B personality pathology.

Just wondering if anyone's clinical experience with buproprion and cluster B personality disorders has been more positive than mine.

 

[Anasazi23]

I'm not sure of the relative differences in efficacy between the wellbutrin preparations and other SSRIs in treating cluster B's. As you know, while the SSRIs are structurally similar, they have differing side effect profiles, which you can use to your advantage depending on the patient.

I know you know this fiat...🙂

Pharmacological treatment of borderlines is an enigma. If you consider the original pathogenesis of the term, the borderline between psychosis and neurosis, it is not too surprising that a variety of antipsychotics have been tried in treating this disorder, with somewhat mixed results.

A recent article in the Journal of Clinical Psych showed a relatively low mean dose of quetiapine (300mg I think) showed marked improvement with good tolerability for borderlines. This was measured by a variety of psychological rating scales, which are often marvelously useless in assessing borderlines from a self-report standpoint.

Another recent article from the 'green' journal showed aripiprazole also had relatively good efficacy with good tolerability.

I have a long-term psychotherapy patient who is borderline. This woman is exquisitely sensitive to medications, but is now relatively stable on a very small dose of abilify and fluoxetine (her episodes worsen around her menses). However, I'm a little concerned about her recent hypomanic flair. We'll see.

Let's hear from others' experience in treating borderlines and "cluster bees" pharmacologically.

 

[fiatslug]

I'm not sure of the relative differences in efficacy between the wellbutrin preparations and other SSRIs in treating cluster B's. As you know, while the SSRIs are structurally similar, they have differing side effect profiles, which you can use to your advantage depending on the patient.

I know you know this fiat...🙂

Indeed--and it seems like mine have had best mood efficacy with the more sedating versions (Paxil). However...

I have a long-term psychotherapy patient who is borderline. This woman is exquisitely sensitive to medications, but is now relatively stable on a very small dose of abilify and fluoxetine (her episodes worsen around her menses).

My cluster Bs tend to all be exquisitely sensitive to side effects, AND they read all about every possible permutation of side effects on the web ("I get the head zaps and the wrist tingles"). So they also have a hx of bouncing around on a lot of the SSRIs.

 

[whopper]

In general, I don't like giving Seroquel to anyone unless that person is bipolar manic, schizoprhenic or shizoaffective and with no other diagnosis.

Reason why, and I mentioned this a few times is that in my area, several people want Seroquel for abuse purposes.

As we probably all know, Borderlines tend to have drug abuse problems. Giving them Seroquel IMHO for several of them is just feeding their drug habit.

Several of the attendings I've worked with tell me that in their opinioin-with evidence to back it up that no one with an Axis II disorder should be treated with a psychotropic med unless they have a coexisting Axis I d.o.

I have read some articles stating that antidepressants may help borderlines who follow a specific behavioral pattern where they exhibited depressive mood but not enough features to quality for an Axis I depressive d.o. Unfortunately I forgot the source. I have read specific articles mentioning some benefits with some psychotropics, but the original article I mentioned reviewed several articles and mentioned that except for antidepressants, none showed enough data or enough reproducible data to suggest that any other class offered Borderlines reasonable benefit.

Otherwise it mentioned that Dialectical Behavior Therapy is the only therapy that reliably has been verified by studies.

Unfortunately, I do not remember the source of the article, but IMHO it was the best and most definitive guide to treating the d.o I've ever seen. Darnit. If I find it, I'll post it.

 

[MBK2003]

I hope that I haven't been made completely cynical by my PGY-3 year and the turn-over patients, but I had a LOT of cluster B's who had been put on WBTN because of concerns about or history of weight gain on SSRIs, and did just as poorly on WBTN. When I switched them to SSRIs because they were dissatisfied with WBTN (and the previous PGY 3/4 who they felt "dumped" them), they invariably did better for a while only to start gaining weight and beg me to put them back on WBTN. Part of me felt like their therapeutic benefit was pharmacologic and part was likely psychodynamic - wanting to put me in the idealized "good physician who knows what I need to feel better" until they ultimately devalued my "expertise." As with any medication interaction, consider whether the improvement could also have a psychodynamic explanation, because it can be frustrating when that psychodynamic portion comes back to bite you in the a&$.

MBK2003

 

[50960]

What is the abuse potential of seroquel? It must potentiate something else. Anyone know ??

 

[Anasazi23]

You can abuse seroquel in the strict sense of the definition, but cannot become dependent on it. Like I said in another thread, low dose seroquel is the new Seconal (without the physiologic dependence). Of course I'm exaggerating, but patients say it gives a mild high and dissociative feeling at low doses.

 

[worriedwell]

heroin addicts feel that seroquel enhances their high...seroquel has street value and is commonly sold on the streets.

seroquel is such an odd drug because i know some attendings who use it like candy and others who call it ZERO quel and never use it for anything. interesting though because the Bolder I trial seems to be reasonably well designed and it shows decent results for bipolar depression with seroquel. I anticipate in a few years that this will become the primary use for seroquel, and possibly for justifiable reasons.

 

[50960]

Hmmm, but isn't that all just sedation from the H1 antagonism?? Wouldn't benadryl do the same thing without the D2 blockade??😎

 

[fiatslug]

I hope that I haven't been made completely cynical by my PGY-3 year and the turn-over patients, but I had a LOT of cluster B's who had been put on WBTN because of concerns about or history of weight gain on SSRIs, and did just as poorly on WBTN. When I switched them to SSRIs because they were dissatisfied with WBTN (and the previous PGY 3/4 who they felt "dumped" them), they invariably did better for a while only to start gaining weight and beg me to put them back on WBTN. Part of me felt like their therapeutic benefit was pharmacologic and part was likely psychodynamic - wanting to put me in the idealized "good physician who knows what I need to feel better" until they ultimately devalued my "expertise." As with any medication interaction, consider whether the improvement could also have a psychodynamic explanation, because it can be frustrating when that psychodynamic portion comes back to bite you in the a&$.

MBK2003

your post was eerily prescient--had almost this same scenario in clinic today! I'm really looking forward to our DBT lectures...

 

[whopper]

What is the abuse potential of seroquel? It must potentiate something else. Anyone know ??

As mentioned above it heightens the high experienced with opioids.

This isn't just anecdotal. It is published in several psychiatric books and journals.

It has been published that antihistamines when mixed with opioids has this effect. Seroquel, as we should know, its strongest effect is its antihistiminic effect. In several urban centers, Seroquel has a strong street value.

Most drug abusers don't know that any antihistmine will heighten an opioid high, but since so many patients are dual diagnosis--the coincidentally discover that Seroquel causes this effect. Because there's so many people who are on Seroquel who are opioid addicts--there were enough people to spread around the information for it to become a cottage industry onto itself. Benadryl in theory should do the same thing as Seroquel, but the drug abusers haven't figured that one out yet because none of them take it, and I'm not going to exactly educate them on this either.

I've had several docs in my program think that Seroquel is some type of miracle med because all their opioid abusers want it. They actually started thinking that it could be used as a possible agent to detox patients. Yes it does have detox potential inpatient-wise, but outpatient, you're running the risk of feeding their habit.

It wasn't until we got a new doctor (who happened to be a professor of Psychiatry at Dartmouth) who was utterly shocked with everyone's love fest with Seroquel and instructed everyone in the dept the error of their ways.

 

[Analyzethis]

I have seen quite a bit of sucess with ability in Borderline patients-There was a large study that had took place at the university I am at and a couple docs here strictly treat Axis 2's and ablify is their first line for BLers

 

[50960]

Why do you think abilify is effective with these pts? What is the mechanism?

 

[Analyzethis]

I am sure it is the same lines as the study above with seroquel. I mean to me it makes someone anecotal sense just because borderline patients remind me a lot of manic, add and uncontrolled impusive anger patients-all which when dopamine is regulated seem to respond so it makes sense on that note-as for mechanism, in the study I have seen here at my univ-no specific mechanism is stated why it regulateds it-it was a large study though and the results look promising-I go to the univ where the Dean is the Chief editor of Journal of Cinical psychiatry and it is close to being published in there I believe.

 

[50960]

I meant that Abilify is a partial agonist/antogonist at dopamine receptor sites, and how would that help BPD pts? I do not know the answer, but am trying to get a discussion going on your ideas with this med for this condition. As to the OP, how would Wellbutrin's action (dopamine reuptake inhibition) play into this. Personally I have not had luck with BPD folks in outpatient settings; they either want me to be their new lover, or they want to kill me.... LOL

 

[sdn1977]

What is the abuse potential of seroquel? It must potentiate something else. Anyone know ??

Sorry I'm late to this discussion. In my neck of the woods - western CA prisons - its a very popular "yard" drug.

Its insufflated - crushed & inhaled. It rapidly magnifies the high of any other associated drug which induces a high (can vary day by day - opiods, amphetamines, etc..), but allows a lower & slower "relaxant" (not in the muscular sense - more the dissociateive sense Ansazi mentioned) effect which lasts.

As for benadryl - why doesn't it work - its got too many other components which make up the tablet/capsule - the binders, compressants, etc to make it an easier drug to inhale. To put it bluntly....it makes them cough & sneeze.

In a prison - fast & easy with the least amount of notice works!

Sorry....can't help you with your Abilify & BPD - out of my realm again.