Issues with seroquel

[Matteomm]

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I've got a difficult patient who has been taking seroquel for several years. However, comes to me in his mid 20's complaining of difficulties functioning. Can't figure out what he wants to do with his future. Can't think, easily stressed, no motivation, no energy to get up and do things during the day. In general, I suspect depression.

I suggest prozac. He complains that ssri's "induce anhedonia and brain fog" (his words) and therefore won't take them. Despite my assurance that many patients do in fact benefit from antidepressants, he remains reluctant. After further discussion, I wanted to determine why he was on seroquel. Apparently, he has been taking 100mg for 4 years just for insomnia and anhedonia. As I've never heard seroquel referred to help anyone in such a way for anhedonia, part of me is confused.

I wanted to switch him over to trazodone mainly because I felt that his level of functioning would be better versus a continued life on seroquel. He did not like this idea at all. He's insisted that he's always liked seroquel because it has helped him to enjoy listening to music, and essentially from what I gathered, more able to enjoy emotional media.

This has put me in an uncomfortable position. Seeing a patient for the first time without having any history of records and I'm already required to look at medication options that aren't first-line.

After further discussion and frustration, I end up asking him "If there is a medication that you feel would tackle your symptoms, which one would it be?" His answer being "Anything but an SSRI, however while we are on that subject, I need some clonazepam for my seroquel induced anxiety."

I ask him to elaborate. He further explains that the seroquel makes him feel this huge adrenaline rush. He says that he feels like this presense is in his room watching him with malicious intentions, and that the clonazepam makes the terror go away.

At this point I'm not sure whether to believe this, or think that maybe there was a legitimate reason for him having been prescribed seroquel in the past that I've yet to be aware of. In either case, I suggest to him again that perhaps it would be best to come off of the seroquel. Despite his experiences, he still wants to stay on the bloody seroquel.

Now I'm just utterly bewildered. Why would anyone want to take a medication like seroquel, if they were experiencing paranoia from it? (If that's even what's happening)

My question is has anyone actually had patients describe getting symptoms of severe anxiety and paranoia from seroquel? My patient strongly believes that it is the seroquel causing this and will not budge on the matter.

How can someone who claims to want to get better, be so utterly against getting better?

On another note, should I be concerned about substance abuse? I have read in the literature that seroquel does have an abuse potential, but I've never really thought anything of it.

 

[birchswing]

I'm a patient. I was prescribed Seroquel for Tourette's/OCD off label. It doesn't do much, but it's been grandfathered in. Max dose has been 50 mg. I've been on it since around 2002 so my effects have varied over time.

The first time I took it was absolutely terrorizing. I am someone who hates being out of control. I was taking it for tics and had no idea it was going to knock me out. I could not voluntarily stay awake and every instinct in my body was to fight as hard as possible to stay awake because I didn't know it would knock me out and didn't know what was happening. So I started taking it at night. Still caused the same terrifying feeling of losing control so I timed it to take it as I was at the point of falling asleep anyway.

Now oddly the effects of Seroquel are extremely variable in me. Some nights when I take it, I feel no effect. Some nights it's extremely soporific in a dysphoric way. Sometimes it's soporific in a pleasant way. Sometimes I have a lot of hypnic jerks falling asleep after taking it. I've fallen asleep after taking for a second it mid-bite while eating and ended up choking and coughing out the food.

I would say, based on my own personal experience of taking a low dose, it has the effect of knocking a person out like anesthesia, but the induction period (to continue the analogy) can be extraordinarily unpleasant. I can see why it would make someone want a benzo. As far as paranoia, I can't speak to that experience as I haven't had it.

The other thing is that it makes my heart race incredibly fast right after taking it sometimes. Not every time. The effect is stronger the more tired it makes me. I have POTS, but my pulse lying down never gets as high as it does when the Seroquel kicks in hard (again, the effect is variable). I get tachycardia up to 130 bpm lying down after taking my Seroquel dose, and higher when standing. (Normally it would be 60 lying, 130 standing.)

So overall, I would say it's a very unpleasant drug. I've never understood the value of it as a recreational drug, but I guess each person experiences it differently.

 

[Doctor Bagel]

How can someone who claims to want to get better, be so utterly against getting better?

On another note, should I be concerned about substance abuse? I have read in the literature that seroquel does have an abuse potential, but I've never really thought anything of it.

It's amazing how opposed some people seem to be to getting better. That's where that whole you can't work harder than your patient thing comes in. Getting better is scary -- he might actually have to face some of that 20s stuff like getting a job.

And yes, you should be concerned about substance usage, especially with the using clonazepam to treat the side effects of the quetiapine. I'd be tempted to say no to that combo.

 

[birchswing]

It's amazing how opposed some people seem to be to getting better. That's where that whole you can't work harder than your patient thing comes in. Getting better is scary -- he might actually have to face some of that 20s stuff like getting a job.

And yes, you should be concerned about substance usage, especially with the using clonazepam to treat the side effects of the quetiapine. I'd be tempted to say no to that combo.

"
How can someone who claims to want to get better, be so utterly against getting better?
"

was a sequitur to nothing that was explicitly stated.

You'd have to make a lot of assumptions about the patient to assume he doesn't want to get better. From what the OP wrote, the patient described what he knows and experiences. I didn't read anything in there there that indicated he doesn't want to get better. It's just information. Jumping to moral failure so quickly on the psychiatrist's part doesn't bode well for the patient's treatment.

I would think many psychiatrists would say wanting to stay on a medication that causes unpleasant side effects is about as dedicated as you can be to treatment.

As far as a doctor working harder than a patient--I think it's an egoic-biased assertion that any psychiatrist has ever worked harder than a patient at improving their health. It's an abstract concept to begin with, but in that abstract world, I don't think it's possible. You can't compare 15 minutes to an hour of being with someone every 1, 2, or 3 months to the experience of being a human being, no matter how good the doctor is or how apathetic the patient is. There's some weird mix-up of agency in that thought.

 

[shan564]

My first suspicion would be that he has some vague psychotic disorder, and he likes Seroquel because it helps him organize his thoughts (although I doubt it has much antipsychotic efficacy at that dose). In that hypothetical scenario, his paranoia would be caused by his psychotic illness, and he's misattributing it to Seroquel. How did he do on abstract reasoning? Is there no collateral? Is it possible to get records from his previous psychiatrist? Why did he switch psychiatrists?

If he doesn't like SSRIs, why not try him on an SNRI? Also, I wonder if there's some delusional thought content behind his beliefs about Prozac.

I'm not convinced that normal people abuse Seroquel. I think it's primarily abused in prisons where it's the best thing they can get. Even there, they have to crush it up and snort it. It's called a "Q-ball." I think it's mostly just because of the quick sedative effect, but I've also heard of people using it to alleviate some of the symptoms of cocaine crash (maybe just because they want to sleep through it?).

 

[clausewitz2]

Around here 'Quel' is also popular in combination with meth, and with anyone who is getting drug tested routinely (it is not gonna get picked up by a urine screen). So folks on parole, folks in shady pain/suboxone clinics, folks in residential, etc.

 

[birchswing]

Around here 'Quel' is also popular in combination with meth, and with anyone who is getting drug tested routinely (it is not gonna get picked up by a urine screen). So folks on parole, folks in shady pain/suboxone clinics, folks in residential, etc.

I don't know anything about meth or addiction to it, but if Seroquel is good enough for sustaining a person's sanity during meth withdrawal (for the purpose of a drug test) that the person addicted will seek out Seroquel illicitly, then why wouldn't it be good as a licit treatment for more permanent meth withdrawal? Lord knows it's beenprescribed for every other unapproved condition under the sun. If someone thinks it works enough to seek it out illegally, it must have some good efficacy for the withdrawal phenomenon.

 

[675015]

I've been taught that Seroquel has street value due to its ability to potentiate the high of several drug highs, particularly opiates.

That seems to be somewhat backed up by this old forum post of some of the more respected posters on SDN.

http://forums.studentdoctor.net/threads/rant-about-seroquel.306998/

 

[Doctor Bagel]

My first suspicion would be that he has some vague psychotic disorder, and he likes Seroquel because it helps him organize his thoughts (although I doubt it has much antipsychotic efficacy at that dose). In that hypothetical scenario, his paranoia would be caused by his psychotic illness, and he's misattributing it to Seroquel. How did he do on abstract reasoning? Is there no collateral? Is it possible to get records from his previous psychiatrist? Why did he switch psychiatrists?

If he doesn't like SSRIs, why not try him on an SNRI? Also, I wonder if there's some delusional thought content behind his beliefs about Prozac.

I'm not convinced that normal people abuse Seroquel. I think it's primarily abused in prisons where it's the best thing they can get. Even there, they have to crush it up and snort it. It's called a "Q-ball." I think it's mostly just because of the quick sedative effect, but I've also heard of people using it to alleviate some of the symptoms of cocaine crash (maybe just because they want to sleep through it?).

I don't get super uptight about the addiction potential of quetiapine either and suspect that, yes, it's probably more of a prison thing than something you see where people have access to better stuff. It's there, but we might chase it more than we see it. I agree, too, that there's something odd about this guy's thinking -- coupled with his low functioning, psychosis is in the differential.

With his prescribing, I'm troubled by the notion of prescribing something for an unclear indication that then has a side effect that requires you to prescribe something else (clonazepam no less), but with a patient like this who is insistent on not changing anything, I can see where you wind up with things like this wind up happening. It sounds like a very frustrating patient encounter.

 

[PikminOC]

Urine drug screen results?

 

[deleted314290]

It sounds like he is using this opportunity to push a new provider in a corner to rx him benzos.

 

[Matteomm]

I'm a patient. I was prescribed Seroquel for Tourette's/OCD off label. It doesn't do much, but it's been grandfathered in. Max dose has been 50 mg. I've been on it since around 2002 so my effects have varied over time.

The first time I took it was absolutely terrorizing. I am someone who hates being out of control. I was taking it for tics and had no idea it was going to knock me out. I could not voluntarily stay awake and every instinct in my body was to fight as hard as possible to stay awake because I didn't know it would knock me out and didn't know what was happening. So I started taking it at night. Still caused the same terrifying feeling of losing control so I timed it to take it as I was at the point of falling asleep anyway.

Now oddly the effects of Seroquel are extremely variable in me. Some nights when I take it, I feel no effect. Some nights it's extremely soporific in a dysphoric way. Sometimes it's soporific in a pleasant way. Sometimes I have a lot of hypnic jerks falling asleep after taking it. I've fallen asleep after taking for a second it mid-bite while eating and ended up choking and coughing out the food.

I would say, based on my own personal experience of taking a low dose, it has the effect of knocking a person out like anesthesia, but the induction period (to continue the analogy) can be extraordinarily unpleasant. I can see why it would make someone want a benzo. As far as paranoia, I can't speak to that experience as I haven't had it.

The other thing is that it makes my heart race incredibly fast right after taking it sometimes. Not every time. The effect is stronger the more tired it makes me. I have POTS, but my pulse lying down never gets as high as it does when the Seroquel kicks in hard (again, the effect is variable). I get tachycardia up to 130 bpm lying down after taking my Seroquel dose, and higher when standing. (Normally it would be 60 lying, 130 standing.)

Your experience with seroquel intrigues me. I have heard of hypnic jerks as a common occurence. Oftentimes patients of mine will complain of that. Especially from the low doses of seroquel.

Overall, I'm gathering that your experience with seroquel is quite unpleasant. Feeling out of control, severe anxiety presenting as a feeling of terror with rapid heartbeat. You've got me curious. May I ask why you continue to take it if it causes such an overwhelming and uncomfortable experience. I understand that you take it for Tourette's/OCD. Have other medications not worked for you in the past?

 

[birchswing]

Your experience with seroquel intrigues me. I have heard of hypnic jerks as a common occurence. Oftentimes patients of mine will complain of that. Especially from the low doses of seroquel.

Overall, I'm gathering that your experience with seroquel is quite unpleasant. Feeling out of control, severe anxiety presenting as a feeling of terror with rapid heartbeat. You've got me curious. May I ask why you continue to take it if it causes such an overwhelming and uncomfortable experience. I understand that you take it for Tourette's/OCD. Have other medications not worked for you in the past?

Why I've kept taking it. I probably don't have enough insight to know for sure. When I left college on medical leave I was tried on so many drugs so quickly and each time I had an anxious response because I was anxious *about* taking any medication. The doctor I was seeing at the time was going through diagnoses and medications quite quickly. I got to a point where I just wanted to stop changing anything. I'm not sure if it's my OCD or my anxiety or something more obscure about my personality but I am generally terrified of change. I have cut my dose of Seroquel to 37.5 mg and am now trying to cut the second pill to more of a third than a half. There was about a 10 year period where I made absolutely no medication changes in spite of my regimen not working for me. Just cutting the Seroquel to 37.5 mg was a huge deal. Just getting on bisoprolol to control my heart rate took a lot of hand-holding from my cardiologist (whom I have in desperation asked to take over all my meds because he's amazing). I've just never had a hand-holding psychiatrist. Can't find one. Change is hard and scary. Have to go at the moment, but I'll write more later if I have a moment of insight into my non-changing ways. I think part of it is also that my psychiatrists have never seen the Seroquel as a priority. Going down on it has been my own goal.

 

[Matteomm]

"
How can someone who claims to want to get better, be so utterly against getting better?
"

was a sequitur to nothing that was explicitly stated.

You'd have to make a lot of assumptions about the patient to assume he doesn't want to get better. From what the OP wrote, the patient described what he knows and experiences. I didn't read anything in there there that indicated he doesn't want to get better. It's just information. Jumping to moral failure so quickly on the psychiatrist's part doesn't bode well for the patient's treatment.

I would think many psychiatrists would say wanting to stay on a medication that causes unpleasant side effects is about as dedicated as you can be to treatment.

As far as a doctor working harder than a patient--I think it's an egoic-biased assertion that any psychiatrist has ever worked harder than a patient at improving their health. It's an abstract concept to begin with, but in that abstract world, I don't think it's possible. You can't compare 15 minutes to an hour of being with someone every 1, 2, or 3 months to the experience of being a human being, no matter how good the doctor is or how apathetic the patient is. There's some weird mix-up of agency in that thought.

You're absolutely right. There was no direct verbal communication made by the patient regarding "not wanting to get better". What frustrates me is when a patient comes to me complaining about difficulties functioning, yet refuses to take anything that possesses an SSRI mechanism. Or anything pro-serotonergic. You know what, fine I can deal with that. What I will not do though is give someone clonazepam 2mg (as requested by patient) with seroquel alongside an upper. Which is essentially what I would have otherwise given him for all intents and purposes. This was my first time assessing this patient. Without the patients prior medical records as of yet, I am uneasy to just handout such a regimen. I offered effexor, he refused on the basis that it possessed an SSRI mechanism, which according to him, means that it will induce a state of anhedonia.

 

[birchswing]

You're absolutely right. There was no direct verbal communication made by the patient regarding "not wanting to get better". What frustrates me is when a patient comes to me complaining about difficulties functioning, yet refuses to take anything that possesses an SSRI mechanism. Or anything pro-serotonergic. You know what, fine I can deal with that. What I will not do though is give someone clonazepam 2mg (as requested by patient) with seroquel alongside an upper. Which is essentially what I would have otherwise given him for all intents and purposes. This was my first time assessing this patient. Without the patients prior medical records as of yet, I am uneasy to just handout such a regimen. I offered effexor, he refused on the basis that it possessed an SSRI mechanism, which according to him, means that it will induce a state of anhedonia.

I can understand why anyone would be hesitant to prescribe a benzodiazepine, and I also think that if a person isn't already benzodiazepine-dependent, using them as a long-term treatment is almost invariably the wrong answer to any problem I can think of. If I were in the business of giving out doctors' names on the Internet, I could give you the names of several practicing doctors who still see long-term benzodiazepine therapy as a low-risk, positive, and necessary solution to anxiety disorders. If there are doctors who believe these medications are innocuous, it stands to reason there are patients who do as well. I then believe it follows that it's hard to jump to the conclusion that the patient doesn't want to get better. I'm not disagreeing with your conclusion of not wanting to prescribe the benzos--just that I didn't follow the part about the patient not wanting to get better. It seems to assume the patient knows something about benzodiazepines that he might not.

 

[Matteomm]

My first suspicion would be that he has some vague psychotic disorder, and he likes Seroquel because it helps him organize his thoughts (although I doubt it has much antipsychotic efficacy at that dose). In that hypothetical scenario, his paranoia would be caused by his psychotic illness, and he's misattributing it to Seroquel. How did he do on abstract reasoning? Is there no collateral? Is it possible to get records from his previous psychiatrist? Why did he switch psychiatrists?

If he doesn't like SSRIs, why not try him on an SNRI? Also, I wonder if there's some delusional thought content behind his beliefs about Prozac.

I'm not convinced that normal people abuse Seroquel. I think it's primarily abused in prisons where it's the best thing they can get. Even there, they have to crush it up and snort it. It's called a "Q-ball." I think it's mostly just because of the quick sedative effect, but I've also heard of people using it to alleviate some of the symptoms of cocaine crash (maybe just because they want to sleep through it?).

Overall, I didn't see any abnormalities in his cognition that stuck out to me. I got the impression that he was actually a fairly intelligent person. Verbal communication skills weren't very developed. No autistic spectrum disorder though. I believe the excessive tiredness and sedation from the seroquel is hindering his capabilities. I'm currently trying to get medical records from his previous psychiatrist. Despite the psychotic like symptoms he was describing, I have no other reason to suspect a related disorder.

Unlikely any delusional thought content regarding his beliefs about prozac. His complaints are legitimate. SSRI's like prozac can sort of worsen states of apathy and limit the variety or flavors if you will of what can be experienced from all experiences that life has to offer. I suspect this is in part what was meant by "anhedonia". Likely also the basis as to why he was unwilling to take any SSRI. I find it intriguing that he would say that seroquel possesses "anti-anhedonic properties"(his words literally). I guess it could make a bit of sense considering how it works in lower doses.

 

[Ceke2002]

I can only speak from my own experience, but I've been on Seroquel to treat psychotic symptoms, and also had it prescribed off label to treat anxiety and sleep disturbances (and psychotic symptoms, but I wasn't open about that at the time - long story). Anyway my first experience with it was when it was prescribed to me by a GP (Family Doctor), who didn't really know what he was doing and kept upping the dosage every time I reported the rather heavy sedation effects were beginning to wear off, and eventually had me on around 1200 mg per day. At around 600 mg I did have a complete cessation of all psychotic symptoms, along with just feeling a lot more grounded and motivated in general (it was kind of like it unscrambled the scramble that was my brain at the time, if that makes sense). Unfortunately it came with a price in that along with the good stuff like no hallucinations and being more motivated it also made me completely lose all ability to engage in, or with, any type of imaginative or creative process - so for example being able to appreciate and feel a connection to things like art, and literature, and music was just totally gone for me. And then I ended up developing extra pyramidal symptoms (on top of the rather extreme non stop binge eating and rapid weight gain that was already present) and my GP pulled me off it. Even if he hadn't, or hadn't needed to, I probably still would have chosen to stop the medication myself because whilst it did work, and worked really well at that, losing the experience of imagination and creativity to the level that I did was too high a price to pay - at least it was for me.

I've since been back on Seroquel (a few years ago now), which was prescribed by a Psychiatrist and I made the choice this time (after consulting with him) to limit the amount I took to what might be considered a sub therapeutic dosage of around 200 mg. At that level it didn't stop the psychotic type symptoms, but it at least kind of turned the volume down on them a bit and gave me some breathing space to then engage in other non medication methods of symptom management (which is what I prefer). I did still notice some slight dampening of creativity et all even at the lower dosage, but it was manageable. What wasn't manageable was the eventual anxiety and panic attacks that developed (after being on Seroquel for several months or so), which were mainly attributable to the fact that I was ever so slightly freaked out when my heart started attempting to do the Lambada in my chest every time a dose kicked in. I was being prescribed Valium at the same time as well, but it didn't really do much in terms of either lowering my heart rate, making it feel like my heart wasn't about to leap from my chest and boogie on down the road at a moment's notice, or made me feel in any way safe and/or relaxed unless I did something really ill advised like take some stupidly high amount of Valium above my prescribed dosage of 10 mg. On top of that my calves, ankles and feet began to swell to the point where I was physically unable to place my feet flat on the ground to walk most days, and that was when my Psychiatrist and I decided to scratch Seroquel off my medication list for good and I was changed over to Olanzapine instead which I personally found to be way better.

Just sharing my experience to give some first hand perspective from an individual point of view on how someone may react to different doses of Seroquel in different ways so you can maybe see if that gels with what your patient is reporting as well.

 

[nicnic]

How about Bupropion? Not exactly an SSRI, and also good at targeting that lack of motivation? I can certainly understand the hesitancy towards prescribing Seroquel when you aren't quite sure why/ if it's helpful but if he's really that fixated on staying on it maybe for the sake of therapeutic alliance don't challenge that quite yet?
With all this lack of motivation and paranoia I wonder if you got to asking him about cannabis use?

 

[Matteomm]

I can understand why anyone would be hesitant to prescribe a benzodiazepine, and I also think that if a person isn't already benzodiazepine-dependent, using them as a long-term treatment is almost invariably the wrong answer to any problem I can think of. If I were in the business of giving out doctors' names on the Internet, I could give you the names of several practicing doctors who still see long-term benzodiazepine therapy as a low-risk, positive, and necessary solution to anxiety disorders. If there are doctors who believe these medications are innocuous, it stands to reason there are patients who do as well. I then believe it follows that it's hard to jump to the conclusion that the patient doesn't want to get better. I'm not disagreeing with your conclusion of not wanting to prescribe the benzos--just that I didn't follow the part about the patient not wanting to get better. It seems to assume the patient knows something about benzodiazepines that he might not.

I'll give patients benzodiazepines but usually only alongside an ssri to combat the initial anxiety.

How about Bupropion? Not exactly an SSRI, and also good at targeting that lack of motivation? I can certainly understand the hesitancy towards prescribing Seroquel when you aren't quite sure why/ if it's helpful but if he's really that fixated on staying on it maybe for the sake of therapeutic alliance don't challenge that quite yet?
With all this lack of motivation and paranoia I wonder if you got to asking him about cannabis use?

Bupropion did come to mind. I am suspecting substance abuse of some sort. I did ask him if he ever uses recreational drugs. He replied with a no. I'm more than ok with seroquel.

 

[OldPsychDoc]

I did ask him if he ever uses recreational drugs. He replied with a no.

"It's not recreation. It's my career."

 

[Shikima]

Your experience with seroquel intrigues me. I have heard of hypnic jerks as a common occurence. Oftentimes patients of mine will complain of that. Especially from the low doses of seroquel.

Overall, I'm gathering that your experience with seroquel is quite unpleasant. Feeling out of control, severe anxiety presenting as a feeling of terror with rapid heartbeat. You've got me curious. May I ask why you continue to take it if it causes such an overwhelming and uncomfortable experience. I understand that you take it for Tourette's/OCD. Have other medications not worked for you in the past?

Hypnic jerks are a common occurrence as the brain is transition quite rapidly from wake to sleep. As Seroquel has pretty strong histamine blocking capabilities, and lower the dosage the stronger this effect is. And some people, depending on their neurochemistry, will respond more strongly to this effect than other people.

 

[thoffen]

Substance abuse is one thing, but diversion of substances with street value is another consideration, especially when you can't figure out how someone might be using these substances to get high.

Personally, it seems that the patient does not have a healthy set of boundaries for the Dr-Patient relationship. It's perfectly reasonable to assert your boundaries in providing care to him. If he doesn't like your boundaries, he can find another psychiatrist.

 

[mojetter]

With patients like this Ill usually tell them I understand if they dont want to come off of the seroquel but if it is not indicated or if it is contraindicated I wont be able to be the one who is prescribing it. Rarely do I get into these conversations but coincidentally its 99.99999999% related to a medication with abuse potential.

In the past I inherited a caseload where patients from the local methadone clinic were almost all on odd rx for their reported sx....Seroquel +/- clonidine +/- promethazine (all said seroquel made them nauseated) and researched to find all of these potentate the high of methadone.

...not saying your patient is getting high but I'd include this in the differential.