Poll Time- If it comes to taking an antipsychotic, which one would you prefer?

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If it comes to taking an antipsychotic, which one would you prefer?

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Toby, they did this social support and supported living stuff in the 70's as part of new-age and fringe research. The results were disastrous. Not scientific, but still....see if you can track down the videos. They're still available.

A large proportion of the patients brought to the hospital are done so by family members. Oftentimes they live with the family since they (if they are SPMI) are too sick to live on their own.

Social support is incredibly expensive (can be more than medication I would think), and the simple fact is, many don't want it as a result of the inherent part of their illness.

Patients that are on our unit and refusing meds basically don't get better. Then we take them to court, they take the meds and they get better. Seen it a thousand times. The meds aren't perfect, but they do well in many instances if you know how to use them and are good at it.
 
Anasazi23 said:
Patients that are on our unit and refusing meds basically don't get better. Then we take them to court, they take the meds and they get better. Seen it a thousand times. The meds aren't perfect, but they do well in many instances if you know how to use them and are good at it.
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Amen to that! Seeing someone get better on meds is a beautiful thing to behold! 😀
 
Toby, what I'm saying is that comparing two groups of inpatients, one with placebo and one with meds...the med group did better by alot (60% to 20%). The social support portion that I am inferring occured (because I don't even know what constitutes appropriate social support to you) was occurring equally among both groups (ie, inpatient "respite"). This therefore controls for that variable and it says that it might help in 20% of the cases (placebo group) but it also may have been placebo effect contributing as well. I'm not sure what made those twenty percent better and I don't feel like looking up the study. I fully understand if you don't want to take my word for it and I admit that there is a possibility that I misread the study as it was old and I didn't scrutinize it...but this is what I recall they did. Just look at the latest edition of the APA guidelines for the treatment of schizophrenia and its referenced in there somewhere.

I do agree with the sentiment noted by my colleagues that people who don't take meds on the inpatient unit, don't usually show evidence of thinking more clearly when examined over time. However, after some time on medication, they often show a profound improvement in clarity of thinking, are able to care for themselves and don't talk to themselves out loud or act out nearly as much. The initial effects are only really sedation, so they don't talk as much about their psychosis, but eventually downstream changes occur such that their psychosis improves. This may be a form of social control, but I also seem to notice that they feel much better and are happier. I feel good when I do that for someone, even if originally it took some "paternalism" to get them to take their medications. I do worry about the long term consequences of meds for sure, but that is part of the job description...to make tough informed decisions based on the latest scientific information at hand. That is doctoring. It happens for cardiologists and oncologists and every other specialty. Most nonpsychotic patients in regular medical treatment often just accept whatever med the doctor prescribes and are ignorant to the long term consequences. Some of the meds they use have side effects and are toxic...but they are in the business of prolonging life and reducing morbidity. Medicine evolves.
 
Hey. I really want to make sure that people understand that I'm not severely sceptical of psychiatry in general (I'm trying to defend psychiatry as a branch of medicine against the anti-psychiatry critique - which of course is why I'm reading their stuff and really trying to come to grips with what they are saying.

I also get that people really are trying to make the best treatment decisions they can. If you look back in history (I've been reading some of that too) there have been an aweful lot of charlatins and quacks around - and in many respects they still are. I appreciate scientific methodology and evidence based medicine are significant improvements on that past state of things. That being said, the current status of scientific reasoning / evidence based medicine could do with being improved because while it is better than what went before it surely isn't perfect.

One thing I'd like to see is more quality studies being done on both social and cognitive interventions. The majority of the funding presently comes from pharma and the majority of the funding is thus focused on areas where there are prospective big gains for pharma - namedly in genetic and neurophysiological causal mechanisms and interventions. There really haven't been many quality studies done on psychological and social mechanisms / interventions. Partly because pharma won't fund that (like they won't fund investigation into side-effects of their medications) and partly because of ethical and practical issues around social and psychological interventions. And (of course) partly because one needs to operationalize problematic notions like 'socially supportive envioronment' before we can study the effects of one.

Are we actually allowed to randomly assign individuals to 'anti-psychotics' and general chats vs 'placebo' and psychotherapy in order to test the efficacy of (a particular kind) of psychotherapy? Or has it become so thoroughly ingrained that... It would be unethical to not prescribe anti-psychotic medication for people with schizophrenia?

I'm not sure the studies have been done...

:-(

Personally... I'd rather go with psychotherapy and placebo meds if it happened to me... Because I don't like the look of those long term side effects (that haven't been adequately studied) either. But then... Thats just me, I guess...

Lack of evidence for the efficacy of something doesn't show us that that something isn't effective. It just shows us that the study hasn't been done. If you consider the sociological reasons why (to do with pharma funding) I'd actually be fairly optimistic that we could make some significant scientific gains with studying the cognitive and / or sociological mechanisms for a change. I mean... If 9 out of 10 studies show that drug x is no more effective than wheet-bix pharma runs to the FDA with that one... If 1 study shows that Jungian Analysis is no more effective than wheet-bix people write off cognitive mechanisms / interventions as 'unscientific'. Now... That don't seem fair...
 
toby jones said:
One thing I'd like to see is more quality studies being done on both social and cognitive interventions. The majority of the funding presently comes from pharma and the majority of the funding is thus focused on areas where there are prospective big gains for pharma - namedly in genetic and neurophysiological causal mechanisms and interventions. There really haven't been many quality studies done on psychological and social mechanisms / interventions. Partly because pharma won't fund that (like they won't fund investigation into side-effects of their medications) and partly because of ethical and practical issues around social and psychological interventions. And (of course) partly because one needs to operationalize problematic notions like 'socially supportive envioronment' before we can study the effects of one.
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Sure, I'd support social and cognitive interventions research. Why not? Seriously doubt, however, that it would ever replace medications in patients, as you imply.

When you say "pharma", are you talking about pharmaceutical companies? Why in the world would they fund social support studies?
 
toby jones said:
Hey. I really want to make sure that people understand that I'm not severely sceptical of psychiatry in general (I'm trying to defend psychiatry as a branch of medicine against the anti-psychiatry critique - which of course is why I'm reading their stuff and really trying to come to grips with what they are saying.

I also get that people really are trying to make the best treatment decisions they can. If you look back in history (I've been reading some of that too) there have been an aweful lot of charlatins and quacks around - and in many respects they still are. I appreciate scientific methodology and evidence based medicine are significant improvements on that past state of things. That being said, the current status of scientific reasoning / evidence based medicine could do with being improved because while it is better than what went before it surely isn't perfect.

One thing I'd like to see is more quality studies being done on both social and cognitive interventions. The majority of the funding presently comes from pharma and the majority of the funding is thus focused on areas where there are prospective big gains for pharma - namedly in genetic and neurophysiological causal mechanisms and interventions. There really haven't been many quality studies done on psychological and social mechanisms / interventions. Partly because pharma won't fund that (like they won't fund investigation into side-effects of their medications) and partly because of ethical and practical issues around social and psychological interventions. And (of course) partly because one needs to operationalize problematic notions like 'socially supportive envioronment' before we can study the effects of one.

Are we actually allowed to randomly assign individuals to 'anti-psychotics' and general chats vs 'placebo' and psychotherapy in order to test the efficacy of (a particular kind) of psychotherapy? Or has it become so thoroughly ingrained that... It would be unethical to not prescribe anti-psychotic medication for people with schizophrenia?

I'm not sure the studies have been done...

:-(

Personally... I'd rather go with psychotherapy and placebo meds if it happened to me... Because I don't like the look of those long term side effects (that haven't been adequately studied) either. But then... Thats just me, I guess...

Lack of evidence for the efficacy of something doesn't show us that that something isn't effective. It just shows us that the study hasn't been done. If you consider the sociological reasons why (to do with pharma funding) I'd actually be fairly optimistic that we could make some significant scientific gains with studying the cognitive and / or sociological mechanisms for a change. I mean... If 9 out of 10 studies show that drug x is no more effective than wheet-bix pharma runs to the FDA with that one... If 1 study shows that Jungian Analysis is no more effective than wheet-bix people write off cognitive mechanisms / interventions as 'unscientific'. Now... That don't seem fair...
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One thing that you need to realize though is that it takes an enormous amount of time and resources to do psychotherapy/social interventions for people with major mental illness compared to giving someone a pill. The entire paradigm of western medicine is "to give pills". Its driven by pharma big business for sure, but it is also societially wanted. There is a good argument to it in some senses too, in that the time that it takes to get better through these other means makes people suffer more and there is no guarantee they will work. The goal is to alleviate suffering promptly...which probably has long term protective effects as well compared to people who have chronic courses of mental illness.

For most people who get type 2 diabetes, exercise and diet managment will cure their diabetes in the early stages, but it just is so hard to do that for most people because they don't readily change their behavior. And by the way, most of those people aren't even psychotic or depressed. Its even harder in those other cases.

The goal is a noble one, to try and help people through a supportive "village". But it strikes me as somewhat less than pragmatic and probably not optimally effective anyway.

But there is definitely truth to the fact that pharma selectively skews things to push patented drugs and one must be skeptical of their data, but we are working on trying to remedy that influence as a field too.
 
worriedwell said:
The goal is a noble one, to try and help people through a supportive "village". But it strikes me as somewhat less than pragmatic and probably not optimally effective anyway.

But there is definitely truth to the fact that pharma selectively skews things to push patented drugs and one must be skeptical of their data, but we are working on trying to remedy that influence as a field too.
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What you say is true. This reminds me of the studies showing how medication intervention is as effective as CBT for simple phobia and panic disorder. The catch is that the time to effective improvement with the latter is much longer, and overall, more expensive than the medication trial. Does this mean that pills are inherently better? Not necessarily, but you'd be surprised how many patients actually do prefer pills. Many seem to make the assumption that every and all patients want extended therapy and social intervention. The fact is that many do not. I have many patients that want to spend as little time in my office as possible. There are a number of possible reasons for this, not the least of which is that it's an inherent part of the schizophrenic illness in many cases.

Medications have taken us a long way. Max Fink not withstanding, catatonia is exceedingly rare, and there are actually concerns that psychiatry PDs are having difficulty in finding "good" TD or parkinsonized cases to show their residents.
 
Anasazi23 said:
I have many patients that want to spend as little time in my office as possible. There are a number of possible reasons for this, not the least of which is that it's an inherent part of the schizophrenic illness in many cases.
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This is so true of many pts with schizophrenia. They sit on that chair about to run after getting their prescription or go to the med room for the injection. Any attempt to warm up to them or to get to know them better is, more often than not, going to be met with vague or no answers. Of course, there will be some who might be more forthcoming.
 
TheWowEffect said:
This is so true of many pts with schizophrenia. They sit on that chair about to run after getting their prescription or go to the med room for the injection. Any attempt to warm up to them or to get to know them better is, more often than not, going to be met with vague or no answers. Of course, there will be some who might be more forthcoming.
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I do not doubt this at all, and certainly am willing to learn from residents/attendings who have a lot more experience in this.

But I have read and heard of numerous cases of individuals with schizophrenia who talk about the incredibly meaningful and immeasurable value of having someone "be with" them even if their illness made interpersonal communication difficult/impossible.

Patients with schizophrenia have expressed this in different ways, but a common theme seems to be that not only do they, because of their illness, distance themselves from others, but also the illness causes others to distance themselves from the patient. But we must remember that no matter how psychotic a patient, there's still a person there. Ego boundaries might be poorly defined, but there is an ego. And patients have described that having the same therapist "be there" during and after acute episodes has helped them, through a constancy in the relationship, maintain some sort of constancy of self.

A psychotic episode must be a tough thing to endure ... but what about afterwards? How do patients deal with their sense of self as mentally ill? Do they integrate their psychotic episode into their sense of self? Do they "seal it off"?

There's no way I can think of to develop good studies to test all this ... and I *definitely* agree that medication is extremely important in treating schizophrenia ... the only point I want to make is that even though the illness these patients suffer affects their interpersonal relationships severely, I really think it would be helpful to force ourselves, even with zero immediate discernible benefit, to spend time with them and get to know them.
 
manwhoisthursdy said:
I do not doubt this at all, and certainly am willing to learn from residents/attendings who have a lot more experience in this.

But I have read and heard of numerous cases of individuals with schizophrenia who talk about the incredibly meaningful and immeasurable value of having someone "be with" them even if their illness made interpersonal communication difficult/impossible.

Patients with schizophrenia have expressed this in different ways, but a common theme seems to be that not only do they, because of their illness, distance themselves from others, but also the illness causes others to distance themselves from the patient. But we must remember that no matter how psychotic a patient, there's still a person there. Ego boundaries might be poorly defined, but there is an ego. And patients have described that having the same therapist "be there" during and after acute episodes has helped them, through a constancy in the relationship, maintain some sort of constancy of self.

A psychotic episode must be a tough thing to endure ... but what about afterwards? How do patients deal with their sense of self as mentally ill? Do they integrate their psychotic episode into their sense of self? Do they "seal it off"?

There's no way I can think of to develop good studies to test all this ... and I *definitely* agree that medication is extremely important in treating schizophrenia ... the only point I want to make is that even though the illness these patients suffer affects their interpersonal relationships severely, I really think it would be helpful to force ourselves, even with zero immediate discernible benefit, to spend time with them and get to know them.
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I think you are absolutely right.👍 My post simply reflects a superficial observation in a light manner and we should all make our best efforts to establish good rapport with the patients. This is even more true with schizophrenia pts to ensure compliance.
 
Chimed said:
Could it be that you scare them? :meanie:

"The innocent shall suffer...big time." :laugh:
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I knew when I was writing this that someone would catch it. Heh

To answer another poster, I'll say that yes, ideally it's good to have a therapist of some sort help a patient through a psychotic decompensation from start to finish. Oftentimes due to time constraints alone, this cannot be the physician.

I see many schizophrenics in the outpatient clinic and during my moonlighting gigs. Many are very social...too much so in some ways. Others are the opposite, and it cannot, nor should it be, forced upon them. I'll always refer back to classic Kraepelin and Bleuler literature to have those grasp a good understanding of what inherent process we're dealing with.
 
> Seriously doubt, however, that it would ever replace medications in patients, as you imply.

I would think that we should intervene to help people with the most effective treatment. It is still up for grabs whether the most effective treatments are going to turn out to be genetic, neurological, psychological, or social or some combination of the above. Will have to see how things turn out.

> One thing that you need to realize though is that it takes an enormous amount of time and resources to do psychotherapy/social interventions

If we are able to run more experiments to isolate the effective aspects of psychotherapy and eliminate the time-wasting ones then therapy might become more cost effective in time. I'm not sure on the price differential. It would seem to me that medication for the rest of your life would be more expensive than a couple years psychotherapy (if it turned out that they were equally efficacious and both together didn't give significant benefit).

> The entire paradigm of western medicine is "to give pills".

Yeah. Some people think that that is the defining feature of psychiatry. But... If you look in the history of psychiatry then you will see that psychiatry doesn't have to define itself in that way. There were 'alienists' before we started calling them psychiatrists and their job was to run an asylum in a way that was theraputic for the people who were confined (it was thought that that took a doctor with special qualities). There were 'psychoanalysts' (who used to have to be medically trained). And then there were medications, of course.

I guess I just thought... That it was about helping these people in the best way we could. That EBM wasn't just about deciding on medications, it was about deciding on the most effective treatment and delivering that. Whatever that turned out to be...

> The goal is to alleviate suffering promptly...which probably has long term protective effects as well compared to people who have chronic courses of mental illness.

If you have the 'kindling' view of mental disorders, yeah. The notion there is that people deteriorate if you don't intervene (with medications) early. It is unclear whether the 'kindling' model is correct, however. I don't deny that medications are able to provide powerful effects very quickly. Can calm a patient down and get them a good nights sleep etc. That that can substantially benefit. I don't deny that. I think there will always be some role for medications, yeah. But I do worry about how much of a role they have at present, yeah.

> For most people who get type 2 diabetes, exercise and diet managment will cure their diabetes in the early stages, but it just is so hard to do that for most people because they don't readily change their behavior.

I wonder how much it would cost to arrange groups for people. Walking groups, stuff like that. A kind of an outpatient follow-up thing to do. Helping people into forms of exercise they enjoy...

> But there is definitely truth to the fact that pharma selectively skews things to push patented drugs and one must be skeptical of their data, but we are working on trying to remedy that influence as a field too.

Yeah. There is much work being done 🙂

> Medication intervention is as effective as CBT for simple phobia and panic disorder. The catch is that the time to effective improvement with the latter is much longer, and overall, more expensive than the medication trial.

Did you get the crucial bit there *more expensive than the medication trial*. How long was the trial? seven weeks? Less? Are you talking benzodiazapines for simple phobia and panic? If so I'd expect the trial to be less than seven weeks. You don't want to build in the cost of addiction... And of course therapy isn't going to be optimally effective in seven weeks.

How long to people need to stay on the medication for to manage their simple phobia and panic? Do their symptoms spontaneously recurr when the medication is ceased? If so... Then you have a course of psychotherapy on the one hand (say two years to be generous) vs medication for... The rest of their life???

> you'd be surprised how many patients actually do prefer pills.

I think the thought is that if they take pills and they help then that is evidence to believe that they have a bona fide somatic disorder. It isn't 'all in their head' because physical treatment works for their physical disorder. And not giving them psych meds would be like... Withholding HIV medication or Cancer treatment (you know the pharma line). Take a pill and it is all better now vs working hard at exposure and the like in psychotherapy. No effort vs effort. Is it any surprise that people go for the quick fix???

> Many seem to make the assumption that every and all patients want extended therapy and social intervention.

Yes they do. I'm not making that assumption though. I know that most patients want the prescription for the medication they just saw on TV. What I'm saying... Is that it is about what is best for them and not merely what they want...

> There are actually concerns that psychiatry PDs are having difficulty in finding "good" TD or parkinsonized cases to show their residents.

?
I thought the people who got that off the old generations were still alive and kicking around? And I thought... That there was a movement disorders category introduced into DSM IV-TR for the purpose of SSRI induced parkinsonian symptoms...

> And patients have described that having the same therapist "be there" during and after acute episodes has helped them, through a constancy in the relationship, maintain some sort of constancy of self.

Yeah.

There are accounts by clinicians who were known for developing great rapport with their schizophrenic patients, too. I can't remember their names... Bentall's "Madness Explained" talks about building rapport with them. Lots of little things... Empathy... Some kind of ability to empathise with delusional awareness. Hard to operationalize, I guess. The closest I've seen is probably something along the line of Marsha Linehan's account of validation for people with Borderline Personality Disorder...
 
Interesting article. Without giving away names and what not, I actually worked with someone in medical school who has done research on cognitive therapy with schizophrenics (I was involved in a different project). This person, however, would never state that cognitive therapy could ever replace medications.

Cognitive Behavior Therapy for Schizophrenia
Douglas Turkington, M.D., David Kingdon, M.D., and Peter J. Weiden, M.D.
Am J Psychiatry 163:365-373, March 2006

For a link to the full article go to this website and then the full version is on the right side: http://ajp.psychiatryonline.org/cgi/content/abstract/163/3/365

OBJECTIVE: A growing body of evidence supports the use of cognitive behavior therapy for the treatment of schizophrenia. A course of cognitive behavior therapy, added to the antipsychotic regimen, is now considered to be an appropriate standard of care in the United Kingdom. The objective of this article is to offer a broad perspective on the subject of cognitive behavior therapy for schizophrenia for the American reader. METHOD: The authors summarize current practice and data supporting the use of cognitive behavior therapy for schizophrenia. RESULTS: Five aspects of cognitive behavior therapy for schizophrenia are addressed: 1) evidence from randomized clinical trials, 2) currently accepted core techniques, 3) similarities to and differences from other psychosocial interventions for schizophrenia, 4) differences between the United States and United Kingdom in implementation, and 5) current directions of research. CONCLUSIONS: The strength of the evidence supporting cognitive behavior therapy for schizophrenia suggests that this technique should have more attention and support in the United States.
 
I'm not saying that therapy will turn out to be more effective than medication, I'm just saying that it is a possibility that we should be open to. In the spirit of science and the world telling us rather than us just thinking we know BEFORE adequate experiments have been done.

I think that there is a lot of caution in how psychologists (or psychotherapists more generally) 'market' their therapies. In particular, they are best to keep pharma at a 'neutral stance' rather than at a 'defensive stance' and the best way for them to do that is to play all nice happy happy bio-psycho-social why can't we all just get along and everybody make a little money along the way ;-)

(I'm being facecious - kinda)

There really aren't many studies being done on cognitive behaviour therapy (or any other variety for that matter) for psychosis. Cognitive behaviour therapy studies have started to boom fairly recently, though. One thing I'm noticing is that the studies tend to compare cognitive behaviour therapy plus meds compared to just meds. My concern here is that they might not be adequately controlling for 'some nice person just talking to me without giving me cognitive behaviour therapy'. My other concern here is that they might not be testing cognitive behaviour therapy with medication to cognitive behaviour therapy with placebo. Wouldn't it be grand if they did all that 🙂

But of course better medications will be developed...
And better therapies too...

(Biggest problem with cognitive therapy for delusions is the high drop out rates. Sometimes the drop outs are excluded from the study - similarly to how people who stop taking the medication due to side effects are excluded from the study. Very telling data in both cases, however. I'm wondering... If some of Linehan's validation of experience - as experience techniques might be able to help with drop outs like how it helps with drop outs who have borderline personality disorder. But then... I never was particularly fond of the 'thought disorder' vs 'mood disorder' distinction)
 
toby jones said:
>

Did you get the crucial bit there *more expensive than the medication trial*. How long was the trial? seven weeks? Less? Are you talking benzodiazapines for simple phobia and panic? If so I'd expect the trial to be less than seven weeks. You don't want to build in the cost of addiction... And of course therapy isn't going to be optimally effective in seven weeks.
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SSRIs aren't addictive.
It's incorrect to say that stopping a medication will result in spontaneous return of phobic response. I'm not saying that CBT isn't helpful for simple phobia. I would argue it's the standard of care. But even though K&S state it's the #1 most common psychiatric disorder (which I don't believe) find me a patient with one simple phobia, and no concomitant symptoms, and I'll give you a nickle.



I think the thought is that if they take pills and they help then that is evidence to believe that they have a bona fide somatic disorder. It isn't 'all in their head' because physical treatment works for their physical disorder. And not giving them psych meds would be like... Withholding HIV medication or Cancer treatment (you know the pharma line). Take a pill and it is all better now vs working hard at exposure and the like in psychotherapy. No effort vs effort. Is it any surprise that people go for the quick fix???
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You say this, then tell us to get walking groups together for diabetics. Again, not disagreeing, just saying that there is unfortunately a difference between what patients are able/willing to do, and what we can get to them from a practical standpoint.


Yes they do. I'm not making that assumption though. I know that most patients want the prescription for the medication they just saw on TV. What I'm saying... Is that it is about what is best for them and not merely what they want...
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Except in rare cases, I give patients what they need, not what they want. In most cases (you'll criticise me for being paternalistic here) I convince them that the two are one in the same. If they don't like what I'm willing to give, I refer them out.

?
I thought the people who got that off the old generations were still alive and kicking around? And I thought... That there was a movement disorders category introduced into DSM IV-TR for the purpose of SSRI induced parkinsonian symptoms...
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This is simple math. Many of the people who "grew up" on typicals (and have TD) are dead or tucked away in nursing homes. New cases of TD are getting harder to find. That means that residents will be less exposed to it. In that way, the medications have improved.

SSRI movement disorders is a different topic.
 
Seroquel- no questions, give it only HS no morning dose go up @100 mg/day. Not tried the ER yet. Have a nice peaceful sleep.
Next w/b Risperdal.
 
How come clozapine is in italics in the poll but none of the other drugs are? I wonder if I went too far out on a limb by choosing that one. I know it's not first line for patients, but for myself I figure I'll take the risks.

However, I assume doctors cannot actually prescribe themselves medications? So my dream of taking clozapine will have to wait until I've failed other antipsychotics?
 
Omacor 3g and either Abilify or Trilafon.

The research being done at the NIH seems to focus on genetics. We know that people with schizophrenia tend to have a post-morbid IQ at least one SD lower than their pre-morbid IQ, so if we can work on cognitive enhancers that are safe (there's Depakote, but it doesn't show promise at hitting a >1 SD+ range) along with a safe antipsychotic that's been around awhile (hence why I mention Trilafon), I'd go with that for all pts, including myself.
 
whopper said:
Can anyone talk about a case where psychotherapy and no meds effectively treated schizophrenia?

No?

I thought so.
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Well, if you consider psychoanalysis psychotherapy, then Freud would say he's seen it.

;p
 
Any experience with paliperidone(invega) yet? I haven't yet started any pt on it and don't intend to too soon but have seen pts come from other clinics hospitals on it.
 
I use quite a bit of it in the outpatient setting. Seems to work fairly well, but I do get a significant amount of failures on it. I think this is due to my selection bias, however. I'm finding I'm using it with patients that have failed other agents, or claim some sort of "allergy" or intolerability to every other antipsychotic I name. In other words, they're tough patients.

Significant amount of severe constipation complaints, more so than with risperdal...at least in my experience.
 
Anasazi23 said:
I use quite a bit of it in the outpatient setting. Seems to work fairly well, but I do get a significant amount of failures on it. I think this is due to my selection bias, however. I'm finding I'm using it with patients that have failed other agents, or claim some sort of "allergy" or intolerability to every other antipsychotic I name. In other words, they're tough patients.
Significant amount of severe constipation complaints, more so than with risperdal...at least in my experience.
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Hmmm...interesting. So, how does it compare with regards to efficacy? Theoretically, it should be as good as Risperdal..
 
Right. Theoretically, it should be similar. But like I mentioned, I think it's hard for me to determine this to some degree, since I've used it quite a bit in refractory or multiple med-failure patients.

On the number of patients I've used it with that are more neuroleptically naive, I've certainly seen decent to good efficacy. I've gone as high as 12mg so far.
 
I'm choosing Perphenazine. You guys can keep your metabolic abnormalities.
 
Anasazi23 said:
Right. Theoretically, it should be similar. But like I mentioned, I think it's hard for me to determine this to some degree, since I've used it quite a bit in refractory or multiple med-failure patients.

On the number of patients I've used it with that are more neuroleptically naive, I've certainly seen decent to good efficacy. I've gone as high as 12mg so far.
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Here's an interesting, though very biased, review of Invega on the Carlat Report.
http://www.thecarlatreport.com/index.asp?page=wp3152007185348
 
Chrismander said:
Here's an interesting, though very biased, review of Invega on the Carlat Report.
http://www.thecarlatreport.com/index.asp?page=wp3152007185348
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Exactly what I've thought--though said much more elegantly.

Why do you say this is "biased" exactly? It is an editorial opinion, but based on clearly cited evidence (or lack thereof). Wouldn't "bias" imply a "mind made up in advance", regardless of the evidence to the contrary--say like the information supplied by the manufacturers?
 
Chrismander said:
Here's an interesting, though very biased, review of Invega on the Carlat Report.
http://www.thecarlatreport.com/index.asp?page=wp3152007185348
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I read Carlat regularly. If by 'biased,' you mean that he is very reluctant to embrace new drugs, then perhaps you're right. The title of the article "patent extender" may have some truth...or a lot of truth. But in my experience and based on science, I'll take an active metabolite in most cases over a pro-drug or something with a similar mechanism.

Carlat, btw, is continuously touting his lack of bias and influence by drug company monies. Not sure how really biased he is to be honest. Seems like most articles are relatively bias-free to me.
 
There is no doubt carlat reviews are quite honest and straightforward. He did a really nice disection of the CATIE trial as well. It would be a tragedy if we started switching people from Risperdal to Invega just because......

On the other hand, it certainly is another option available.
 
To me that is much to broad of a question.

For severe psychosis or mania requiring inpatient stayit is hard to argue against using risperdal unless they have had a previous bad experience. Has the highest D2 blockade and works really quickly in comparison to most

Other thing is you can step into Consta when the patient leaves-which is a huge deal with most of my inpatient people-compliance! The other non-conventionals cannot offer this.

Second choice is geodon forsure. Has great efficacy and solid D2 block for quick control of positive symptoms such as psychosis. Has the AD effect which is great since most patients have some type of mood component and is weight neutral for the most part and has good SE profile.

Now if it is a strict manic patient I prefer seroquel all at night. Helps them get some much needed sleep and also has great efficacy. Severe manics I will use both risperdal and seroquel in combo

Now if anyone fails a trial on 1 or 2 I prefer to go straight to clozaril. I think Cloz is the most under used drug we have in psychiatry.

Especially in the schizophrenic people who are relatively young and have minimal brain changes clozaril can prevent a lot of that damage down the line most people experiencel I think clozaril should be used much more aggressively than it is.

Bottom line

Psychosis in any situation on the inpatient unit-Risperdal with second choice geodon.
Mania-Seroquel, second line seroquel and risperdal
 
I would choose Seroquel- minimal EPS, well tolerated except for some sedation. It was a very popular drug in the prisons I used to do locum tenens work in; some prisoners abused it and it therefore was taken off the formulary. Abilify is also a good choice, but there is some akathisia risk.
 
michaelrack said:
I would choose Seroquel- minimal EPS, well tolerated except for some sedation. It was a very popular drug in the prisons I used to do locum tenens work in; some prisoners abused it and it therefore was taken off the formulary. Abilify is also a good choice, but there is some akathisia risk.
Click to expand...

Recently started a pt on Seroquel. Her appetite had a sudden burst and she started gaining a lot of weight- like over 20 odd lbs in a month. Had to switch to another agent. Having said that, it is a very useful drug for a wide variety of patients.
 
Reviving this old thread.....

Recently, saw advertisements for Fiapta in some journals. Turns out it's the good ol' Iloperidone; been in development for many years. Vanda is going to start marketing it soon. Sounds like a risperidone metabolite but apparently it's not, although is from the same class, benzisoxazoles. Let's see how it goes for this drug. It has an odd brand name though, imo.

Any thoughts.....
 
TheWowEffect said:
Reviving this old thread.....

Recently, saw advertisements for Fiapta in some journals. Turns out it's the good ol' Iloperidone; been in development for many years. Vanda is going to start marketing it soon. Sounds like a risperidone metabolite but apparently it's not, although is from the same class, benzisoxazoles. Let's see how it goes for this drug. It has an odd brand name though, imo.

Any thoughts.....
Click to expand...


Sounds like it should be on the name plate of a sub-compact hybrid vehicle.
Then again, Geodon sounds like a dinosaur, and Abilify seems like it should be in ads starring Bob Dole or Mike Ditka or some guy throwing a football through a tire swing... :laugh:
 
OldPsychDoc said:
Sounds like it should be on the name plate of a sub-compact hybrid vehicle.
Then again, Geodon sounds like a dinosaur, and Abilify seems like it should be in ads starring Bob Dole or Mike Ditka or some guy throwing a football through a tire swing... :laugh:
Click to expand...

I always thought that Geodon sounded like a pokemon (probably due to my nieces and nephews).
 
OldPsychDoc said:
Hey, the original question was "If it comes to taking an antipsychotic, which one would YOU prefer?" To me, the votes for Abilify indicate a desire to ingest only the most innocuous! Nothing was asked about effectiveness...:laugh:
Click to expand...

Right, exactly. I voted for Geodon because, well, I'm not psychotic and I'm having a really hard time picturing what it would be like, so I chose based on the side-effect profile.

If I really were seriously ill and the Geodon wasn't cutting it I'd probably go for risperidone next.
 
The number one consideration that I have if choosing and antipsychotic for myself........will it make me fat? I'm scared of becoming psychotic not because psychosis is scary, but because I don't want to take drugs that will make me fat.

How psychotic is that ? 🙄

I picked Abilify. Maybe some of you who actually have experience prescribing them which ones cause weight gain the worst.
 
sikegeek said:
The number one consideration that I have if choosing and antipsychotic for myself........will it make me fat? I'm scared of becoming psychotic not because psychosis is scary, but because I don't want to take drugs that will make me fat.

How psychotic is that ? 🙄

I picked Abilify. Maybe some of you who actually have experience prescribing them which ones cause weight gain the worst.
Click to expand...

No contest--olanzapine wins hands-down.
 
I keep seeing lawyer advertisements that say "if you've have taken a certain antipsychotic (i think it was seroquel) and developed diabetes, call us"

do they get diabetes because they get fat or is there or does it mess with your pancreas or something?
 
sikegeek said:
I keep seeing lawyer advertisements that say "if you've have taken a certain antipsychotic (i think it was seroquel) and developed diabetes, call us"

do they get diabetes because they get fat or is there or does it mess with your pancreas or something?
Click to expand...

http://www.ncbi.nlm.nih.gov/pubmed/14750042

My understanding is that hyperglycemia, hypertriglyceridemia, hypercholesterolemia and increased appetite induced by the antipsychotic(coupled with sedation leading to decreased physical activity) bring about metabolic syndrome-like state in those that are already at risk. Any other ideas?

I think as long as you discuss the risks with the patient, cover your bases by checking (and documenting!) the patient's base BMI, serum glucose levels and lipid profile, and monitor these throughout the treatment, you should be covered.
 
BabyPsychDoc said:
http://www.ncbi.nlm.nih.gov/pubmed/14750042

My understanding is that hyperglycemia, hypertriglyceridemia, hypercholesterolemia and increased appetite induced by the antipsychotic(coupled with sedation leading to decreased physical activity) bring about metabolic syndrome-like state in those that are already at risk. Any other ideas?

I think as long as you discuss the risks with the patient, cover your bases by checking (and documenting!) the patient's base BMI, serum glucose levels and lipid profile, and monitor these throughout the treatment, you should be covered.
Click to expand...



That all makes sense- thanks for the reference. Did you see how they mentioned that one of the risk factors was "negroid" ethnicity? :laugh: That was terrible. I didn't even know that was a word, let alone one that could be printed in a respected publication!!
 
Seroquel! Risperidal seems to cause much more weight gain, which I consider to be a big deal. to the extent that I'd rather have slightly (and I mean slightly) less efficacy with no weight gain, than something slightly more efficacious with pronounced weight gain. I also like the calming anti histaminic action found with seroquel.
 
seroquel clearly causes more weight gain (especially at therapeutic doses) than risperdal...its laughable to think otherwise.
 
worriedwell said:
seroquel clearly causes more weight gain (especially at therapeutic doses) than risperdal...its laughable to think otherwise.
Click to expand...

Source?

In many of the studies I've looked at the weight gain for the two drugs (risperidone and seroquel) seems fairly equivalent. Neither is weight neutral. Risperidone caused greater weight gain than seroquel in women in one study (average difference at 12 weeks: 11 vs 4.65 lbs and at 52 weeks: 19.1 vs 6.47lbs, p<0.01 for both comparisons.) McEvoy Am J Psychiatry. 2007 Jul;164(7):1050-60)) (I guess the women in that study don't think the statement that weight gain is worse on risperdal than seroquel is laughable. 🙄 ) Although there was another study I glanced at that seemed to indicate the percentage of those who gain more than 7% of body weight is somewhat higher for seroquel in the short term. Most systematic reviews on weight gain particularly in the longer term didn't include seroquel because of not enough data.

In any case, when it comes to any particular individual it's entirely possible that risperdal could cause more weight gain for that individual than seroquel regardless of whether there is a difference in the average mean weight gain between groups of people on the drugs. Admittedly it can be inconvenient when patients don't follow the averages reported in studies - but they seem do it all the time. 😛
 
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