Pushing antipsychotics beyond maximum doses

[sweetlenovo88]

I constantly see psychiatrists going above the maximum recommended dose of antipsychotics (not even mentioning max effective dose). Zyprexa 30-40mg, geodon 320mg, high doses of risperdal. It is a personal pet peeve of mine and I especially hate it when they are on multiple antipsychotics along with the excess doses. I always adhere to the max FDA dose even in severe patients in the hospital, do you guys agree?

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[whopper]

Agree and disagree.

The Green Journal every few years comes out with a revised guide of what should be the maximum dosage based on newer data. Their maximum dosages are usually higher for every antipsychotic than what the FDA recommends. See the FDA once they put their guidelines in rarely change them even if they are found to be wrong.

In the state of Ohio for example they have a state-approved revised pharmacy that clearly puts Olanzapine at a max dosage of 40 mg daily. This was reviewed by several pharmacologists and physicians that gave their stamp of approval and it was approved by their state's department of health. They used data more up-to-date than what the FDA uses. Other highly-respected authorities also have printed guidelines stating to give over what the FDA says.

Further Eli Lilly, the manufacturer of Zyprexa, even recommended it be given up to 30 mg a day in the CATIE trial.
Also factor in that some people are rapid-metabolizers and thus may need a dosage higher than the FDA maximum recommended dosage. There are specific genes found to make people rapid metabolizers that could be found on a genetic test. Also some people are slow metabolizers making very low dosages more effective for these people. I have seen patients upfront and in person need mega-dosages of some meds because they are rapid-metabolizers.

Add to the confusion that some people just need higher dosages because of their weight. A guy at 130 lbs is, all things being equal, going to need less medication than a guy weighing 350 lbs.

But in general the FDA guidelines are solid. The above are for the more extreme cases.

Whenever I see a polypharm regimen it's 90% the sign of a poor physician and 10% of the time the result of genius physician and careful work.

 

[HarryMTieboutMD]

Echo above about FDA safety limit. Sometimes really psychotic patients/rapid metabolizers can tolerate really high doses of high potency D2 blockade (eg, >20mg Haldol QD) without cogwheeling or other EPS, but this seems to be the exception rather than the rule. A lot of times people don't recall the old studies on Haldol and some of the others that showed that the antipsychotic effect can take up to 4 weeks to manifest (though there is conflicting data on this as well)- but it's not uncommon for patients to come into our ED with dystonic reactions and complete immobility because the dose was escalated inappropriately. Obviously people who smoke need higher doses of Zyprexa and Clozapine, but if starting it in the hospital (where, in 2016, hopefully a locked psych unit is smoke free), this shouldn't be an issue, and the outpatient doctor can uptitrate as necessary with a patient recalcitrant to smoking cessation.

Regarding multiple antipsychotics, again echo above, but the skilled psychopharmacologists who use multiple antipsychotics are few and far between. A lot of people justify using the Haldol/Clozapine combination, but my reading of the data (meaning, the seminal studies John Kane did that allowed the ban on Clozapine to be lifted) is that people who benefit from Clozaril over other antipsychotics are nonresponsive to other (D2 blocking) antipsychotics. In patients who are D2 blocking responsive (ie, not treatment resistant), Clozapine performs about as well as the others. I had a patient who was prematurely started on clozapine and didn't respond but then greatly improved when switched to haldol. The real issue is that in data justifying clozapine augmentation with another antipsychotics, the patients selected might not be truly treatment resistant and thus would not experience a greater benefit from Clozapine anyway.

That said, if one has a patient who is Clozapine responsive but may have occasional noncompliance issues/issues with blood draws, etc, an LAI antipsychotic is reasonable to prevent complete decompensation

 

[sweetlenovo88]

Thanks for the info, this is why I love this forum. A lot of bad polypharm out there. Had a patient tell me a psychiatrist added mellaril "just for sleep" when patient was already on risperdal.

Speaking of LAI, there are a bunch of patients here on two antipsychotics with an LAI being different from the po med. For example risperdal consta and po seroquel instead of po risperdal. I guess they are hitting different receptors, but I think it would be preferable to maintain the same medication

 

[whopper]

When I worked in a forensic unit I had plenty of treatment-resistant cases. I never saw any studies backing this but from seeing several different forensic units the accepted notion is violent mentally ill people tend to be the more treatment resistant ones.

I try to avoid polypharm whenever possible but I had cases where nothing, really nothing worked except for serious polypharmacy. E.g. high dose lithium, valproic acid, benztropine but two antipsychotics.

One thing I found very bothersome was on occasion I had patients treatment resistant even to high dosages of clozapine-and there is no good data that anything can break through this other than amisulparide mixed with clozapine but amisulparide isn't available in America.

A few times we brought cases like this for the best minds in psychiatry to tackle. Henry Nasrallah recommended reserpine. This was on a specific patient who was treatment resistant, had schizoaffective bipolar type and was known to sexually assault nurses literally at least a few times a week. When nurses were assigned to him they'd call in sick the same day. He could not be on lithium, Depakote or clozapine anymore because some idiot who had him before put him on it those meds (and they were the only ones known to work) but didn't have him do labs. I'm serious and it made the guy's ANC too low (permanently), his kidneys and liver too messed up to continue their use. (How this happened I don't know with the clozapine cause usually the pharmacist will only allow this if they see the labs themselves).

So I was going to do the reserpine and the CCO of the hospital blocked me. Told me I was being too dangerous. Now mind you this is after I already consulted with Nasrallah, had it go through with the hospital's top pharmacist, and 2 grad students lit-searched the heck out of it (one of them saying this was one of the only reasons to justify any use of reserpine-for odd cases like this) and I lit-searched the heck out of it. I also had 3 family meetings with his family telling them the risks cause this guy had been dangerous for few years and was branded with possibly no hope of ever being discharged.

So it was a no-go. The guy just kept being psychotic and manic assaulting people every few days. As bad as it was this is what long-term units are for-for patients that are not expected to get better quickly if at all.

Now mind you, keep this story wrapped up in the genie's bottle cause in usual psychiatry polypharm of these levels aren't needed. This is forensic-long-term-patients cut off other people's heads type units. Polypharm should rarely be done in usual outpatient practice where patient tells you they are feeling slightly depressed and their main complaint is they hate their boss.

 

[Shikima]

When I worked in a forensic unit I had plenty of treatment-resistant cases. I never saw any studies backing this but from seeing several different forensic units the accepted notion is violent mentally ill people tend to be the more treatment resistant ones.

I try to avoid polypharm whenever possible but I had cases where nothing, really nothing worked except for serious polypharmacy. E.g. high dose lithium, valproic acid, benztropine but two antipsychotics.

One thing I found very bothersome was on occasion I had patients treatment resistant even to high dosages of clozapine-and there is no good data that anything can break through this other than amisulparide mixed with clozapine but amisulparide isn't available in America.

A few times we brought cases like this for the best minds in psychiatry to tackle. Henry Nasrallah recommended reserpine. This was on a specific patient who was treatment resistant, had schizoaffective bipolar type and was known to sexually assault nurses literally at least a few times a week. When nurses were assigned to him they'd call in sick the same day. He could not be on lithium, Depakote or clozapine anymore because some idiot who had him before put him on it those meds (and they were the only ones known to work) but didn't have him do labs. I'm serious and it made the guy's ANC too low (permanently), his kidneys and liver too messed up to continue their use. (How this happened I don't know with the clozapine cause usually the pharmacist will only allow this if they see the labs themselves).

So I was going to do the reserpine and the CCO of the hospital blocked me. Told me I was being too dangerous. Now mind you this is after I already consulted with Nasrallah, had it go through with the hospital's top pharmacist, and 2 grad students lit-searched the heck out of it (one of them saying this was one of the only reasons to justify any use of reserpine-for odd cases like this) and I lit-searched the heck out of it. I also had 3 family meetings with his family telling them the risks cause this guy had been dangerous for few years and was branded with possibly no hope of ever being discharged.

So it was a no-go. The guy just kept being psychotic and manic assaulting people every few days. As bad as it was this is what long-term units are for-for patients that are not expected to get better quickly if at all.

Now mind you, keep this story wrapped up in the genie's bottle cause in usual psychiatry polypharm of these levels aren't needed. This is forensic-long-term-patients cut off other people's heads type units. Polypharm should rarely be done in usual outpatient practice where patient tells you they are feeling slightly depressed and their main complaint is they hate their boss.

So, It's not advisable to use IM Risperdal and Seroquel for Axis II?

 

[thoffen]

There is a lot of bad psychopharmacology out there, and a lot of it stems from misunderstanding of dose-response and time-response relationships with antipsychotics. Irrational polypharmacy and doses are good proxies in aggregate of bad psychopharmacology.

Strict adherence to FDA dose ranges, however, is simply a safer version of that misunderstanding.

We should be conscientious of our treatment, and we should discuss and document our reasons to decide on these doses or polypharmacy and use them as an opportunity to revisit diagnosis and non-pharmacologic treatment modalities.

 

[MacDonaldTriad]

When Haldol was new, doses of 70 or 80mg was common. Clearly any increase above 25mg is probably micturition in the general direction of the prevailing air flow, but there definitely are large differences in kinetics that justify some high doses. There isn't a valid argument for polypharmacy be it kinetics or dynamics.

 

[whopper]

So, It's not advisable to use IM Risperdal and Seroquel for Axis II?

I think you're being sarcastic right?

There is data showing that Seroquel does help for borderline PD at low dosages (about 150 mg, arguably less cause the study didn't try a lower dosage. Over 150 mg was found to not be beneficial more so than 150 mg).
There is also data showing low dose risperidone also helps borderline PD. Aripiprazole has the most data supporting it's use in borderline PD but only at low dosages and from experience with seeing these in action they only take the edge off at best.

I used to not give out Abilify for borderline PD despite the data cause it was so expensive and it did not do much if at all. The generic, thankfully, now is at about $100 a month.

Why they work is of debate. Some argue it's the 5HT2A blockage which causes neuro-protection and anti-inflammation in the brain then correspondingly offering some psychiatric benefit outside the neurological benefit given that we're finding inflammation more and more causes psychiatric problems.

And anyone giving a low dose atypical for borderline PD needs to acknowledge that the best treatment is psychotherapy. The medication should be the adjunct treatment and not a replacement for psychotherapy, heck often I don't even find the medication for borderline PD useful at all.

 

[Ceke2002]

I constantly see psychiatrists going above the maximum recommended dose of antipsychotics (not even mentioning max effective dose). Zyprexa 30-40mg, geodon 320mg, high doses of risperdal. It is a personal pet peeve of mine and I especially hate it when they are on multiple antipsychotics along with the excess doses. I always adhere to the max FDA dose even in severe patients in the hospital, do you guys agree?

Patient point of view only, but reading through the replies I do tend to agree that higher than recommended medication doses may be necessary in some situations, and completely unnecessary in others. I suppose the trick then is to work out which situation is which. A friend of mine that I lost touch with some years back was on a much higher dosage of Haldol than the recommended level set by Australian prescribing regulations; however, his was a case of Schizophrenia that was unresponsive to lower dosage levels, and even at the higher dose levels they still never managed to achieve full remission of symptoms, or even a level of stability that would have enabled him to try and live a half normal life. In contrast I experience episodes of MDD with Psychotic fx and once had a family physician start me on Seroquel 200mgs and quite rapidly titrate the dosage up to between 1000 and 1200mgs, which was a completely farcical amount for me to be on (as I later realised). So two different situations, two different pharmacologically based prescribing processes - one was right, one was wrong.

 

[Shikima]

I think you're being sarcastic right?

There is data showing that Seroquel does help for borderline PD at low dosages (about 150 mg, arguably less cause the study didn't try a lower dosage. Over 150 mg was found to not be beneficial more so than 150 mg).
There is also data showing low dose risperidone also helps borderline PD. Aripiprazole has the most data supporting it's use in borderline PD but only at low dosages and from experience with seeing these in action they only take the edge off at best.

I used to not give out Abilify for borderline PD despite the data cause it was so expensive and it did not do much if at all. The generic, thankfully, now is at about $100 a month.

Why they work is of debate. Some argue it's the 5HT2A blockage which causes neuro-protection and anti-inflammation in the brain then correspondingly offering some psychiatric benefit outside the neurological benefit given that we're finding inflammation more and more causes psychiatric problems.

And anyone giving a low dose atypical for borderline PD needs to acknowledge that the best treatment is psychotherapy. The medication should be the adjunct treatment and not a replacement for psychotherapy, heck often I don't even find the medication for borderline PD useful at all.

It was sarcasm.

 

[HarryMTieboutMD]

When I worked in a forensic unit I had plenty of treatment-resistant cases. I never saw any studies backing this but from seeing several different forensic units the accepted notion is violent mentally ill people tend to be the more treatment resistant ones.

I try to avoid polypharm whenever possible but I had cases where nothing, really nothing worked except for serious polypharmacy. E.g. high dose lithium, valproic acid, benztropine but two antipsychotics.

One thing I found very bothersome was on occasion I had patients treatment resistant even to high dosages of clozapine-and there is no good data that anything can break through this other than amisulparide mixed with clozapine but amisulparide isn't available in America.

A few times we brought cases like this for the best minds in psychiatry to tackle. Henry Nasrallah recommended reserpine. This was on a specific patient who was treatment resistant, had schizoaffective bipolar type and was known to sexually assault nurses literally at least a few times a week. When nurses were assigned to him they'd call in sick the same day. He could not be on lithium, Depakote or clozapine anymore because some idiot who had him before put him on it those meds (and they were the only ones known to work) but didn't have him do labs. I'm serious and it made the guy's ANC too low (permanently), his kidneys and liver too messed up to continue their use. (How this happened I don't know with the clozapine cause usually the pharmacist will only allow this if they see the labs themselves).

So I was going to do the reserpine and the CCO of the hospital blocked me. Told me I was being too dangerous. Now mind you this is after I already consulted with Nasrallah, had it go through with the hospital's top pharmacist, and 2 grad students lit-searched the heck out of it (one of them saying this was one of the only reasons to justify any use of reserpine-for odd cases like this) and I lit-searched the heck out of it. I also had 3 family meetings with his family telling them the risks cause this guy had been dangerous for few years and was branded with possibly no hope of ever being discharged.

So it was a no-go. The guy just kept being psychotic and manic assaulting people every few days. As bad as it was this is what long-term units are for-for patients that are not expected to get better quickly if at all.

Now mind you, keep this story wrapped up in the genie's bottle cause in usual psychiatry polypharm of these levels aren't needed. This is forensic-long-term-patients cut off other people's heads type units. Polypharm should rarely be done in usual outpatient practice where patient tells you they are feeling slightly depressed and their main complaint is they hate their boss.

ECT??

 

[HarryMTieboutMD]

ha! the number of state hospitals that peovid ECT these days is quite limited and it is even more challenging proposition in the forensic population because of its past history as a tool of coercion and abuse. Also ECT is not an effective treatment for schizophrenia except in cases of catatonia, post-schizophrenic depression or augmentation of clozapine in treatment resistant depression. one could argue for its use in other refractory cases but it can be nigh impossible to do in forensic patients or state hospital setting depending on the state

Oops... skipped over the forensic patient part. But since the patient is "schizoaffective-bipolar type" you can definitely shock through the mania

 

[Salpingo]

I think you're being sarcastic right?

There is data showing that Seroquel does help for borderline PD at low dosages (about 150 mg, arguably less cause the study didn't try a lower dosage. Over 150 mg was found to not be beneficial more so than 150 mg).
There is also data showing low dose risperidone also helps borderline PD. Aripiprazole has the most data supporting it's use in borderline PD but only at low dosages and from experience with seeing these in action they only take the edge off at best.

The literature for quetiapine XR and BPD is dodgy at best, and a perfect example of why you shouldn't accept psychiatric clinical trials at face value (even the ones published in AJP)

See: http://mobile.nytimes.com/2015/04/19/business/seroquel-xr-drug-trial-frayed-promise.html

 

[whopper]

ECT??

Already answered above. When one already has their rights severely confined by the state doing something like ECT seems all so more evil even if the patient can benefit from it.

We got a phenomenon in Missouri where people are getting ECT maybe more than they should cause of the lack of access to state hospitals and in other states ECT closed off to patients that could benefit from it because they're in a state institution.

While I worked in the state hospital there were about 4 patients I can think of out of a few hundred that IMHO needed ECT cause nothing else was working. Only one got it. This was one where the docs had to fight over it for a few years to finally get the permission. When it was done-it didn't work either.

http://mobile.nytimes.com/2015/04/19/business/seroquel-xr-drug-trial-frayed-promise.html

An extremely good article. Should be required reading for all residents.

 

[nitemagi]

Doses above FDA max can be quite rationale sometimes. Risperdal has been tested to be safe up to 16mg. Zyprexa is easily lowered by 1A2 inducers (such as smokers), so to get an active blood level of 20mg you might need to give 40mg. There's also logic at times for the "rationale polypharmacy." Abilify and haldol, for example, where more abilify won't lower your dopaminergic tone, but a touch of haldol will.

All that being said there's craploads of people prescribing multiple meds without any rationale and it's quite reckless.

 

[Igor4sugry]

When I worked in a forensic unit I had plenty of treatment-resistant cases. I never saw any studies backing this but from seeing several different forensic units the accepted notion is violent mentally ill people tend to be the more treatment resistant ones.

I try to avoid polypharm whenever possible but I had cases where nothing, really nothing worked except for serious polypharmacy. E.g. high dose lithium, valproic acid, benztropine but two antipsychotics.

One thing I found very bothersome was on occasion I had patients treatment resistant even to high dosages of clozapine-and there is no good data that anything can break through this other than amisulparide mixed with clozapine but amisulparide isn't available in America.

A few times we brought cases like this for the best minds in psychiatry to tackle. Henry Nasrallah recommended reserpine. This was on a specific patient who was treatment resistant, had schizoaffective bipolar type and was known to sexually assault nurses literally at least a few times a week. When nurses were assigned to him they'd call in sick the same day. He could not be on lithium, Depakote or clozapine anymore because some idiot who had him before put him on it those meds (and they were the only ones known to work) but didn't have him do labs. I'm serious and it made the guy's ANC too low (permanently), his kidneys and liver too messed up to continue their use. (How this happened I don't know with the clozapine cause usually the pharmacist will only allow this if they see the labs themselves).

So I was going to do the reserpine and the CCO of the hospital blocked me. Told me I was being too dangerous. Now mind you this is after I already consulted with Nasrallah, had it go through with the hospital's top pharmacist, and 2 grad students lit-searched the heck out of it (one of them saying this was one of the only reasons to justify any use of reserpine-for odd cases like this) and I lit-searched the heck out of it. I also had 3 family meetings with his family telling them the risks cause this guy had been dangerous for few years and was branded with possibly no hope of ever being discharged.

So it was a no-go. The guy just kept being psychotic and manic assaulting people every few days. As bad as it was this is what long-term units are for-for patients that are not expected to get better quickly if at all.

Now mind you, keep this story wrapped up in the genie's bottle cause in usual psychiatry polypharm of these levels aren't needed. This is forensic-long-term-patients cut off other people's heads type units. Polypharm should rarely be done in usual outpatient practice where patient tells you they are feeling slightly depressed and their main complaint is they hate their boss.

Was there a trial of Amoxapine?

 

[Jules A]

Whenever I see a polypharm regimen it's 90% the sign of a poor physician and 10% of the time the result of genius physician and careful work.

Sublime.

 

[whopper]

I'm already convinced that forensic patients in general are treatment resistant but I had a conversation with another forensic psychiatrist a few days ago where we were trading war stories and told me pretty much the same thing I figured out. This is a good thing with practicing in different areas. You pick up stuff you didn't had you just stayed in the same place. I can tell you that only until I hit Cincinnati did I learn about making Depakote almost always mandatory with Clozapine over 200-300 mg a day, using Parnate, putting dosages beyond their maximums, pharmacogenomics, L-methylfolate, reserpine, vaccinating people for Alzheimers as a potential treatment, etc.

Didn't try amoxapine but I did try loxapine and it provided no benefit.

 

[PistolPete]

I'm already convinced that forensic patients in general are treatment resistant but I had a conversation with another forensic psychiatrist a few days ago where we were trading war stories and told me pretty much the same thing I figured out. This is a good thing with practicing in different areas. You pick up stuff you didn't had you just stayed in the same place. I can tell you that only until I hit Cincinnati did I learn about making Depakote almost always mandatory with Clozapine over 200-300 mg a day, using Parnate, putting dosages beyond their maximums, pharmacogenomics, L-methylfolate, reserpine, vaccinating people for Alzheimers as a potential treatment, etc.

Didn't try amoxapine but I did try loxapine and it provided no benefit.

Why adding Depakote above clozaril doses of 200? Because of increased seizure risk? I may be taking a job in a forensic setting next year, so I'm curious if you have any other pearls.

 

[splik]

Why adding Depakote above clozaril doses of 200? Because of increased seizure risk? I may be taking a job in a forensic setting next year, so I'm curious if you have any other pearls.

personally I wouldn't start departed on a clozaril pt until they were on 45omg or >500ug levels. if you starred everyone on 200mg clozaril on depakoye then pretty much everyone on clozaril would be on depakoye... totally unnecessarily

 

[whopper]

Why adding Depakote above clozaril doses of 200? Because of increased seizure risk?

Recommended by Paul Keck in fact it worked it's way into the state procedures in the mental hospitals for clozapine. Reason why is the seizures. Where I did the training they just stated it increased risk of seizures while in Cincinnati it's the norm to add it once it gets to higher dosages.
I'm not saying Splik is wrong. Like I said you pick up different things in different areas and start seeing for yourself what's best.

 

[splik]

different places definitely have different guidelines - you just have follow the institutional guidance.

 

[splik]

let's not even mention how much money keck got from Abbott - the makers of depakote... maybe I'm just being suspicious though...

 

[whopper]

Well wouldn't be surprised! There are, however, plenty of the psychiatrists in the area that don't take any of that money and are very critical of it that follow Keck's recommendation.

The main problem I've had with the Depakote/Clozaril combo is the majorly increased risk of neutropenia. Most people aren't aware that Depakote also can cause it. It's not as risky as Clozapine but the two mixed together could be the straw that breaks the camel's back. That said I still put people on both just that I'm wary of the ANC when they are both, more so than Cloazapine by itself.

So I went through a phase where I thought maybe we ought to try a different anti-seizure med instead of Depakote but after doing about a week of lit-searching on it turns out all of them can cause neutropenia. So I just stuck with Depakote cause at least that one could augment then effect of the Clozapine while a different seizure med like Dilantin will not.

 

[cookymonster]

The weight gain alone associated with the Clozaril-Depakote combo falls into the category of cruel and unusual punishment (more justifiable than the Zyprexa-Depakote combo though). There's at least some evidence for adding on Lamictal.

 

[PistolPete]

How about Topamax? Can counter some of the weight gain associated with clozaril, but not really convinced that it's a great anti-seizure med... Or is it?

 

[chocomorsel]

When I worked in a forensic unit I had plenty of treatment-resistant cases. I never saw any studies backing this but from seeing several different forensic units the accepted notion is violent mentally ill people tend to be the more treatment resistant ones.

I try to avoid polypharm whenever possible but I had cases where nothing, really nothing worked except for serious polypharmacy. E.g. high dose lithium, valproic acid, benztropine but two antipsychotics.

One thing I found very bothersome was on occasion I had patients treatment resistant even to high dosages of clozapine-and there is no good data that anything can break through this other than amisulparide mixed with clozapine but amisulparide isn't available in America.

A few times we brought cases like this for the best minds in psychiatry to tackle. Henry Nasrallah recommended reserpine. This was on a specific patient who was treatment resistant, had schizoaffective bipolar type and was known to sexually assault nurses literally at least a few times a week. When nurses were assigned to him they'd call in sick the same day. He could not be on lithium, Depakote or clozapine anymore because some idiot who had him before put him on it those meds (and they were the only ones known to work) but didn't have him do labs. I'm serious and it made the guy's ANC too low (permanently), his kidneys and liver too messed up to continue their use. (How this happened I don't know with the clozapine cause usually the pharmacist will only allow this if they see the labs themselves).

So I was going to do the reserpine and the CCO of the hospital blocked me. Told me I was being too dangerous. Now mind you this is after I already consulted with Nasrallah, had it go through with the hospital's top pharmacist, and 2 grad students lit-searched the heck out of it (one of them saying this was one of the only reasons to justify any use of reserpine-for odd cases like this) and I lit-searched the heck out of it. I also had 3 family meetings with his family telling them the risks cause this guy had been dangerous for few years and was branded with possibly no hope of ever being discharged.

So it was a no-go. The guy just kept being psychotic and manic assaulting people every few days. As bad as it was this is what long-term units are for-for patients that are not expected to get better quickly if at all.

Now mind you, keep this story wrapped up in the genie's bottle cause in usual psychiatry polypharm of these levels aren't needed. This is forensic-long-term-patients cut off other people's heads type units. Polypharm should rarely be done in usual outpatient practice where patient tells you they are feeling slightly depressed and their main complaint is they hate their boss.

What about ECT in a patient like this?

 

[chocomorsel]

What about ECT in a patient like this?

Never mind. See it addressed.

 

[chocomorsel]

When you successfully treat a patient for their psychosis or mood disorder with ECT, can you then back off on their medications? To a lower dose or no drugs at all?
What about treating patients with ECT who already have some short term memory problems? Is ECT contraindicated in this setting?

 

[NickNaylor]

When you successfully treat a patient for their psychosis or mood disorder with ECT, can you then back off on their medications? To a lower dose or no drugs at all?
What about treating patients with ECT who already have some short term memory problems? Is ECT contraindicated in this setting?

For the first question, I haven't followed our ECT patients long-term, but the general practice is to continue medications.

Pre-existing cognitive impairment is not in and of itself a contraindication for ECT, but it would change the risk/benefit calculus and likely make one a bit more weary to recommend.

 

[chocomorsel]

For the first question, I haven't followed our ECT patients long-term, but the general practice is to continue medications.

Pre-existing cognitive impairment is not in and of itself a contraindication for ECT, but it would change the risk/benefit calculus and likely make one a bit more weary to recommend.

If they show improvement can you decrease their oral dosage?

 

[OldPsychDoc]

 

[SeniorWrangler]

At least when I was in training, I learned that the FDA dosing guidelines are based on the dose that works (for most people) without too many side effects (for most people). There's nothing particularly scientific about it most of the time.

 

[thoffen]

At least when I was in training, I learned that the FDA dosing guidelines are based on the dose that works (for most people) without too many side effects (for most people). There's nothing particularly scientific about it most of the time.

Certainly dose-responde relationship is not reflected in most people's clinical practice. But I'd also caution to view this over time. How clinical trials were designed and required for FDA approval has changed over time, so FDA-approved dose ranges don't necessarily reflect best practice.

I think for lower potency (speaking purely of D2 receptor affinity) antipsychotics, there is more rationale for higher dosing. Zyprexa and CATIE is a good example of how (by manufacturer recommendation) a max dose of 30mg became standard.

 

[AD04]

The Green Journal every few years comes out with a revised guide of what should be the maximum dosage based on newer data.

Is this an article or a book? What is the title? Thanks.

 

[romanticscience]

Green Journal = American Journal of Psychiatry


Sent from my iPhone using SDN mobile

 

[AD04]

I have the latest AJP and I don't see it. What is the name of the article / guide?

 

[whopper]

I don't remember the name of the article but it doesn't come out monthly. Last time I remember it was definitely over 2 years ago. If I catch it I'll post it. Anyone here beat me to it post it please.