Prozac twice daily vs once daily

[decgra]

Is there any rationale to all this?

a) Will taking half dose morning and half dose post afternoon, help in reducing side effects like nervousness with the same benefits?

b) Have a high functioning patient (bipolar II with ocd) on a academically demanding job, whose been doing well on low dose Prozac. He insists on taking a low dose twice daily (5mg) since he believes that is all he needs.

c) He also claims he sleeps <5 hours a day in a room with the lights on(so as not to fall into deep sleep), so that he can function in a perpetual productive hypomanic phase daily.

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[wolfvgang22]

Twice daily fluoxetine doesn't make much pharmacological sense, but if my patients will take necessary medication I don't fight with them over minor non-dangerous things like that. I would spend my energy more on trying to help this patient live a healthier lifestyle and watch out for mania/ impulsivity that is more likely to have a negative impact on his life.

 

[MacDonaldTriad]

I agree with picking your battles, but norfluoxitane (the active Prozac metabolite) has a half life of a week. Splitting Prozac dosing into BID would have less difference that changing Ativan from 1 mg Q4 hours to 0.5 mg Q2 hours. He sounds obsessional and the sleep depravation isn't a good thing.

 

[HarryMTieboutMD]

Is there any rationale to all this?

a) Will taking half dose morning and half dose post afternoon, help in reducing side effects like nervousness with the same benefits?

b) Have a high functioning patient (bipolar II with ocd) on a academically demanding job, whose been doing well on low dose Prozac. He insists on taking a low dose twice daily (5mg) since he believes that is all he needs.

c) He also claims he sleeps <5 hours a day in a room with the lights on(so as not to fall into deep sleep), so that he can function in a perpetual productive hypomanic phase daily.

What are you treating in that patient with Prozac 10mg (TDD)? If you are targeting obsessionality (I agree with mcdonaldtriad on this) the dose needs to be higher. Are you using prozac in combo with Zyprexa? Symbyax dosing is usually higher...

 

[decgra]

He refuses to go on anything other than low dose prozac monotherapy for the bipolar. and says this dose is helping his ocd as well.

Sorry if ignorant, whats the relation between ocd and sleep? does sleep deprivation make ocd worse?

(medical student on a subi)

 

[hamstergang]

does sleep deprivation make ocd worse?

What doesn't sleep deprivation make worse?

 

[MacDonaldTriad]

You described him as Bipolar II, sleep deprivation will worsen bipolar disorder generally and mania particularly. Often in mania, if you can just get them to sleep 10 or 12 hours, they get a lot better.

 

[nexus73]

I think the general recommendation is to not have bipolar patients on ssri's without a mood stabilizer at therapeutic dose beforehand.

 

[splik]

For bipolar I, bipolar II patients are often (though not always) fine on antidepressant monotherapy

 

[muhali3]

What doesn't sleep deprivation make worse?

Depression, at least acutely. (https://www.scientificamerican.com/article/why-sleep-deprivation-eases-depression/)

 

[Armadillos]

What doesn't sleep deprivation make worse?

My understanding is isolated short term sleep deprivation on the order of 24-30 hrs can be quite euphorogenic and in some cases be used to help break depressive episodes in unipolar depression . (I assume this is anecdotal and not supported by any big body of evidence)

 

[HarryMTieboutMD]

For bipolar I, bipolar II patients are often (though not always) fine on antidepressant monotherapy

The conclusion I generally draw from this is that the most of these people (BPAD2 depressed) are either pure personality disorder or get really dysregulated when decompensating into major depressive episodes and somehow get labeled with BPAD 2. Every true BPAD 2 patient I have seen who does not have a personality disorder is really like a Bipolar 1.5 (their grandiosity borders on delusional but is not quite psychotic, not impaired in functioning, do not get hospitalized).

In either case it's not so much that I'm worried that SRI treatment will flip these patients to mania, my experience is simply that in a bipolar variant depression SRI treatment doesn't work

 

[wolfvgang22]

The conclusion I generally draw from this is that the most of these people (BPAD2 depressed) are either pure personality disorder or get really dysregulated when decompensating into major depressive episodes and somehow get labeled with BPAD 2. Every true BPAD 2 patient I have seen who does not have a personality disorder is really like a Bipolar 1.5 (their grandiosity borders on delusional but is not quite psychotic, not impaired in functioning, do not get hospitalized).

In either case it's not so much that I'm worried that SRI treatment will flip these patients to mania, my experience is simply that in a bipolar variant depression SRI treatment doesn't work

This is a really unorthodox understanding of Bipolar II Disorder, I don't agree with it.

 

[WingedOx]

This is a really unorthodox understanding of Bipolar II Disorder, I don't agree with it.

I'm not sure I agree with his assessment, but I've been seeing a pattern of "oh, c'mon man" Dx's of BPII the last couple months. Just because a depressed person displays impulsive behavior with poor sleep doesn't make a BPAD dx. That person could simply be...depressed.

Is there any rationale to all this?

a) Will taking half dose morning and half dose post afternoon, help in reducing side effects like nervousness with the same benefits?

b) Have a high functioning patient (bipolar II with ocd) on a academically demanding job, whose been doing well on low dose Prozac. He insists on taking a low dose twice daily (5mg) since he believes that is all he needs.

c) He also claims he sleeps <5 hours a day in a room with the lights on(so as not to fall into deep sleep), so that he can function in a perpetual productive hypomanic phase daily.

Well at least it's just low dose Prozac and not QID methylphenidate like the last guy I had come into my office who had sx like this.

 

[PistolPete]

The conclusion I generally draw from this is that the most of these people (BPAD2 depressed) are either pure personality disorder or get really dysregulated when decompensating into major depressive episodes and somehow get labeled with BPAD 2. Every true BPAD 2 patient I have seen who does not have a personality disorder is really like a Bipolar 1.5 (their grandiosity borders on delusional but is not quite psychotic, not impaired in functioning, do not get hospitalized).

In either case it's not so much that I'm worried that SRI treatment will flip these patients to mania, my experience is simply that in a bipolar variant depression SRI treatment doesn't work

I would tend to agree. In my opinion, the vast majority of so-called bipolar II patients (especially the adolescent females) actually just have borderline personality disorder, and the affect dysregulation gets characterized as "mania." The do better on SSRI monotherapy because it targets the irritability, aggression, depression, etc. I see so many patients who come in diagnosed as bipolar, and then I get a history of self-harm behavior, suicidal threats with few or no actual attempts, abuse, and hospitalization records document no hypomania or mania, I pretty much know the diagnosis.

I agree that bipolar disorder is on the spectrum and that bipolar I and II is somewhat simplistic. Stahl talks about bipolar 1, 1.5, 2, 2.5 etc...

 

[SeniorWrangler]

I'm a little suspicious of bipolar patients who seem to do fine on SSRI monotherapy, but then I think bipolar is wildly overdiagnosed anyway.

 

[splik]

I'm a little suspicious of bipolar patients who seem to do fine on SSRI monotherapy, but then I think bipolar is wildly overdiagnosed anyway.

perhaps you've been brainwashed by drug company marketing? Before 1994 nobody batted an eyelid about having someone on SSRI monotherapy for bipolar II. Then depakote came along and though it has never been demonstrated to actually be useful for bipolar II, they heavily promoted it for this and we had all this nonsense about how everyone who wasn't responding to treatment was actually bipolar. Flash foward to the 2000s and then the atypicals were aggressively marketed for bipolar disorder. We even saw the olanzapine-fluoxetine combo pill (symbyax) though jay amsterdam at penn had shown that you could use fluoxetine monotherapy without problems. The risk of switching with SSRIs is about 11% so it's not like the majority of patients flip into mania/hypomania. Some do, some have worsening cycling, agitation, mixed states etc, but most patients don't require long-term drug therapy, and they can be on antidepressant monotherapy unless it's clear that they cannot. This is in contrast with bipolar I disorder where no one would recommend antidepressant monotherapy.

https://msrc.fsu.edu/system/files/A...rapy for bipolar type II major depression.pdf
http://bjp.rcpsych.org/content/bjprcpsych/202/4/251.full.pdf?cited-by=yes;202/4/
http://www.jad-journal.com/article/S0165-0327(15)30094-X/fulltext
Efficacy and Safety of Long-Term Fluoxetine Versus Lithium Monotherapy of Bipolar II Disorder: A Randomized, Double-Blind, Placebo-Substitution Study
http://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.2016.15040558

 

[nexus73]

The conclusion I generally draw from this is that the most of these people (BPAD2 depressed) are either pure personality disorder or get really dysregulated when decompensating into major depressive episodes and somehow get labeled with BPAD 2. Every true BPAD 2 patient I have seen who does not have a personality disorder is really like a Bipolar 1.5 (their grandiosity borders on delusional but is not quite psychotic, not impaired in functioning, do not get hospitalized).

In either case it's not so much that I'm worried that SRI treatment will flip these patients to mania, my experience is simply that in a bipolar variant depression SRI treatment doesn't work

I think a lot of patients get diagnosed with bipolar II and they've never been hypomanic for 4+ days.

 

[Shikima]

Irritable patient.
Therapist thinks the patient needs a mood stabilizer.
Doctor prescribes said mood stabilizer, usually Latuda or Saphris.

Everyone bills BP2 and goes home happy.

 

[Armadillos]

I go back on forth on BPAD2. As a medstudent and intern I liked to feel smug rolling my eyes every time I saw it on a chart. But as I've gone through residency seems like I'm swinging the other way because I've seen so many patients with long term irritability and depression look way better on a couple hundred of seroquel than they ever did before. Maybe seroquel is just a fantastic antidepressant, who knows. But does seem like there are a lot of patients out there I've seen languish for awhile but then finally someone pulls the trigger on a BPAD2 treatment and they look way better.

 

[HarryMTieboutMD]

I go back on forth on BPAD2. As a medstudent and intern I liked to feel smug rolling my eyes every time I saw it on a chart. But as I've gone through residency seems like I'm swinging the other way because I've seen so many patients with long term irritability and depression look way better on a couple hundred of seroquel than they ever did before. Maybe seroquel is just a fantastic antidepressant, who knows. But does seem like there are a lot of patients out there I've seen languish for awhile but then finally someone pulls the trigger on a BPAD2 treatment and they look way better.

I agree with this; however absent definitive hypomania (that reliable collateral describes or I see in person) I conceptualize these patients as having a Bipolar variant (or mixed) depression, especially if there is a strong family history, etc. Most of the time I am still pretty suspect of BPAD II diagnoses (meaning, they are either personality disorders/substance or their hypomania borders on mania and it's the operationalized criteria that compels me to label them as II)

 

[birchswing]

perhaps you've been brainwashed by drug company marketing? Before 1994 nobody batted an eyelid about having someone on SSRI monotherapy for bipolar II. Then depakote came along and though it has never been demonstrated to actually be useful for bipolar II, they heavily promoted it for this and we had all this nonsense about how everyone who wasn't responding to treatment was actually bipolar. Flash foward to the 2000s and then the atypicals were aggressively marketed for bipolar disorder. We even saw the olanzapine-fluoxetine combo pill (symbyax) though jay amsterdam at penn had shown that you could use fluoxetine monotherapy without problems. The risk of switching with SSRIs is about 11% so it's not like the majority of patients flip into mania/hypomania. Some do, some have worsening cycling, agitation, mixed states etc, but most patients don't require long-term drug therapy, and they can be on antidepressant monotherapy unless it's clear that they cannot. This is in contrast with bipolar I disorder where no one would recommend antidepressant monotherapy.

https://msrc.fsu.edu/system/files/Amsterdam and Brunswick 2003 Antidepressant monotherapy for bipolar type II major depression.pdf
http://bjp.rcpsych.org/content/bjprcpsych/202/4/251.full.pdf?cited-by=yes;202/4/
http://www.jad-journal.com/article/S0165-0327(15)30094-X/fulltext
Efficacy and Safety of Long-Term Fluoxetine Versus Lithium Monotherapy of Bipolar II Disorder: A Randomized, Double-Blind, Placebo-Substitution Study
http://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.2016.15040558

This relates to a question I've wondered about. You mentioned Depakote "came along" in the 1990s. I've wondered why it's on patent when according to Wiki it was discovered in 1881 and first used medically in 1962.

 

[splik]

This relates to a question I've wondered about. You mentioned Depakote "came along" in the 1990s. I've wondered why it's on patent when according to Wiki it was discovered in 1881 and first used medically in 1962.

Depakote is a special formulation - a 1:1 molar ratio of valproic acid and sodium valproate. Which is why its sometimes called semi-sodium valproate or divalproex. Valpromide (an amide of it) has been around longer, and valproic acid was used in the treatment of seizures long before, but Abbott marketed Depakote in this new formulation (that supposedly had fewer GI effects) for bipolar mania from 1994 after a landmark study in JAMA. This study found patients who did not respond to lithium may respond to depakote. The term mood stabilizer really took off after that though it had been used sparsely in the literature before. See David Healy's Paper from a while back for further reading: The Latest Mania: Selling Bipolar Disorder

 

[Blitz2006]

perhaps you've been brainwashed by drug company marketing? Before 1994 nobody batted an eyelid about having someone on SSRI monotherapy for bipolar II. Then depakote came along and though it has never been demonstrated to actually be useful for bipolar II, they heavily promoted it for this and we had all this nonsense about how everyone who wasn't responding to treatment was actually bipolar. Flash foward to the 2000s and then the atypicals were aggressively marketed for bipolar disorder. We even saw the olanzapine-fluoxetine combo pill (symbyax) though jay amsterdam at penn had shown that you could use fluoxetine monotherapy without problems. The risk of switching with SSRIs is about 11% so it's not like the majority of patients flip into mania/hypomania. Some do, some have worsening cycling, agitation, mixed states etc, but most patients don't require long-term drug therapy, and they can be on antidepressant monotherapy unless it's clear that they cannot. This is in contrast with bipolar I disorder where no one would recommend antidepressant monotherapy.

https://msrc.fsu.edu/system/files/Amsterdam and Brunswick 2003 Antidepressant monotherapy for bipolar type II major depression.pdf
http://bjp.rcpsych.org/content/bjprcpsych/202/4/251.full.pdf?cited-by=yes;202/4/
http://www.jad-journal.com/article/S0165-0327(15)30094-X/fulltext
Efficacy and Safety of Long-Term Fluoxetine Versus Lithium Monotherapy of Bipolar II Disorder: A Randomized, Double-Blind, Placebo-Substitution Study
http://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.2016.15040558

Great post.

I presume the 11% is in reference to only BPD2 flipping? Not Bipolar I?

And to follow-up, what is the switch rate for Bipolar I for SSRIs? And is it true that Wellbutrin has the lowest switch rate, vs. SNRIs which have the highest?

 

[splik]

Great post.

I presume the 11% is in reference to only BPD2 flipping? Not Bipolar I?

And to follow-up, what is the switch rate for Bipolar I for SSRIs? And is it true that Wellbutrin has the lowest switch rate, vs. SNRIs which have the highest?

no most of the data is people with bipolar I. the vast majority of people with BP don't switch into mania even with antidepressant monotherapy, but when it does happen it's obviously potentially disastrous. Also pts treated with antidepressant become lithium resistant, do when you finally start them on lithium it doesn't work as well. This is not to mention the other things mention previous (cycle frequency, mixed stated, rapid cycling, agitation, suicidality). There is some weak data that you have a lower switch rate with wellbutrin and paxil but Im not sure I would believe it. TCAs have the highest switch rate. Basically, dual acting drugs are considered to cause switching more often (its about 33% switch rate to mania in BP1 depressives rx with TCAs). There was a paper that did give % of switch for different drugs but it wasnt based on huge data sets and I cant remember the paper

 

[MacDonaldTriad]

I question the purity of the BP-I subjects used to calculate switch rates. If TCAs approach a third, this is a real problem. I also hate it when people quote the relative safety of Welbutrin as a justification to use it as monotherapy. So what if it is a little less likely. I don't play Russian roulette with a magnum so why should it be OK to play Russian roulette with a 22? Splik is right to clarify that we are talking BP-I and not II. Especially if your definition of BP-II is less than convincing BP-I.

 

[carlosc1dbz]

I go back on forth on BPAD2. As a medstudent and intern I liked to feel smug rolling my eyes every time I saw it on a chart. But as I've gone through residency seems like I'm swinging the other way because I've seen so many patients with long term irritability and depression look way better on a couple hundred of seroquel than they ever did before. Maybe seroquel is just a fantastic antidepressant, who knows. But does seem like there are a lot of patients out there I've seen languish for awhile but then finally someone pulls the trigger on a BPAD2 treatment and they look way better.

By any chance do you know of any videos that display the difference in mental status between BPI and BPII. I need it as an educational tool. I had a social work intern come and tell me that they learned about mania and she showed me the Youtube video their professor showed the class of a patient who was manic, It ended up just being euthymic lady talking about her past experiences. I then wanted to show her what mania looked like, but found nothing but med students acting manic for a project. (mock interview) There is nothing out there that I could find. Maybe it is related to HIPPA.

 

[singasongofjoy]

By any chance do you know of any videos that display the difference in mental status between BPI and BPII. I need it as an educational tool. I had a social work intern come and tell me that they learned about mania and she showed me the Youtube video their professor showed the class of a patient who was manic, It ended up just being euthymic lady talking about her past experiences. I then wanted to show her what mania looked like, but found nothing but med students acting manic for a project. (mock interview) There is nothing out there that I could find. Maybe it is related to HIPPA.

There are definitely educational videos out there, but unfortunately I can't recall the name of the series. But in a couple of my master's classes we were shown videos that clearly depicted mania; maybe the videos were packaged with some abnormal psych type textbook company or something. I also recall that when I was teaching intro, one of my students sent me a youtube video they had found when researching bipolar disorder; a daughter videotaped her father on their drive to the emergency room. It was distressing to watch but as I recall it certainly seemed to be an actual manic episode. maybe if you search different terms (e.g., bipolar) on youtube you'll find it or something similar.