Q: Atypical Antipsychotics & Level of Sedation
Hello Dr. Phelps
I think I have narrowed down my diagnosis to psychotic depression and possible
bipolar disorder. I do get hypomania from certain drugs. The drug Geodon
has been a godsend for getting rid of paranoia, disoraganized thought, and for
the most part suicidal depression and anxiety. The only problem is that it
has caused some pretty heavy sedation. The weird thing is that the
sedation didn't set in until about two months into dosing. The first two
months I didn't have any sedation. Also, I only take a very low dose of
20mg/day. That is the lowest dose I can take. What are your thoughts
on why this sedation had a delayed onset? I read where the atypical
antipsychotic Seroquel caused drowsiness at lower doses, but at higher doses the
sedation seemed to subside in some users. Could this apply here with
Geodon? Do I need a higher dose? The sedation I believe is starting
to affect my mood instead of it actually being a resurfacing of depression.
It is hurting my motivation and socialbility, because I am sleepy all day long.
My question to you is how do you treat patients in this situation when their
antipsychotic is working, but causing this level of sedation? Also, could
this be something else besides the normal side effect of sedation that so often
goes along with the use of atypical antipsychotics? I have thoroughly
enjoyed this site and its educational value. Thanks for being here.
Dear Tom --
You raise an interesting question, and your parallel with Seroquel (more
drowsiness at lower doses; or, in my understanding, drowsiness lasting longer --
weeks instead of a week or two -- at lower doses) is a good way to approach
this. That's because sedation with medications like this is often
associated with blocking the receptor for histamine. Histamine blockers,
e.g. antihistamines like Benadryl, are usually quite sedating.
So, off I went to remind myself how much histamine
blockade ziprasidone (Geodon) causes. Most websites giving this
information indicate "low to moderate" histamine blockade (e.g. put
ziprasidone histamine in Google and try the links on the first page of
results). The question is whether there is some reason to think the
histamine effect would greater at low doses. With another medication
called mirtazapine (Remeron), the histamine effect is greater at lower doses
because at higher doses, a norepinephrine effect is thought to partially
counter-act the histamine effect. With Seroquel, the histamine effect is
no less at higher doses; in fact, if I have the manufacturer's rationale right
(I haven't tried this approach yet), the sedation may last less long -- a week
or so, instead of several weeks -- if higher doses are used right away.
One article I found suggested the opposite: that
ziprasidone-sedation was worse at higher doses. You'll find that in the
section on sedation in this long summary about ziprasidone.
So, this doesn't quite seem to really explain the
sedation problem. So I wonder about an alternative explanation, for you to
consider as you go along. "Sleepy all day long"; motivation low;
inclination to socialize low. Could be Geodon sedation all right, as you
put it. I wonder if it could also be the underlying mood condition.
What if Geodon treated the paranoia and thought problems, but didn't prevent
some of the components of depression? Bipolar depression is pretty famous
for causing low energy, low motivation, and increased desire to sleep (some
people whose life allows, or whose symptoms are really severe, can sleep 12-16
hours per 24, or more).
Of course if you've read much of my writings here and
elsewhere you'll know I don't recommend turning around and trying to solve that
problem by adding an antidepressant. The main antidepressant-effect things
I consider are: tune up sleep, i.e. shoot for regular hours, about 8
hours, no matter what your body seems to want; tune up exercise, i.e. trying to
get some every day, even though that's definitely not what you body may say it
wants to do; consider fish oil, though that takes months to get going if it does
anything at all; and strongly consider at least low-dose lithium, for
antidepressant effects that appear not to carry any risk at all of making things
cycle or worsen (side effects maybe, and watch out for hypothyroidism, as that
can make things worsen, but otherwise, not "worsen" like antidepressant or
even some atypical antipsychotics like risperidone can do). Then there's
lamotrigine, which is an antiseizure medication originally but has remarkable
antidepressant effects while only rarely (the company says not at all, but I
think I've seen a few) making manic-side symptoms worse, and very few side
effects if you don't get the rash. Here's more on
Good luck with all that.
Published January, 2005