Asking for Information on Saphris and insight on ECT
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Q:   Asking for Information on Saphris and insight on ECT

Dr. Phelps: 

You've been very helpful in answering a couple of my questions in the past and I now have another one - two actually.  I'm a depressive bipolar II, very treatment resistant when it comes to the depression with fairly mild, brief hypomanic episodes. (along with ADD and a little anxiety thrown in on the side)  I spend the rest of my time at some level of depression. My psychiatrist and I have tried everything that I can feasibly take - all kinds of combinations, etc., including the newer atypical antipsychotics Abilify and Geodon over a span of about 12-13 years. 

He just started me on one called Saphris as a last shot before ECT, and it seems to be working, or at least finally and quickly lifting some of the extreme depression I've been experiencing for over a year now.  What do you know about Saphris?  I realize it is brand new and meant for schizophrenia and bipolar mania, not depression, but somehow it's  working for my bipolar depression in combination with all of my other meds. 

Also, what are your thoughts on ECT?  I've tried to put it off as an absolute last resort because of the possible memory problems it can cause, but this episode of depression has lasted so much longer and been much, much worse than any I've had in over 10 years, even to the point of being suicidal for a short period of time.  I  would just like to live depression-free, though I don't know if I'd recognize it if I got there.   

Any information on Saphris and insight on ECT you can provide would be much appreciated.  Thanks again!


Dear Laura --
Three ideas, about strategy, ECT, and asenapine (Saphris).  

1. Strategy -- there are tools for getting out of depression, and there are tools for staying out of it.  As you know, the latter are called "mood stabilizers".  Lots of things work for getting out of depression, but only a smaller group are well recognized as having the capacity to help staying well. 

Very few patients come to me having had rigorous trials of multiple mood stabilizers combined with one another, with no antidepressant in the picture at the time.  You might be one.  If so, you're right, it's hard to know where to go next.  There are so many combinations of mood stabilizers that can be tried, I rarely face that challenge. 

For example, ziprasidone/Geodon is well recognized to act like an antidepressant, especially at low doses, so anything that you were on while you're also on the ziprasidone has to be considered for a do-over.  Same story applies to risperidone; and probably also to aripiprazole/Abilify, which in bipolar depression has not been shown to be more effective than a placebo, and I'm still encountering cases where I'm pretty sure (at least at low doses) that it was possibly making things worse. 

So that means trying things like combinations of lamotrigine/lithium/fish oil/thyroid; or carbamazepine/thyroid/quetiapine (Seroquel); and several other cocktails that are fairly routine for me. 

2.  After all that, you might come around to ECT, at lease to get out of the current episode, but of course that leaves the question of how you're going to stay well thereafter, which rather leads back to number one above, in my view.  In some people, "maintenance ECT" is used as the preventive approach, about one session a month.  It does work. 

3.  And then of course you could be the first on the block to try the new thing, before we have really much of an idea as to whether or not it is superior to any of our other options, or what exactly one might encounter in terms of risks, short-term or long-term. On the other hand, it could be that the new thing, asenapine, for example, would be perfect for you.  Trying it is one way to find out. 

Whichever route you choose, I hope you find something very helpful soon. Have a look at N-acetylcysteine -- NAC -- while you’re at it (another “new thing”, but one with which we have much more experience) 

Dr. Phelps

Published June, 2010



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