Using Abiliify or other antipsychotics as needed

[sarek]

My gf has been prescribed Abilify 10mg/day to combat both depression and psychotic episodes(voices and distorted images of reality 'altered states' mostly).
So far, circumstances have precluded the establishment of an accurate diagnosis however and there is no likelihood that this is going to change any time soon.

On the whole the treatment seems to be somewhat effective although she keeps hearing voices pretty much constantly. Before she was on Abilify she would regularly suffer from episodes taking her completely off the world for as much as two or more days on end. A complicating factor is that she lives in London and I live in the Netherlands so its hard to check up with any kind of regularity.

An unpleasant side effect however is serious fatigue which impairs her normal daily functioning. She wants to up the dosage of the antidepressants or add yet others to the mix but I am reluctant about that idea.

She is also on Effexor and Prozac(fluoxetine) against the depression and I know there is a reported interaction between fluoxetine and Abilify.

Are there ways to reduce Abilify's side effects? Or is the fatigue caused by something else? She has been on the anti deps for a long long time.

I have come across a small note by someone referring to research pertaining to the usage of antipsychotics on an as needed basis but try as I might I cant seem to find that research anywhere. And considering the half life of Abilify that might not be effective either.

 

[Daniel E.]

Personally, I would just encourage her to talk to her psychiatrist, who may want to see her in person before making any changes. (And she can always get a second opinion.)

I have come across a small note by someone referring to research pertaining to the usage of antipsychotics on an as needed basis

But since she is hearing voices almost constantly, that approach (which I am not familiar with) would not seem to apply here. And, in any case, antipsychotics help prevent hallucinations, which would be another reason for daily use. In the case of my family member, the dosages of antipsychotics like Seroquel were adjusted relatively often, but that's very different than PRN.

 

[Retired]

Sarek,

You are correct that combining Prozac with Abilify has the potential for drug / drug interaction at the metabolic level. The mecahnism of action of this interaction involves the liver enzyme Cytochrome P-450-2D6, where Fluoxetine may inhibit the metabolism of Abilify by CYP P-450-2D6.

However, the prescribing doctor may have good reason to use this combination based on your girlfriend's medical history and the doctor's own clinical experience. Combining medications that compete for CYP P-450-2D6 is not all that uncommon and dosage modifications can often compensate for compromised metabolic process.

I would be more interested in understanding the rationale of prescribing Effexor in combination with Prozac, however.

FYI The Effexor does not require the CYP P-450-2D6 process to be metabolized, so the interaction potential you referred to is not an issue with that particular medication.

 

[sarek]

Actually the prescribing doctor is her family physician. Getting her to see a psychiatrist is still a difficult struggle as she has had rather bad even traumatic experiences in the past and is very afraid of trying that road again. It would be for the best but right now we have to make do with what we have. Something had to be done about the serious episodes and thankfully the family physician was willing to cooperate.

I have rechecked and it seems the Abilify is not actually doing much against the hearing of voices. If anything it even seems to increase the problem slightly. But it definitely is keeping the larger episodes at bay. All the more reason for seeing if an ad hoc dosage pattern might be more useful.
I have no clue why the doc would combine Effexor with Prozac. I will ask her if the doc has told her what the reason was. I assume its not a common combination?
Are there perhaps better antidepressants available for a situation like this?

 

[David Baxter PhD]

It may be that she is at a dose with one SSRI that is either near the maximum or likely to cause unacceptable side effects if increased further, so she added a second antidepressant to augment the first. Difficult to say without knowing more details. Can you ask the doctor on her behalf, i.e., by accompanying her to one of her appointments? (The doctor won't be able to tell you anything unless your girlfriend is there to authorize it.)

 

[sarek]

I have been thinking about setting up such a meeting. It would take some organizing but should be doable.

But as for my primary question I am to assume that the research that was referred to does not exist? If I want to talk about options with the family physician it would be beneficial if I had some in the first place.

 

[Retired]

I will ask her if the doc has told her what the reason was. I assume its not a common combination?
Are there perhaps better antidepressants available for a situation like this?

As Dr. Baxter alludes to, the prescribing doctor would be explain the rationale of combining a short acting serotonin / norepinephrine reuptake inhibitor (Effexor) along with a long acting SSRI (Prozac). Both medications are are similar in their mechanism of action, except that Effexor affects 2 neurotransmitters instead of just serotonin in Prozac. It is not a combination that comes to mind as a first choice, but as has been said, there may be reasons based on your girlfriend's particular case to treat in this manner.

As you are probably aware, Prozac increases the supply of serotonin, a chemical (neurotransmitter) that serves as a messenger between brain cells. Effexor increases the supply of a second chemical messenger, norepinephrine, as well as serotonin. Serotonin and norepinephrine are the brain chemicals thought to affect mood and cause depression.

A conversation with the prescribing doctor, with your girlfriend's permission might yield some answers.

In having this conversation with the doctor, polite diplomacy might be the best approach in questioning the rationale of treatment. Depending on the doctor, appearing to ask the doctor to justify a treatment strategy sometimes creates a defensive reaction in the physician and can become confrontational at worst. Explaining you've done some research on your own on the internet and would like to better understand your girlfriend's medications allows the physician to not feel defensive.

If I were in your situation, two key questions I would be curious about would be:

• How do these two similar medications (Prozac and Effexor) work together to address the diagnosis of your girlfriend?
• Should there be any concern about an apparant drug / drug interaction between Prozac and Abilify. (The interaction being in the cytochrome P450 liver enzyme where these two drugs are metabolized)

Cytochrome P450 interaction is a topic most physicians should be familiar with today, as many drugs fall into the category of being metabolized using that system. The skill is to choose drug combinations that do not compete for that particular liver enzyme, and most drug categories have at least one so-called "clean metabolizer". In the case of antidepressants, Effexor happens to be one of those "clean metabolizers"