Suggest an alternative to Quetiapine

[BeMintFatball]

My Dd went on Quetiapine in January. Started on 25mg. Increased to 50mg and developed a tic. She does not have Tourette’s and has never tic’d before. Then increase to 75mg where she is right now. OMg the bad body odour is something else . She showers twice a day . Three times in the hot heatwave we had this year. Now the body aches are getting her down.

she is due a meds review in November. I have read that at such a low dose Quetiapine doesn’t even work as an antipsychotic. More like an antihistamine to make her tired and therefore knock her out at night.

She is diagnosed as bi polar but I think it’s a wrong diagnosis as she is like no other person with bi polar that I have met.

i just don’t think Quetiapine agrees with her.

Maybe aripiprizole? I was on it and it didn’t work for me as I needed a stronger antipsychotic but my friend who has bipolar has had lots of success with it.

The tic and body aches would definitely be worth raising with her doctor. If she’s struggling with the side effects, there may be other options to discuss at the medication review. I wouldn’t change or stop it without speaking to her prescriber first.

If it is for bipolar, it may be worth researching/asking about Lamotragene. I may have spelled that incorrectly, but that is how it sounds. It is an anti-epilepsy drug but works for bipolar as it levels out excessive brain activity (that's a gross simplification, but I'm short on time!)

risperidone?

Aripiprazole or olanzapine are the next line of treatment. The psychiatrist will recommend what they think though, ime. BTW I am unlike stereotypes of people with bipolar. I still have it. Please don’t convince her that her medical diagnosis is wrong. People did that to me and I ruined my life even more before going on regular medication.

Be sure to research the “lamictal rash” when researching this drug, I don’t know anyone with bipolar who hasn’t tried lamotrigine (brand name is lamictal) and eventually ended up with the potentially deadly rash.

She was on risperidone from age 15 for at least 5 years. At most 1mg night and morning. Weaned off slowly. The last psychiatrist she saw when she was discharged from adult mental health service and had the section 117 lifted said she should never go back on Risperidone because there newer medications and less risks to liver. But I agree it was effective for her just wasn’t great for her hormones and she did gain weight on it.

Good old Lamotrigine. I have epilepsy took Lamotrigine and Topiramate for years on my forties. I recall Lamotrigine made my skin spotty. I do remember being told to look out rashes

When you say a tic, what do you mean exactly? It’s not tardive dyskinesia, is it? If so that should be addressed by her psychiatrist as a matter of priority, so I’d be calling and letting them know so they can take her off it ASAP.

Would be interested to hear how your bipolar differs from the stereotypical norm is supposed to be.

I think because my daughter had 2 psychotic episodes in one year during 2017 that was enough to diagnose her as having bi polar.

However I would argue that it was actually all one episode poorly managed and she became so unwell that she was sectioned and spent time as an inpatient on an adolescent’s unit.

She has been majorly unwell 3 times in her life. The first was the only time she has been an inpatient. The second time I managed her at home . But previously there was a clear trigger, something traumatic happening. But this time , no clear trigger. There was a couple of weeks where she seemed withdrawn and then fell
apart.

There is no obvious psychosis. No staying awake all night. No I’m invincible burst of productivity . Nothing manic. No sexual behaviour ( had that in the past wasn’t fun to live with).

This last 10 months have presented as extreme anxiety followed by depression after her grandmother passed. Her memory is shot. There are themes that she is obsessed with. On the daily , asking me where she was at (insert date) has she ever lived anywhere else. Has she ever been in trouble with the police? Has she been to court? Does she have a criminal record. It’s exhausting answering no none of that has ever happened. Could these be intrusive thoughts?

Read the book Bipolar, Not So Much. Hw recommends Lamictal.

What are her symptoms? She could be having mixed episodes.

Her current symptoms anxiety and depression are the main ones. She needs reassurance on the daily that she hasn’t done anything wrong, that she is not in trouble with the police , that she doesn’t owe anyone any money. She worries she owes taxes. She asks do her benefits have to be paid back.

Homelessness is a major concern for her. Even though we have always said we will make sure that never happens . She has a learning disability and has just been awarded LCWRA. When she got the news she cried happy tears. Said that was a great weight off her mind.

She has a lot of friends but says she feels lonely. And I get what she means , she doesn’t have a ride or die special friend. When she was at school she had a couple of very close friends. But they have gone to university and moved in with their lives.

Has she ever had any psychosis? Is she also on SSRIs? Ability is apparently very good for mixed episodes as is good old Haloperidol

As I said in my earlier post yes she had psychosis in 2017. She was at school at the time and history lessons cover WW2. She started seeing images and signs of Hitler everywhere. When she was an in patient she saw each person as a well known athlete in her chosen sport. One girl she called Katie because she thought she was her coach. However this girl really was called Katie. I can see the look of sadness and disappointment on that girl’s face when she realised my daughter thought she was someone else and wasn’t really seeing her. Another friend she met in the psych ward said she knew my daughter was in recovery when my daughter used her real name.

She has said some odd things that are not true but nothing as psychotic as what she was like in 2017.

Btw thank you for the book recommendation.

A close family relative is stable on 5mg Olanzapine and 20mg Citalopram. Had a very severe psychotic episode earlier this year, ended up sectioned it was horrific.

Olanzapine increased appetite , so he did gain a bit, but is eating healthier now and exercising again, which all helps. Bi Polar hasn’t been ruled out, but his psychiatrist is still unsure of cause. Took a lot of med tweaking before he stabilised. Was discharged from section early, and it’s been a very hard year, I empathise @BeMintFatball 💐

@Middlemarch123 thank you . My daughter is now down to 8st . She is too anxious to eat a lot of the time. Food makes her feel physically sick. Gaining a bit of weight wouldn’t hurt.

Hhm well yeah she does sound bipolar spectrum, that book is really good because it breaks down the different types of bi polarity presentations and presents it as a spectrum. Mixed episodes often never have the up of hyper or hypomanias sometimes just psychosis with depression and anxiety which is incredibly painful for the person affected (and their families). In the book, the doctor recommends different medications and ranks them. He also gives strategies of how to manage discussion with treating team.

Then Olanzapine might well help, it’s an anti psychotic, what they call a blanket drug, often used during psychosis, pre diagnoses, because it covers schizophrenia and bi polar. One tablet at night. Weight gain is a known side effect. Good luck.

@BrickMaker I’d never thought of bipolar as a spectrum . I am guilty of having black and white thinking, something that was pointed at to me at a job review a long time ago. I will read the book.

Today has been a non starter. Very difficult to wake Dd. She came downstairs like a zombie complaining of being very tired and in a lot of body pain. Refused to take paracetamol for the pain. Don’t know whether she has taken her morning meds or not. She’s gone back to bed to sleep. Shame as she does a voluntary thing on a Wednesday morning that she enjoys and she has missed it.

That's so hard. Hopefully getting the right meds will help.There is also a good therapy for bi polar which you can do yourself called Social Rhythm Therapy or something like that.

@BrickMaker @MiraculousLadybug @BibbityBoppityTwo @Middlemarch123 @PurpleLovecats @sofffty @Spidey66 @Wajeehakamran

tagged you all as you were kind enough to reply to my OP.

The day took an unexpected turn. The lethargy, headache and pain on legs continued throughout the day. I called 999 . Paramedic called back, said it would be quicker to take her to A&E. Had fast heart rate. Got sent to out of hours GP. Explained her history for last 10 months. GP said symptoms were not mental health and he wanted to know what her iron was doing. My reply well she has pernicious anaemia . She takes iron and B12 everyday plus has B12 injections. Immediately doctor said that changes everything. She has to go back in the morning for range of blood tests and an MRI scan. He also said to leave off all
Quetiapine. Shit going cold turkey on that is not going to be good.

I feel sick to my stomach. If her iron and b12 are so low that they are causing neurological symptoms this could be permanent . She can’t even walk without support now. The unsteady gait is new as of yesterday.

So sorry to read this update, of course you’re worried sick, hopefully they can treat your DD quickly. Look after yourself x

Fast heart rate could be due to quetiapine - it has tachycardia as a potential side effect and it can also cause prolonged qt syndrome.

Quetiapine cold turkey isn't fun but also after a short time it should be fairly self limiting. The key is getting enough sleep in the first couple of days. I have been on it since 2012 and had times when I have forgotten to take it with me in when away. The first night I get pretty awful broken sleep and the next day feel slightly hungover. The day after is usually better and if I've missed a third day I usually start to feel pretty normal.

It's the sedativeness that is the biggest issue for withdrawal so if she is already lethargic that might be a blessing.

In answer to your original question, that does of quetiapine is probably not going to making a huge positive effect. Quetiapine works in several different ways and the dose varies depending which properties you need. It is more sedating at low doses so when it is used as a sleeping aid doses of 25-50mg are usually used this a side effect of it being an antihistamine. It can acts as an antidepressants as well acting on serotonin receptors - doses for this are usually in the 150-450+mg ball park, it can act as an antipsychotic/anti manic agent acting on dopamine receptors and for this you are looking at 300-800mg. Mood stabilising for bipolar needs to balance the antidepressants and antimanic activities and you can be looking at doses that overlap the two criteria.
Obviously these are all rough numbers and the exact numbers needed will vary from person to person and you should raise it with the prescribing doctor. From your initial posts I would have been suggesting you speak to the prescribing Dr about the doses of quetiapine and what is the expected benefit from it - potentially referring to the bsms prescribing recommendations for different symptoms for quetiapine. It may well be that the changes in doses so far haven't hit the sweet spot for symptom management and side effects vary with dose too.

I have been on doses between 300 and 800 mg. 300-450 mg is used as my maintenance dose if I have long term stability. I need 300-600 mg to manage simple depression symptoms, 600+mg and other medications for stubborn depression and 600-800mg if there is any signs of agitated depression, psychosis or mania. I'm in the middle of a very stubborn depressive episode at the moment and an on 650 mg with antidepressants. There were a few features of agitation and anxiety with worries of mania and psychosis which is why it is currently slightly above the 600mg for antidepressants properties but I'm not currently experiencing psychosis so it right at the bottom end of the range I need for those symptoms. It can have a blunting effect on my mood when above 600mg which is beneficial when I'm agitated but when I'm in a flat mood unhelpful. This is the tightrope we are currently walking.

Look at getting physical health stabilised and have a frank conversation about the role of medication and that will have decide on a path forward.

• if quetiapine is meant as sedative what are the other options.
• if quetiapine is meant as an antidepressant - would it be worth looking at sedating antidepressants and adding a mood stabilisers to avoid high moods.
• if quetiapine is meant as a mood stabilisers - it might be worth looking at the old school mood stabilisers such as lithium or lamotrigine
• if quetiapine is meant as an antipsychotic - it would be worth looking at other 2nd generation atypical antipsychotics.

Has she ever had any episodes where mania or hypomania has been experienced?

Some of these medication are hard on the body. I'm going through this at the moment as I have persistent severe fatigue which started in pregnancy due to liver combination. I am also having a bad depressive episode and am on quetiapine, mirtazapine and venlafaxine. The polypharmacy is probably not helping my liver but reducing the meds makes my depression worse. When I had my eldest i spent 10 weeks in a mother and baby unit with treatment resistant depression and psychosis. My team have been trying really hard to keep my mood stable enough to avoid an admission. I'm under endocrinology as well to try to identify the physical stuff it's hard to disentangle everything!!

Bipolar : lithium is a total game changer.