Patient diagnosed with intractable major depression. Olanzapine treatment caused severe drug-induced Parkinsonian symptoms. Olanzapine discontinued 18 months ago and patient recovered from DIP. What alternative medication would you recommend?
Olanzapine is not the cause of Parkinson's symptoms. Later, they would have shown themselves without the use of olanzapine. Antidepressants are a chemical simulation of virtual reality in the brain. The effect of antipressants on depression is limited and unpredictable without completely eliminating depression. Antidepressants are a means of altering the course of depression. This is the same as changing the course of a river, changing the place of flow of the water flow. The alternative is fine tuning the physiological processes in the body.
I would wonder if the person has Bipolar II, why zyprexa for depression if that is the diagnosis. I don't see much parkinsonism with zyprexa but I rarely use it unless I have a skinny violent guy with psychosis. Does the person have a personality disorder? Trintellix with rexulti are supposed to be a good combination for people with resistant depression. In 30 years of work, I have no one with resistant depression. Good luck.
olanzapine, and risperidone were equally effective in the treatment of major depressive episodes with psychotic features and that the three drugs were equally tolerated, without significant differences in reported side effects
There are a number of strategies depending on what has been tried already, and how intractable the condition is. The gold standard treatment, after several medication trials of adequate dose and duration have failed, is electroconvulsive (shock) treatment. Short of that, traditional (usually SSRI or SNRI) antidepressants can be used in combination, with or without a second-generation neuroleptic like olanzapine, aripiprazole, or ziprazodone. Parkinsonian side-effects are uncommon in this class, but not impossible. There are other augmentation strategies as well, such as adding thyroid hormone or lithium to the antidepressant(s). Another option is transcranial magnetic stimulation (TMS). In sum, there are many answers to this question.
one could take advantage from tricyclic antidepressant: used cautiously, these old but still valuable drugs might be especially useful in case of Parkinson(ism)
regards, MC
There seems like 3 clinical issues here-
1) Intractable depression- pseudo resistance should be ruled out first (5 Ds)
2) Olanzapine-induced parkinsonism- should be verified. olanzapine is medium potency. This EPS is theoretically possible esp if an SSRI is being concomitantly used or underlying neuro deficit (e.g. primary PD or dementia). Atypical NMS is a remote possibility.
3) Treatment options-
a) ECT for both MDD and possible PD
b) Esketamine or ketamine infusion
c) Seroquel in lieu of olanzapine
d) augmentation with a dopaminergic agent (pramipexole)
e) Cautious trial of a TCA (provided no CI)- least preferred
Liaison with neuro might help to address underlying incipient neuro d
Regards
Camellia
Rothschild, Anthony J., Douglas J. Williamson, Mauricio F. Tohen, Alan Schatzberg, Scott W. Andersen, Luann E. Van Campen, Todd M. Sanger, and Gary D. Tollefson. "A double-blind, randomized study of olanzapine and olanzapine/fluoxetine combination for major depression with psychotic features." Journal of Clinical Psychopharmacology 24, no. 4 (2004): 365-373.
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