Q:  Paliperidone

Though I have not officially been diagnosed with bipolar disorder, I have struggled with cyclical depression for about 4 years (I am now almost 21). I was originally taking Celexa and a low dose of Ripserdal. However, this spring it seemed that my cycles were not improving and probably getting worse. Based on a suggestion from a doctor, I was weaned off both of those meds and am now taking 200mg of Lamictal.

However, it seems that I will need an additional medication to prevent my cyclic depressive symptoms. Based on the information that I have gained from your website and your book, I am hesitant to go back on an antidepressant. Due to this concern, my doctor suggested I try using paliperidone on an "as needed" basis (when I am not doing well or anticipate not doing as well.) I found limited information about this med in reference to bipolar since it is still fairly new. I was wondering if you have had any experience with this medication?


Dear CB --

Generally I try not to use new medications for as long as possible, so the somebody else's patience can find out what the real problems with the medication are. However, in the case of paliperidone, this medication has actually been around for 15 years -- or rather, its parent medication has. This is just the first metabolite of risperidone. So there is less to worry about as regards unknown risks down the line. Risks we have already known about, such as increasing levels of prolactin, are the same for this as they are for risperidone, the manufacturer has already indicated.

Therefore one could wonder "why should I use paliperidone, then? Why not just use risperidone?" So far I have not heard a good answer to that question. Risperidone will not become available as a lower-priced generic until late 2008, but at that point one would have to have a major reason to use paliperidone instead of risperidone.

Meanwhile, if the idea is that Lamictal alone at 200 mg is not preventing cycling, the options you need to examine are all those which have mood stabilizing properties, perhaps giving me a slight edge to those with antidepressant properties as well. Such options include simply increasing the dose of Lamictal, which does often work better at higher doses than at lower doses. Or lithium, which in low doses as an add-on booster can be very effective with few or no side effects and very little risk (at least compared to some other alternatives). Or really any other mood stabilizers should be considered. Note that on my updated list of mood stabilizer options, risperidone is not really amongst the "mood stabilizers" as such. It is an anti-manic but it has no randomized-trial evidence thus far for antidepressant or mood-maintenance benefits.

The point is, there are still plenty of things to consider before you have to look at going back on an antidepressant. Here are at least nine such antidepressant-but-not-antidepressant options -- as well as risperidone, if it works well and does not cause any trouble. That ought to give you plenty to discuss with your psychiatrist. I hope that might be helpful.

Dr. Phelps