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What causes excessive sleepiness after taking Zyprexa and Trilafon?

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Posted on Mon, 30 Nov 2015
Question: Hello, I am writing regarding my 21 year old son. My question is about sleep and you seem to be the right person to ask. He had a psychotic episode at age 20 after going away to college and doing a lot of marijuana/alcohol/some other drugs. He ended up with mono, came home from school at the end of freshman year, was quite sick and had psychosis a few months later after trying ecstacy. For meds, he started with seroquel/effexor and slept for 4 months, switched to zyprexa and gained 25 lbs in 6 weeks and is still dealing with metabolic syndrome, stopped that after 6 weeks and started lithium and eventually added perphenazine 4 mg. He took lithium for 4 months, but thyroid function was getting worse and worse despite synthroid supplementation. TSH of 10.1 led to cessation of lithium about 6 weeks ago. Currently, my son is taking perphanezine 4mg, effexor 150mg, levothyroxine 75mcg, doxycycline (for scalp infection ongoing since zyprexa - now losing round patches of hair!) and he just stopped metformin 1500mg which he took for several months in hopes of helping his metabolic issue.

Finally,.. Sleeping has been an issue since starting seroquel. He sleeps at least 12 hours a day, sometimes up to 16 hours. He often wakes up exhausted with little energy, even since stopping lithium. He often looks like he got 2 hours of sleep when he wakes up. He says he dreams a lot, usually nightmares. His psych doctor prescribed him 50 mg of trazodone and he took one and said he slept awful, dreamt more then ever, and he woke up looking horrible. This was given in an attempt to increase his deeper sleep cycles.

Do you have any suggestions regarding the sleep issues? After sleeping and taking naps that he has to take because he feels exhausted, he barely has any time left in the day. He works 2 days weekly and takes 2 college classes and works out 5 days a week. This takes up every waking hour he has. No one could survive on their own requiring this much sleep.

I'll take any feedback you have regarding any part of his situation.

Also, he has been working out and eating great for 4-5 months, and can barely lose any weight. He has fat pockets on his outer stomach / upper hips and a belly. He is usually lean and fit. Do you think these metabolic changes will continue to improve over time or are we looking at permanent changes? Any suggestions here?

Thank you SO MUCH!!

doctor
Answered by Dr. Alexander H. Sheppe (33 minutes later)
Brief Answer:
Consultation

Detailed Answer:
Let me begin by thanking you very much for using my direct, private service. I consider your son a direct patient of mine, and will do everything in my power to be of help to you and to him.

I have read over your question carefully, and I have some thoughts that I hope will be helpful.

Your son has been through a tremendous series of difficulties. It appears the medication regimen that has been deemed most appropriate for his condition consists of a mood stabilizer (previously lithium) and a neuroleptic (previously Zyprexa, now Trilafon or perphenazine). He is currently on Trilafon and Effexor.

A couple thoughts. First, if lithium was considered appropriate, Effexor has a chance of "activating" him, or pushing him towards the manic/psychotic spectrum. I would've considered replacing lithium (given thyroid toxicity) with Depakote, a mood stabilizer, rather than Effexor. But this is a side issue and not the heart of your question.

Somnolence, or sleepiness, is a major side effect of both Zyprexa and Trilafon. Typically, the body will adjust to this over a period of several weeks, to the point where somnolence is not a major problem. It seems that with his current regimen, somnolence remains a major problem even after several months. Given this information, I would consider a less sedating neuroleptic to replace Trilafon. Options include Risperdal, Abilify, Latuda, and Saphris. These are generally seen as weaker neuroleptics, but in reality the studies appear to show that they are as effective as Trilafon in controlling psychotic symptoms. I would ask his doctor if switching to one of these would be appropriate for him. I would also check his thyroid function to make sure this is normal, as abnormal thyroid levels can create fatigue.

As for the weight gain, this is a notorious side effect of Zyprexa. Average weight gain on this medication is around 25 pounds. The good news is that now that the Zyprexa has been stopped, this side effect should be entirely reversible. Metformin is intended to help with this, but give it some time -- with proper diet and exercise, I have often seen Zyprexa-added weight melt away relatively quickly. Zyprexa is a very good medication, but this side effect is a tricky one, and fortunately is entirely reversible.

Dr. Sheppe
Above answer was peer-reviewed by : Dr. Prasad
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Follow up: Dr. Alexander H. Sheppe (31 minutes later)
Thank you very much for your response! I'm going to ask a couple of questions and have copied your response:

Your son has been through a tremendous series of difficulties. It appears the medication regimen that has been deemed most appropriate for his condition consists of a mood stabilizer (previously lithium) and a neuroleptic (previously Zyprexa, now Trilafon or perphenazine). He is currently on Trilafon and Effexor.

A couple thoughts. First, if lithium was considered appropriate, Effexor has a chance of "activating" him, or pushing him towards the manic/psychotic spectrum. I would've considered replacing lithium (given thyroid toxicity) with Depakote, a mood stabilizer, rather than Effexor. But this is a side issue and not the heart of your question. HE HAS BEEN ON EFFEXOR SINCE PRIOR TO THE INITIAL PSYCHOTIC EPISODE AND NO ONE HAS WANTED TO TAKE HIM OFF IT. THE LITHIUM WAS ADDED TO THE REGIMEN IN 1/15 IN AN ATTEMPT TO STABILIZE HIS MOOD. WE NEVER FELT HE WAS BIPOLAR BECAUSE ANY MANIA HE HAD EVER EXPERIENCED HAD BEEN ASSOCIATED WITH DRUG USE, SO WE ASKED TO TRY TO GO WITHOUT A MOOD STABALISER AND HE SEEMS TO BE OK WITHOUT IT. IT HAS BEEN 6 WEEKS.

Somnolence, or sleepiness, is a major side effect of both Zyprexa and Trilafon. Typically, the body will adjust to this over a period of several weeks, to the point where somnolence is not a major problem. It seems that with his current regimen, somnolence remains a major problem even after several months. Given this information, I would consider a less sedating neuroleptic to replace Trilafon. Options include Risperdal, Abilify, Latuda, and Saphris. These are generally seen as weaker neuroleptics, but in reality the studies appear to show that they are as effective as Trilafon in controlling psychotic symptoms. HE HAS ACTUALLY TRIED THE FIRST THREE AND DEVELOPED AKETHESIA. HE ABSOLUTELY HATED THE FEELING AND SAID HE WOULD ALMOST RATHER HAVE A LEG CUT OFF THEN GO THROUGH THAT AWFUL, RELENTLESS FEELING AGAIN. DO YOU THINK A DOSE OF 4MG TRILAFON WOULD CAUSE SOMNOLENCE? HIS DOCTOR SAID IT IS A VERY SMALL DOSE. I would ask his doctor if switching to one of these would be appropriate for him. I would also check his thyroid function to make sure this is normal, as abnormal thyroid levels can create fatigue. MY SON HAS HAD THYROID ISSUES SINCE ZYPREXA. HE IS TAKING SYNTHROID AND FINALLY HAS A NORMAL LEVEL. WITH ABNORMAL LEVELS, HE WAS SLEEPING 16 HOURS PER DAY. HE IS NOW SLEEPING 12-14 HRS/DAY. IS THERE ANYTHING THAT CAN BE DONE TO DECREASE DREAMING AND INCREASE QUALITY SLEEP?

As for the weight gain, this is a notorious side effect of Zyprexa. Average weight gain on this medication is around 25 pounds. The good news is that now that the Zyprexa has been stopped, this side effect should be entirely reversible. Metformin is intended to help with this, but give it some time -- with proper diet and exercise, I have often seen Zyprexa-added weight melt away relatively quickly. Zyprexa is a very good medication, but this side effect is a tricky one, and fortunately is entirely reversible. MY SON HAS BEEN OFF ZYPREXA FOR ALMOST 8 MONTHS. HE HAS BEEN EXERCISING AND EATING A VERY HEALTHY DIET FOR 4 MONTHS AND HAS ONLY LOST 5 POUNDS. HIS DOCTOR SAID THIS MAY BE A PERMANENT METABOLIC ISSUE. HE HAS BEEN TAKING METFORMIN FOR 3 MONTHS. HE JUST STOPPED IT YESTERDAY BECAUSE HE IS TIRED OF ALL THE PILLS. IT SOUNDS LIKE YOU DON'T BELIEVE IN PERMANENT METABOLIC CHANGES FROM ZYPREXA. I SURE HOPE HIS METABOLISM IMPROVES. ANY OTHER THOUGHTS?

Sorry for the caps and thank you so much!
doctor
Answered by Dr. Alexander H. Sheppe (7 minutes later)
Brief Answer:
Follow-up

Detailed Answer:
Thanks so much for the additional history and clarifications.

#1 WE NEVER FELT HE WAS BIPOLAR BECAUSE ANY MANIA HE HAD EVER EXPERIENCED HAD BEEN ASSOCIATED WITH DRUG USE, SO WE ASKED TO TRY TO GO WITHOUT A MOOD STABALISER AND HE SEEMS TO BE OK WITHOUT IT. IT HAS BEEN 6 WEEKS.

This makes perfect sense to me. He should remain on the Effexor if it is helping him. No need for Depakote in this case.

#2 HE HAS ACTUALLY TRIED THE FIRST THREE AND DEVELOPED AKETHESIA. HE ABSOLUTELY HATED THE FEELING AND SAID HE WOULD ALMOST RATHER HAVE A LEG CUT OFF THEN GO THROUGH THAT AWFUL, RELENTLESS FEELING AGAIN. DO YOU THINK A DOSE OF 4MG TRILAFON WOULD CAUSE SOMNOLENCE? HIS DOCTOR SAID IT IS A VERY SMALL DOSE.

Akathisia is indeed a terrible sensation. The typical neuroleptics like Trilafon are less likely to cause akathisia, so his doctors are making excellent choices. It is true his dose of Trilafon is small, but I suspect this is at least in part a main contributor to his somnolence. Some solutions to this would be to continue to wait to allow his body to get used to it, really working on a scheduled structured day and sleep hygiene, or perhaps trying a small dose of a stimulant such as Ritalin (though this runs a small risk of precipitating psychosis).

#3 MY SON HAS BEEN OFF ZYPREXA FOR ALMOST 8 MONTHS. HE HAS BEEN EXERCISING AND EATING A VERY HEALTHY DIET FOR 4 MONTHS AND HAS ONLY LOST 5 POUNDS. HIS DOCTOR SAID THIS MAY BE A PERMANENT METABOLIC ISSUE. HE HAS BEEN TAKING METFORMIN FOR 3 MONTHS. HE JUST STOPPED IT YESTERDAY BECAUSE HE IS TIRED OF ALL THE PILLS. IT SOUNDS LIKE YOU DON'T BELIEVE IN PERMANENT METABOLIC CHANGES FROM ZYPREXA. I SURE HOPE HIS METABOLISM IMPROVES. ANY OTHER THOUGHTS?

In my experience, weight gain from Zyprexa can be reversible and studies support that. I think in your son's case, given the fact he has only lost 5 pounds in 5 months, this process may be a long one, but there is no evidence this will or needs to be a permanent problem. Cardiovascular exercise, a healthy diet, and metformin can help. This may be a slow process but it should not be permanent.

You're very welcome!

Dr. Sheppe
Above answer was peer-reviewed by : Dr. Prasad
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Follow up: Dr. Alexander H. Sheppe (17 minutes later)
Thank you so much! One final question, do you think his weight loss will be hindered by stopping metformin? He stopped taking it yesterday because it added 3 more pills to his day and he wasn't convinced it was helping him. Thank you!
doctor
Answered by Dr. Alexander H. Sheppe (2 minutes later)
Brief Answer:
Follow-up

Detailed Answer:
I would probably encourage him to continue taking it for a while. It might not be doing a LOT, but it has been shown to protect against metabolic damage associated with all neuroleptics (including Trilafon), and will probably contribute to weight loss. I understand the inconvenience of taking extra pills during the day, so if he feels strongly about not taking it that's okay, but I do believe it would help the weight loss and has some continued benefit for him at this time.

My name is Dr. Sheppe, and I am an XXXXXXX psychiatrist working in New York City. For a personalized comprehensive evaluation, treatment recommendations, or individual therapy, ask me at HealthCareMagic at this private link: XXXX
Above answer was peer-reviewed by : Dr. Prasad
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Follow up: Dr. Alexander H. Sheppe (20 hours later)
Thank you for your answers! Do you have any idea why he would continue to have persistent, but very mild psychosis? He is very mildly paranoid and has some very mild thought disturbance. It isn't very troubling to him. He stopped using marijuana and has very limited alcohol for the last 6 months. No other drugs, eating healthy, taking fish oil, exercising 5 days a week. Still very fatigued. I'm just confused about why he has psychosis if he doesn't have bipolar.
doctor
Answered by Dr. Alexander H. Sheppe (5 minutes later)
Brief Answer:
Follow-up

Detailed Answer:
You're very welcome!

Sometimes it is very difficult to eliminate psychotic symptoms completely. We can often control the disordered thought and paranoia to a degree where the patient is able to function again, but total elimination of symptoms is rarer. Even if your son does not have bipolar disorder, he may have a primary psychotic illness that was unearthed, but not entirely caused by, drug use. Unfortunately, the only way to tell is with time and continued treatment, and of course abstinence from drugs and alcohol with which he has done a very good job. His treaters should continue to increase neuroleptic medication (in his case, Trilafon) if he is having residual psychosis -- however, as you know, this is a balancing act, because we don't want him to be too sleepy. You need to weigh the benefits of increased Trilafon with the potential risks, like sedation. In time, you all will come to a happy medium that works best for your son.

It has been a pleasure working with you. Please do not hesitate to reach out to me in the future with further questions. I feel you have communicated your son's history to me well, so I would be able to provide continuity of care on this site for you.

My name is Dr. Sheppe, and I am an XXXXXXX psychiatrist working in New York City. For a personalized comprehensive evaluation, treatment recommendations, or individual therapy, ask me at HealthCareMagic at this private link: XXXX
Above answer was peer-reviewed by : Dr. Prasad
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Follow up: Dr. Alexander H. Sheppe (42 hours later)
Hi again Dr. Sheppe, May I ask for a few more of your opinions? You mentioned that effexor has a chance of "activating" my son, or pushing him towards the manic/psychotic spectrum without a mood stabilizer. When he stopped taking lithium, he did not become manic, so I was assuming he didn't have bipolar. t is confusing for me, however, because mildly manic is really my son's usual self since he was a teenager. (creative, lots of ideas, some silly/impractical, a little hyper focused on ideas at times.) This definitely did recur after he stopped the lithium, but I was thinking the lithium took away his personality and that his personality was just coming back. Now I am confused.

My son also decreased trilifon a few weeks after stopping the lithium. (6mg to 4mg) He has been having worsening psychosis symptoms since somewhere around the lithium cessation / trilafon decrease. Last night, the psychosis symptoms became bothersome to him and he decided he would rather be tired then have psychosis, so he took an extra trilafon. He isn't feeling any better yet.

His psychosis worsens if he works for more then about 5 hours. His head starts to hurt and he starts to feel really crappy. I can't really describe it to you very well. It seems like a stressful situation or argument will also precipitate worsening psychosis symptoms.

I am wondering if you think it sounds like he has bipolar?

Do you think not taking a mood stabilizer has made his psychosis symptoms worsen? I am wondering if he could try a small dose of topamax and if that would help his psychosis and also his weight, without making him dopey. "dopamax"

You previously mentioned taking a less sedating AP, but I told you he had akathisia from all but one - the saphris hasn't been tried. Would saphris likely give him akathisia if the other three newer ones did? (risperdone, latuda, abilify.)

Is a neuroleptic the only medication that can treat psychosis? If we could figure out and treat the underlying cause, would the psychosis go away? (bipolar vs depression vs anxiety vs psychotic condition vs mood disorder?) His doctors all agree he does not have schizophrenia, I believe because there have never been voices talking to him. His psychosis symptoms were initially feeling a ghost was coming in his room at night and getting into his spine. He said he felt intense pain and the fear of the ghost was very real to him. He realized it wasn't real when it went away after taking seroquel. The seroquel dose was decreased after 4 months because of sedation (sleeping 16-18 hrs/day) and eventually he developed psychosis symptoms centered around feeling the government was going to create a war, we needed to move out of the country to be safe, we needed guns to protect ourselves, and other conspiracy-type fears. Zyprexa fixed this pretty quickly. Now, psychosis symptoms involve feeling headachy, brain getting tired, being a little paranoid (sort of believes fluoride was put in water to calcify the pineal gland, but he is open to the idea that perhaps the pineal gland hardening was an unintended consequence of fluoride treatment that was put in water with good intentions of preventing tooth decay.) He also believes a lot of the government is corrupt, but is open to ideas that are more mainstream.

Of note, he has a severe neck sprain when he was 16 and it never healed right and developed into a chronic pain situation. Both seroquel and lithium took his pain away. Not sure if this is pertinent to diagnosis. He also claims he has had anxiety since he was about 14 years old and has compained of depression on and off from 16 years old on. Marijuana use started at 16-17.

Thank you for your help. I am so desperate for him to start living a normal life again. He is very intelligent and was previously high functioning academically and socially.
doctor
Answered by Dr. Alexander H. Sheppe (8 minutes later)
Brief Answer:
Follow-up

Detailed Answer:
I'd be happy to answer more of your questions, of course! I hope you are doing okay.

The things you are describing to me -- paranoia, delusions about the government, delusions about ghosts entering his spine, conspiracy fears -- these are classic symptoms of paranoid schizophrenia. One does not need to have auditory or visual hallucinations in order to have schizophrenia -- 6 months or more of paranoid delusions are sufficient to make this diagnosis.

Now, just because this seems the most likely diagnosis to me, does not mean this is definitely the diagnosis. Your concerns about bipolar disorder are also totally legitimate. The fact that he improved with lithium and worsened after stopping lithium means this could well be a bipolar manic/hypomanic picture with psychotic elements. He should probably resume a trial of a mood stabilizer -- lithium (even with thyroid issues, treating with lithium and treating the thyroid is acceptable), depakote, lamictal, tegretol, or trileptal. Topamax is typically not used as a monotherapy mood stabilizer. A mood stabilizer can help lessen psychosis if the psychosis is caused by a mood episode.

Time will tell. Schizophrenia is a chronic illness, and if your son has it, this means he will not return to baseline functioning and will probably need assistance his whole life. This is treatable with neuroleptics. However, if this is bipolar disorder, this is more treatable with the combination of mood stabilizers and neuroleptics, and the prognosis is better. It takes time to see what he responds to and how he functions longitudinally.

Dr. Sheppe
Above answer was peer-reviewed by : Dr. Vinay Bhardwaj
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Follow up: Dr. Alexander H. Sheppe (19 hours later)
Wow, this is devastating to hear but I appreciate your honesty. I realized I forgot to mention the first psychosis episode happened when my son took ecstasy. Thank you!
doctor
Answered by Dr. Alexander H. Sheppe (2 minutes later)
Brief Answer:
Follow-up

Detailed Answer:
I know this isn't easy to discuss, but I think I should be up front and honest about the possibilities here. That way you can prepare yourself and do everything possible to help you son whom you clearly care about so much.

The drug use is absolutely very important here. Oftentimes psychotic episodes are due entirely to drugs (ecstasy, marijuana, etc). It sounds like your son's symptoms have persisted long after the discontinuation of drugs, which suggests the drugs exacerbated or unearthed an underlying problem rather than caused the psychosis directly, but again this will take more time to figure out for sure.

Always feel free to open up another question thread and reach out to me with any questions you have. Thanks for involving me in your son's care.

Dr. Sheppe
Above answer was peer-reviewed by : Dr. Vaishalee Punj
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What causes excessive sleepiness after taking Zyprexa and Trilafon?

Brief Answer: Consultation Detailed Answer: Let me begin by thanking you very much for using my direct, private service. I consider your son a direct patient of mine, and will do everything in my power to be of help to you and to him. I have read over your question carefully, and I have some thoughts that I hope will be helpful. Your son has been through a tremendous series of difficulties. It appears the medication regimen that has been deemed most appropriate for his condition consists of a mood stabilizer (previously lithium) and a neuroleptic (previously Zyprexa, now Trilafon or perphenazine). He is currently on Trilafon and Effexor. A couple thoughts. First, if lithium was considered appropriate, Effexor has a chance of "activating" him, or pushing him towards the manic/psychotic spectrum. I would've considered replacing lithium (given thyroid toxicity) with Depakote, a mood stabilizer, rather than Effexor. But this is a side issue and not the heart of your question. Somnolence, or sleepiness, is a major side effect of both Zyprexa and Trilafon. Typically, the body will adjust to this over a period of several weeks, to the point where somnolence is not a major problem. It seems that with his current regimen, somnolence remains a major problem even after several months. Given this information, I would consider a less sedating neuroleptic to replace Trilafon. Options include Risperdal, Abilify, Latuda, and Saphris. These are generally seen as weaker neuroleptics, but in reality the studies appear to show that they are as effective as Trilafon in controlling psychotic symptoms. I would ask his doctor if switching to one of these would be appropriate for him. I would also check his thyroid function to make sure this is normal, as abnormal thyroid levels can create fatigue. As for the weight gain, this is a notorious side effect of Zyprexa. Average weight gain on this medication is around 25 pounds. The good news is that now that the Zyprexa has been stopped, this side effect should be entirely reversible. Metformin is intended to help with this, but give it some time -- with proper diet and exercise, I have often seen Zyprexa-added weight melt away relatively quickly. Zyprexa is a very good medication, but this side effect is a tricky one, and fortunately is entirely reversible. Dr. Sheppe