US Brand Name: Risperdal
Other Brand Names: Neripros (Indonesia)
Risperdal Consta (United Kingom; Ireland; New Zealand)
Rispolept (Poland)Rizodal (Indonesia)
りス パ ダ —ル / Risperdal (Japan). Transliterated back from the Katakana as “risupadāru” and phonetically “reesupadayru.”
Generic Name: risperidone
Other Forms: Orally disintegrating tablets. Oral solution (I can tell you from personal experience that it tastes horrible; the PI sheet states that it absolutely cannot be chased by colas or teas). Intramuscular injection.
What is Risperdal?: Risperdal is an Antipsychotic, specifically an atypical antipsychotic.
Read up on these sections if you haven’t done so already, because they cover a lot of information about multiple medications that I’m not going to repeat on many pages. I’m just autistic that way about not repeating myself.
What are Risperdal’s FDA Approved Uses:
Psychosis. Schizophrenia. – Approved 1993.
Bipolar Disorder – Approved December 2003.
Autistic Spectrum Disorders and Pervasive Developmental Disorders in children – Approved 6 October, 2006.
What are Risperdal’s Off-Label Uses. Risperdal is also used for:
Autistic Spectrum Disorders adults There are more studies for kids, of course. Many more. You get the picture.
Augmenting SSRIs to treat OCD.
Augmenting SSRIs to treat major depression. T
reating Tourette’s syndrome (but watch out for depression and dysphoria). Stuttering.
Although frequently given to treat Alzheimer’s, the latest reports have it that all atypical antipsychotics are pretty much a bust. Especially that bit about their dropping dead and all. More details to come.
What are Risperdal’s Pros and Cons:
Risperdal’s Pros: Risperdal (risperidone) is the bomb when dealing with the combination of Asperger’s and bipolar, or just Asperger’s and other forms of autism alone. At least we adults who have taken it for such report that, so of course it has to be consensual, and not just drugging someone into submission, or giving some kid yet another drug in a vain attempt for a “cure.” Other than the fact it’s working you can’t even tell you’re taking it for most applications.
Risperdal’s Cons: While its side effect profile is low at the low dosages, at the dosages required to treat the primary approved applications – schizophrenia, psychosis and bipolar – it frequently does a number on your hormones, and hits you with sexual side effects. Too many pediatricians and parents start at dosages too high for their autistic children, thus incurring weight gain, sedation, confusion and, oh wait, drugging the kids into submission seems to be a feature and not bug for these people who got the less-than-perfect children. Apparently you can’t use it for hallucinogen-persisting perception disorder (HPPD).
Even though it’s class action lawsuit city with Risperdal (risperidone) and other atypical antipsychotics these days because of their side effects, the side effects really aren’t that bad! But if you’re into that sort of thing, we have a page to help you find a lawyer.
Risperdal’s Typical Side Effects:
The usual for atypical antipsychotics – headache, nausea, dry mouth, sleepiness and lethargy or insomnia and way too much energy. Most everything but the sleepiness & lethargy or bouncing off the walls usually goes away within a couple of weeks.
For tips on how to cope with these side effects, please see our side effects page.
These aren’t all the side effects possible, just the most popular ones.
Risperdal’s Not So Common Side Effects: Loss of libido and other sexual dysfunctions, but those are mostly at the mid-to-higher dosages. You know, the amount you need to treat schizophrenia, psychosis and bipolar. A large Spanish study has Risperdal (risperidone), the standard antipsychotic Haldol (haloperidol) and Zyprexa (olanzapine) the worst offenders for sexual side effects. They all seem to be dosage-related, so the higher the dosage the worse the sexual dysfunction will be. Risperdal (risperidone) tends to mess with your hormones at those dosages, so you might get all sorts of hormonal stuff involving estrogen and prolactin, including wacky periods and lactation issues. It does mess with the girls more, but sexual side effects are prevalent at dosages required to treat schizophrenia or as the only medication to treat bipolar. Oh, and guys, you may learn more than you ever wanted to personally know about lactation.
Also heart palpitations, tachycardia and other cardiac weirdness that I honestly don’t have a clue about what is scary and what is annoying. So you’ll have to ask your non-head-shrinking doctor about the heart issues. Like other antipsychotics Risperdal (risperidone) can also mess with how you process sugars, but it’s nowhere near as bad as Zyprexa (olanzapine) or Seroquel (quetiapine) in that regard.
Like any antipsychotic there is a slight, but real risk for extrapyramidal symptoms (EPS), tardive dyskenesia, and neuroleptic malignant syndrome (NMS). Please see the page on these risks. If you start twitching, kicking, jerking, or in any way any part of you moves and it wasn’t your idea – and it happens more than once – it’s time to call your doctor. Just don’t freak out. Rather, you have reason to calm down. None of this stuff is permanent. I’ve now twice had mild symptoms of EPS, including TD with Risperdal (risperidone), and lowering the dosage took care of it at one point, but eventually I had to stop taking this med because the TD symptoms wouldn’t go away. And that sucks. I don’t have any hard numbers on this, but a lot of anecdotal evidence is pointing at Risperdal as being the worst of the popular novel / atypical antipsychotics when it comes to people getting EPS.
Restless Leg Syndrome – not to be confused with the twitching of the above, but only a doctor can determine the difference. Believe me, my doctor grilled me for an hour and a half when I started twitching. It turned out to be a pinched nerve, and not EPS. Only later at a much higher dosage of Risperdal (risperidone) did I start getting real EPS. But at a lower dosage the symptoms went away. No big deal that time! However Risperdal can start or aggravate RLS, so you may have to deal with that.
These may or may not happen to you don’t, so don’t be surprised one way or the other.
Risperdal’s Freaky Rare Side Effects: Rabbit Syndrome. Duck syndrome! Rabbit syndrome! Duck syndrome! Sorry. Plus discolored feces, and increased pigmentation. Hey, maybe we can tan after all! And, as always, that priapism.
Risperdal’s Suicide Risk: The use of Risperdal has documented suicide attempts in the clinical trials for schizophrenia (1.2% for Risperdal vs. 0.6% for placebo). But all psychiatric and neurological meds have a potential suicide risk. It actually tests extremely well as a suicide preventative, and in that respect its use far outweighs any suicide risk.
Interesting Stuff Your Doctor Probably Won’t Tell You About Risperdal: Risperdal is extensively metabolized by your liver using the enzyme CYP2D6. About 6-8% of Caucasians, and a very low percentage of Asians, have little or no activity of that enzyme, and are known in the trade as “poor metabolizers.” Risperdal (risperidone) and other medications, including Strattera (atomoxetine), Prozac (fluoxetine) and Paxil (paroxetine) are flushed out of your system by that enzyme. As such you have to be very careful if you are a poor metabolizer, as I am, and you combine Risperdal (risperidone) with one of those meds, as I do. Hell, even if you aren’t a poor metabolizer you need to watch out if you mix meds that use the same enzymes. The most recent case of EPS I experienced came after adding a new med, Reminyl (galantamine HBr) that is also extensively metabolized by CYP2D6. My system was suddenly flooded with a higher concentration of the active metabolite of Risperdal (risperidone) and it decided to hang around for a longer time than usual.
Because it works your liver pretty hard and does a double metabolism, there are going to be plenty of drug-drug interactions. Check with your pharmacist and double-check at my preferred Drug-Drug Interactions site if you’re taking any other medications, either prescription or over-the-counter. I’d also recommend an annual liver function panel, just to make sure your liver is always up to snuff.
Risperdal’s dosage and how to take Risperdal:
Once again I strongly disagree with the standard dosing schedule. By the book for both bipolar disorder and schizophrenia they would start you out at 2 to 3mg a day! No matter how bad your symptoms are. That’s just crazy! Risperdal (risperidone) is, milligram for milligram, the most potent antipsychotic on the market and they’d start you out half-way to the maintenance dosage for bipolar!
Now I’m reading study after study about schizophrenia, and improvement is seen when people start at 2mg a day within two days to a week. So here’s where you’re going to have to decide what is sucking most. If your symptoms are really harsh right now, then start at 2mg a day and get fast, fast relief. Just be prepared to put up with the potential of harsh, if temporary, side effects. That’s really what it’s all about, easing into the med, and putting off it’s effect, or getting it to work right away. You also increase the chances of EPS, and having to stop Risperdal and switching to another med. Decisions, decisions.
So it’s like this, if the ambassador from Zeta Reticula is visiting you every day with orders on how to start The Cleansing, and you’re not taking any medications at all, then starting at 2mg a day is a Very Good Idea.
But if you’re already on Depakote, your levels are good but you’re just getting a bit hypomanic now and then, you should talk to your doctor about starting at 0.25 to 0.5mg a day. Maybe it’ll work in three days to a week, maybe you’ll have to work up to a higher dosage. Trust me, your liver will be happier if your brain isn’t flipping out.
If you’re a friend or family member reading this and your loved one is in a hospital and they’ve been started at 3mg a day, there’s a reason for it. They’ve been hospitalized! Starting that high is going to suck, it’s going to really suck, it’s going to suck worse because they’re in a hospital. But all of that is going to suck much, much less than what could happen to them outside of the hospital setting.
But anyone who is together enough to not be in a hospital does not necessarily need to start Risperdal (risperidone) at 2mg a day. That’s all there is to it. I think it’s optional.
Hey, why the hell do you think they make the 0.25mg pills in the first place? The pediatric market isn’t that big. So if you’re not in a hospital and the next horsie to ride on the med-go-round is Risperdal (risperidone) ask about starting at 0.25 to 0.5mg a day and try to think about what a higher dosage means.
In any event, the clinical trials for Risperdal’s approval, as well as numerous studies vs. other meds, are showing that 6mg a day is the optimal dosage for most people. See the How Risperdal Works page for details.
Unless you’re switching from another atypical antipsychotic that you’ve had to stop because of EPS or other nasty side effects. In which case a rough guide to dosage conversion is as follows:
Risperdal (risperidone) – 0.5mg = Zyprexa (olanzapine) – 2.5mg = Abilify (aripiprazole) – 3mg = Geodon (ziprasidone) – 20mg = Seroquel (quetiapine) – 100mg
This guide works best at the lower dosages as given. As these things aren’t that linear, it doesn’t map out that well at the higher dosages. So if your doctor switches you from one to another and you jump from one mid-to-high dosage to some other mid-to-high dosage, the odds are it’s going to be the correct dosage.
Sorry, I don’t know the conversion of typical antipsychotics to atypicals. I know you can do it, I just don’t know the ratios.
So if you were on 400mg of Seroquel (quetiapine) then it would be OK to start taking 2mg of Risperdal (risperidone). You’d probably skip some of the common side effects during the transition.
Anyway, if you’re not switching from one antipsychotic to the other, and you’re not really wigging out, there’s no need to ramp up the Risperdal (risperidone) so quickly! Start at 0.25 to 0.5mg a day and increase it by 0.25 to 0.5mg a day every week or two (depending on how often you see your doctor) until your symptoms go away, the side effects get too harsh, or you hit the maximum 6-8mg a day (out patient) or 16mg a day (in patient) dosage.
You can take Risperdal (risperidone) one to four times a day. It looks like once a day works for bipolar and multiple doses work better for schizophrenia.
The dosages I could find for all of the off-label applications are really low. Nothing was above 2mg a day and all started at 0.25mg a day. I was taking 0.5mg a day and it was a huge help for both the autism and the bipolar. As a poor metabolizer and in the autistic spectrum I define cheap date, so your mileage will vary on the dosage.
How Long Risperdal Takes to Work: Like all antipsychotics you’ll feel something the next day. By the time you reach a steady state, in five to six days, you’ll know if this med is going to do anything for you. Various studies and trials have shown results in 2 to 7 days. See the How Risperdal Works page for details. Most studies are showing effect after you reach 2mg a day, but that’s when it’s the only med you’re taking.
How to Stop Taking Risperdal: Your doctor should be recommending that you reduce your dosage by 0.25 or 0.5mg a day every 4 to 5 days, if not more slowly than that. Based on the 20 hours for psychiatric effects, so it’s 4 to 5 days to step down each dosage. For more information, please see the page on how to safely stop taking these crazy meds.
If you’ve worked your way up to a particular dosage, it’s usually best to spend this many days at the next lowest dosage before going down the next lowest dosage before that and so forth. This is the least sucky way to avoid problems when stopping any psychiatric medication. Presuming you have the option of slowly tapering off them.
Average Time for Risperdal to Clear Out of Your System: Since Risperdal’s half-life is complicated, the average time is going to be four days.
Chances Risperdal Will Work and How Risperdal Compares to Other Meds: Odds it will work for schizophrenia – excellent for “normal” schizophrenia, schizoaffective and schizophreniform disorders. That is, you don’t have the refractory/treatment resistant forms. How do you know if you’re treatment-resistant or not? Basically meds don’t work. So if a bunch of other meds haven’t worked, Risperdal probably won’t either, but if you’re desperate you may as well try it because it has worked for those forms. It’s just sort-of OK with them. If Risperdal is your first med, go for it! It works fast at dosages of 2mg a day and above and the side effects aren’t too bad.
Odds it will work for bipolar mania – pretty good as far as antipsychotics go. What I and lots of other people in Bipolarland like about it as an add-on to anticonvulsants is that it can work at a super-low dosage, 0.25 to 0.5mg a day, and as long as your prolactin levels are fine (usually an issue with women more than men), you hardly know that you’re taking a med, except that your symptoms go away. For monotherapy (i.e. it’s the only med you take) for bipolar disorder you’ll probably have to take at least 2mg a day for any effect, and I’m not too big on antipsychotics as monotherapy for bipolar disorder, but it seems to work for many people. If anticonvulsants don’t do it for you, it’s worth a shot.
Odds of it working for panic / anxiety disorders – OK. Antipsychotics aren’t front-line meds for panic / anxiety but they work well for some forms of the disorders. Risperdal is an OK med for panic / anxiety, but you’d probably be better off trying Seroquel (quetiapine) or Zyprexa (olanzapine) first.
Odds of it working for autism – Good. Better than any other med out there. Risperdal (risperidone) is set to be the first med approved to treat any form of autism. It will probably help people in the Asperger’s part of the spectrum more, but any amount of help in some forms of autism could be life-changing. Even though I can’t take it any more, I’m less of a jerk than I was before I started taking it, so it’s positive effects can be permanent even if the treatment is temporary. For more information, see the comments page.
Odds of it working for depression – Good. As a stand-alone med for depression I wouldn’t bet a lot of money on its working, but if you mix it with an antidepressant for treatment-resistant major depressive disorder the odds are pretty good that Risperdal (risperidone) will work.
Now for the details as to how I arrived at the above odds. Mostly it’s from anecdotal evidence gathered from various online support groups I monitor, user ratings and comments at Remedy Find, experiences people send to me via e-mail and summaries of efficacy from the books in the references at the end of this page. Additionally there are these trials and studies from the PI sheet and that I found through Pub Med:
For schizophrenia it’s efficacy was established in four short-term (4-8 week) controlled trials of psychotic inpatients. The following metrics were used:
Brief Psychiatric Rating Scale (BPRS), a multi-item inventory of general psychopathology traditionally used to evaluate the effects of drug treatment in schizophrenia. The BPRS psychosis cluster (conceptual disorganization, hallucinatory behavior, suspiciousness, and unusual thought content) is considered a particularly useful subset for assessing actively psychotic schizophrenic patients. It’s like the MMPI of crazy.
Clinical Global Impression (CGI), reflects the impression of a skilled observer, fully familiar with the manifestations of schizophrenia, about the overall clinical state of the patient. In other words, how loony your doctor thinks you are.
The Positive and Negative Syndrome Scale (PANSS) a 30-item rating instrument evaluating the presence/absence and severity of positive, negative and general psychopathology of schizophrenia. The scale was developed from the BPRS and includes other symptoms, such as aggression, thought disturbance, and depression. This is a much more accurate test, if standardized tests are your thing, of insanity.
Scale for the Assessment of Negative Symptoms (SANS). This is a relatively new test looking at an axis of five “negative” symptoms: affect flattening (i.e. you talk like I do), alogia (periods of speechlessness, in other words you still talk, or not talk, like I do), avolition-apathy (i.e. not giving a shit before you were put on antipsychotics), anhedonia-asociality (nothing is pleasurable, you don’t like people, i.e. you’re a natural born goth) and attentional impairment (huh? What did you say?). If this is the scale of negative symptoms what the fuck is the corresponding “positive” assessment? Oh, hallucinations, delusions, formal thought disorder, and bizarre or disorganized behavior.
In a 6 week, placebo-controlled trial of 160 people taking up to 10mg a day of Risperdal (risperidone) in two doses it was “generally superior” to placebo on the BPRS total score, on the BPRS psychosis cluster, and “marginally superior” to placebo on the SANS.
In an 8 week, placebo-controlled trial of 513 people involving 4 fixed doses of Risperdal (risperidone) – 2, 6, 10, and 16 mg/day, on a twice-a-day schedule, all 4 Risperdal (risperidone) groups were “generally superior” to placebo on the BPRS total score, BPRS psychosis cluster, and CGI severity score; the 3 highest risperidone dose groups were “generally superior” to placebo on the PANSS negative subscale. The most consistently positive responses on all measures were seen for the 6 mg dose group, and there was no suggestion of increased benefit from larger doses. – Emphasis mine. I like to point out when people do well on lower dosages in clinical trials. This doesn’t mean that everyone can get away with a lower dosage, but that a lot of people can.
In an 8 week, dose comparison trial of 1356 people involving 5 fixed doses of Risperdal (risperidone) – 1, 4, 8, 12, and 16 mg/day taken twice a day, the four highest Risperdal (risperidone) dose groups (everyone taking more than 1mg a day) were “generally superior” to the 1 mg Risperdal (risperidone) dose group on BPRS total score, BPRS psychosis cluster, and CGI severity score. None of the dose groups were superior to the 1 mg group on the PANSS negative subscale. The most consistently positive responses were seen for the 4 mg dose group. Again, emphasis mine. When this stuff works, mid-level dosages are often enough to do the job. I hope the doctors read this part of the PI sheets before they ramp people up to 10mg a day. Give the 4-6mg a day dosages a chance to work.
In a 4 week, placebo-controlled dose comparison trial of 246 people involving 2 fixed doses of Risperdal (risperidone) of 4 and 8 mg/day on taken four times a day, both Risperdal (risperidone) dose groups were “generally superior” to placebo on several PANSS measures, including a response measure (>20% reduction in PANSS total score), PANSS total score, and the BPRS psychosis cluster (derived from PANSS). The results were “generally stronger” for the 8 mg than for the 4 mg dose group. OK, here we’re seeing where more is better, but still under 10mg a day. That 20% or greater reduction in the PANSS score is the closest thing to a hard number from a clinical trial as we’re going to get from the PI sheet.
As far as long-term results go, in a trial of 365 adult outpatients who had been clinically stable for at least 4 weeks on an antipsychotic medication were randomized to Risperdal (risperidone) (2-8 mg/day) or to an active comparator (whatever the hell it was), for 1-2 years of observation for relapse. Patients receiving Risperdal (risperidone) experienced a significantly longer time to relapse over this time period compared to those receiving the active comparator. In other words, taking Risperdal kept them saner longer than the unnamed antipsychotic the other people were taking. Relapses still occurred, but lest often. Generally people like atypical antipsychotics more than the older standard antipsychotics because they usually work better and the side effects suck a lot less. The main downsides are atypicals are more likely to make you gain weight, mess with your blood sugar and are vastly more expensive. otherwise it’s a lot easier to be med-compliant with an atypical than it is with a standard antipsychotic.
So that’s what Janssen did. How about some independent research?
Low-dosage Risperdal risperidone for in the treatment of patients with first-episode schizophrenia, schizophreniform disorder, or schizoaffective disorder – This is the sort of study that I like, because it backs up what I’ve been writing all this time! Starting at 1mg a day and working up to 6mg a day for all but 2 of the 62 patients in this study (those two needed more than 6mg a day), 80% showed improvement on the Clinical Global Impression, while scores on The Positive and Negative Syndrome Scale were considered “superior” for everybody at 2mg a day. After a year only 8 people had to switch to another antipsychotic, and one person ultimately got worse on Risperdal. Three people taking Risperdal (risperidone) developed EPS – which goes along with it being a bit more likely to cause EPS than other atypicals.
Risperdal (risperidone) for treating outpatients with chronic schizophrenia. 79 people for one year, starting at 2mg a day with the option to go up to 6mg a day. 38 finished the study with good management of symptoms. Of the remaining 41, 10 couldn’t deal with the side effects, it just didn’t work for 12 of them (at all or 6mg a day wasn’t enough), and the remaining 19 were non-compliant, dropped out or disappeared. There was “significant” improvement in the Clinical Global Impression and The Positive and Negative Syndrome Scale scores for the 38 who did improve. 38 out of 79 people in the real world (not a clinical trial) isn’t bad.
I’m a bit happier with the bipolar trials than with Zyprexa (olanzapine). The number of people in these trials were larger, there were four of them, and there was a combination of monotherapy and combination therapy. My complaints are that they lasted only three weeks and the researched relied only on the Young Mania Rating Scale to determine how well Risperdal (risperidone) worked. The YMRS, although the gold standard of standardized tests for how bouncing-off-the-ceiling batshit manic you are, it doesn’t tell you all that much. You score 0-60 on all of 11 items assessing irritability, disruptive/aggressive behavior, sleep, elevated mood, speech, increased activity, sexual interest, language/thought disorder,
thought content, appearance, and insight. Basically if you didn’t have the bipolar diagnosis already the test would be fairly pointless in trying to figure out if you bipolar, schizophrenic, obsessive-compulsive, schizoaffective or even ADHD. Even some people in particular parts of the autistic spectrum who aren’t bipolar would score well on it. Try taking it during a bout of severe depression, you may not have any self-esteem, sexual interest or least of all elevated mood and activity, but everything else could be really out of whack and you could get hit with a bipolar 2 diagnosis even if you aren’t really bipolar 2.
I won’t deny that Risperdal (risperidone) is an effective medication for bipolar mania. I just think that like any atypical antipsychotic it’s better used in a supplemental role for bipolar disorder, unless you can’t tolerate any anticonvulsants or good old lithium.
Independent studies and trials will use more and better metrics than just the YMRS. These will include some or all of the ones listed for schizophrenia as well as:
The Hamilton Rating Scale For Depression (HAM-D) – 21 questions where your doctor determines how much your life sucks.
Beck Depression Inventory (BDI) – Another 21 questions where you give your opinion on how much your life sucks.
The Montgomery-Asberg Depression Rating Scale (MADRS) – For doctors too busy to ask the 21 questions on the HAM-D. No shit.
The Manic State Rating Scale (MSRS) – 26 behaviors, scored on frequency and intensity. Covers dysphoric and euphoric manias. There’s less cross-over with ADD/ADHD than the YMRS and as someone who has lived long-term manias and has been around plenty of people in dysphoric and euphoric manias, this is a much better indicator of mania. Does OK as far as standardized go in covering mixed states.
Clinician-Administered Rating Scale For Mania (CARS-M) – Better than the Young scale, but not as thorough as the MSRS. However the extra questions do differentiate between mania and ADD/ADHD.
The efficacy of Risperdal (risperidone) in the treatment of acute manic or mixed episodes was established in 2 short-term (3-week)
placebo-controlled trials in patients who met the DSM-IV criteria for Bipolar I Disorder with manic or mixed episodes. These trials
included patients with or without psychotic features.
(1) In one 3-week placebo-controlled trial of 246 people with manic episodes, which involved a dose range of 1-6 mg/day, once daily, starting at 3 mg/day (mean modal dose was 4.1 mg/day), Risperdal (risperidone) was “superior” to placebo in the reduction of Y-MRS total score.
(2) In another 3-week placebo-controlled trial of 286 people which involved a dose range of 1-6 mg/day, once daily, starting at 3 mg/day (mean modal dose was 5.6 mg/day), Risperdal (risperidone) was “superior” to placebo in the reduction of Y-MRS total score.
The efficacy of Risperdal (risperidone) taken with lithium or valproate (they don’t specify which of the three was used) in the treatment of acute manic or mixed episodes was established in one 3-week placebo-controlled trial of 148 in- or outpatients with Bipolar I Disorder. This trial included patients with
or without psychotic features and with or without a rapid-cycling course.
In this combination trial the people on lithium or valproate therapy with inadequately
controlled manic or mixed symptoms were randomized to receive Risperdal (risperidone), placebo, or an active comparator (probably Haldol), in combination with their original therapy. Risperdal (risperidone), in a dose range of 1-6 mg/day, once daily, starting at 2 mg/day (mean modal dose of 3.8 mg/day), combined with lithium or valproate (in a therapeutic range of 0.6 mEq/L to 1.4 mEq/L or 50 mcg/mL to 120 mcg/mL, respectively) was “superior” to lithium or valproate alone in the reduction of Y-MRS total score.
In a second 3-week placebo-controlled combination trial, 142 in- or outpatients on lithium, valproate, or Tegretol (carbamazepine) therapy with inadequately controlled manic or mixed symptoms were randomized to receive Risperdal (risperidone) or placebo, in combination with their original therapy. Risperdal (risperidone), in a dose range of 1-6 mg/day, once daily, starting at 2 mg/day (mean modal dose of 3.7 mg/day), combined with lithium, valproate, or Tegretol (carbamazepine) (in therapeutic ranges of 0.6 mEq/L to 1.4 mEq/L for lithium, 50 mcg/mL to 125 mcg/mL for valproate, or 4-12 mcg/mL for carbamazepine, respectively) was not superior to lithium, valproate, or Tegretol (carbamazepine) alone in the reduction of Y-MRS total score. A possible explanation for the failure of this trial was induction of Risperdal (risperidone) and 9-hydroxyrisperidone clearance by Tegretol (carbamazepine), leading to subtherapeutic levels of Risperdal (risperidone) and 9-hydroxyrisperidone. See the page on enzyme-inducing anticonvulsants for more information on how and why Tegretol (carbamazepine) and other drugs in this family will have similar effects.
In independent trials:
Rapid antimanic effects of Risperdal 134 people taking Risperdal (risperidone) vs. 125 people on placebo. Tests included Young Mania Rating Scale, Clinical Global Impression, The Positive and Negative Syndrome Scale and the Montgomery-Asberg Depression Rating Scale. Much better than just the YMRS. At an average of 4mg a day, improvement was seen in 3 days. So if you want to start that high, you can stop bouncing off of the ceiling that quickly. Of course, “Extrapyramidal Symptom Rating Scale scores were significantly greater in patients receiving risperidone”, so you risk that when starting at the higher dosage.
Mood stabilizers plus risperidone or placebo in the treatment of acute mania. This study looks like it was the failed clinical trial mentioned above. It tests efficacy of Risperdal (risperidone) taken with lithium or Depakote (divalproex sodium). In addition to the lithium or Depakote (divalproex sodium) 75 people were given Risperdal (risperidone) and 76 were given a placebo. Those taking the Risperdal had their Young Mania Rating Scale score decrease by 14.5 points after one week, while those on the placebo saw a 10.3 point reduction. This study also included people taking Tegretol (carbamazepine), but they were excluded because of the way it messes with the Risperdal. Oh well, at least we have an idea of what the drug companies consider as “significant” on the YMRS. Compared to what I’ve been able to dig up for SSRI trials, that is rather significant decrease, although it is just on one test that asks 11 questions and scores you on a scale of 0 to 60. But it points out what I don’t like about these short trials for bipolar mania. Look how well the wonder drug Placebo works! Seriously, in the short run, all sorts of non-med approaches will actually work to bring someone down from a manic high for a day or a week. That’s why Bach Flower Remedies or that Serenity crap appear to work in the short term. It’s part of the reason why so many of us fall into the trap of thinking we can deal with our illness without meds, or with dangerously bogus “treatments.”
Acute and continuation risperidone monotherapy in mania. – 96 people in a manic state (Young Mania Rating Scale score of 20 or more) were given an average of 4mg a day of Risperdal (risperidone) for 6 months in this open-label study. 80 people finished the study. “Significant improvement” in Young Mania Rating Scale, Clinical Global Impression, The Positive and Negative Syndrome Scale and even he Hamilton Rating Scale For Depression scores. EPS was a big issue.
Role of risperidone in bipolar II: an open 6-month study. Forty-four people with bipolar 2 started this study, but only 34 finished it. Averaging between 2.5 and 3mg a day, of those that did finish 20 of them didn’t have any symptoms of hypomania. The 10 who were taking only Risperdal (risperidone) and nothing else were able to use it as their sole mood stabilizer and not need an antidepressant. But another 9 did get depressed with only Risperdal (risperidone), so it’s not all that great as a true mood stabilizer.
Let’s see how Risperdal (risperidone) stacks up against other meds. Keep in mind who sponsors the study, as it will tends to make the results more favorable for the med in question (on average 3.6 times more likely, according to a Yale study).
First for schizophrenia:
Zyprexa vs. Risperdal. This independent-looking study has Zyprexa (olanzapine) testing as superior to Risperdal (risperidone) after 30 weeks. Nothing in the abstract about the dosages used.
Zyprexa vs. Risperdal vs. Clozaril vs. Haldol. This decent sized, 14-week study was sponsored by NIMH (with each of the drug companies chipping in the meds). The results – Zyprexa (olanzapine) is the superior atypical antipsychotic, but it all depends on the form of schizophrenia being presented. They’re all better than Haldol (haloperidol) as long as you’re more concerned about effect and all the non-weight gain side effects.
Zyprexa vs. Risperdal. In this Janssen-sponsored study, 2-6mg a day of Risperdal (risperidone) tests as working as well as (slightly better at some things, not quite as good at others) and sucking less than 5-20mg a day of Zyprexa (olanzapine) after only eight weeks. See what I mean about when the manufacturer sponsors the study it often comes out in their favor?
Zyprexa + glycine vs. Risperdal + glycine. This small study indicates that adding high dosages of the amino acid glycine to either Zyprexa (olanzapine) or Risperdal (risperidone) can help with treatment-resistant schizophrenia. It’s something to discuss with your doctor before making the switch to Clozaril (clozapine).
Abilify vs. Risperdal vs. placebo Big study of 404 people with schizophrenia and schizoaffective disorder. 101 each taking either 20 or 30mg a day of Abilify (aripiprazole) (30mg is the maximum dosage) against 99 people taking 6mg a day of Risperdal and 103 taking a placebo. Smells alike a Bristol-Myers-Squibb sponsored test to me. The results – Risperdal and Abilify both work! However Abilify (aripiprazole) doesn’t mess with the hormone prolactin the way Risperdal does. Otherwise they’re equally effective and don’t suck that much.
ECT + Risperdal or Zyprexa vs. Risperdal or Zyprexa alone for treatment-resistant schizophrenia. Hey, now we’re really getting down to what is going to suck less, ECT or Clozaril (clozapine). In this study, ECT combined with either Risperdal (risperidone) or Zyprexa (olanzapine) didn’t work that much better and didn’t really sucks less. So you’d probably want to try the glycine treatment mentioned above first, but it that pans out, there are treatment options.
Risperdal vs. Solian. Solian (amisulpride) is a standard antipsychotic available in the UK, Europe, and parts of Asia. It is similar in action to Orap (pimozide). 48 people took either 400-800 mg a day of Solian (amisulpride) or 4-8 mg a day of Risperdal (risperidone). They both worked equally well. There was slightly more weight gain reported with Risperdal. Solian would lower blood pressure and heart rate more. Otherwise they just sucked in different ways, but didn’t really suck that much.
Risperdal vs. Seroquel. This AstraZeneca study of 728 three people with schizophrenia and “other psychotic disorders” had 553 take Seroquel (quetiapine) and 175 take Risperdal (risperidone) in a multicenter, 4-month, open-label. Talk about stacking the deck! An average of 250mg of Seroquel was as effective as 4.5mg of Risperdal. Hey, those are pretty low dosages for efficacy, but what the hell, low dosage efficacy is what this site is all about! Not surprisingly, about a third of the people taking Seroquel (quetiapine) were too tired to get out of bed, and the rates of EPS were much lower with Seroquel (quetiapine) than with Risperdal. What was surprising at first read, but what is being backed up with further studies, is that the people taking Seroquel (quetiapine) were less likely to get depressed. Maybe it’s all that quality sleep you get.
Risperdal vs. Haldol 227 people with DSM-III chronic schizophrenia received 4mg a day of Risperdal (risperidone) and 226 people got 10mg a day of Haldol (haloperidol). Over the course of 8 weeks and using the Clinical Global Impression and The Positive and Negative Syndrome Scale the idea was to see which drug acted faster. Risperdal was shown to work within a week.
Risperdal vs. Clozaril When it comes to refractory schizophrenia, Clozaril (clozapine) is still the go-to drug. In this small study Risperdal (risperidone) did OK. As it states in the conclusion, “The results of this study support the utility of first giving a risperidone trial in a treatment algorithm for refractory patients because of its better risk/benefit profile compared with clozapine.” In other words, it sucks a lot less, so you may as well try it first.
Risperdal vs. Haldol For treatment-resistant schizophrenia. 34 people taking Risperdal (risperidone) and 33 people taking Haldol (haloperidol). Dosages were flexible. For the first four weeks Risperdal worked better according to the Brief Psychiatric Rating Scale, but after that they were equally sort-of effective. As usual, Risperdal sucked less.
Seroquel vs. Zyprexa vs. Risperdal vs. Serdolect vs. Haldol vs. Placebo. Antipsychotic cage match! Five drugs enter, …and five drugs leave. Unfamiliar to US readers would be Serdolect (sertindole), a European atypical antipsychotic that is unlikely to be introduced to the US market. It’s been withdrawn from the UK market and is admitted by Lundbeck to be a med of last resort. Anyway, the results of this analysis of multiple studies involving over 2,400 people with schizophrenia show Risperdal (risperidone) and Zyprexa (olanzapine) to be more effective than Haldol (haloperidol) when it comes to all of schizophrenia’s symptoms, while Seroquel (quetiapine fumarate) and Serdolect (sertindole) are just as effective. When it comes to the negative symptoms, though, Seroquel (quetiapine fumarate) tested as less effective Haldol while Risperdal and Zyprexa continue to be more effective. As usual Risperdal had the greatest risk of EPS. Surprisingly the wonder drug Placebo didn’t do too badly in some of the studies.
Zyprexa vs. Risperdal vs. Seroquel vs. Clozaril – Straight from the trenches of a state psychiatric hospital in Louisiana, where people get anticonvulsants, antidepressants, benzodiazepines and anything else that makes the real world a messy place to treat the mentally interesting. 100 people staying on average a year in the hospital. The results – Zyprexa (olanzapine) had a slight edge over Risperdal (risperidone). Yet when you came down to the people with hard-core refractory disorders, nothing beat Clozaril (clozapine). Zyprexa was still the better drug to try first, but sometimes you have to just give in to conventional reality and go with the Clozaril.
Between the two – schizoaffective disorder:
Risperdal vs. Haldol 62 people, depressed and bipolar types, taking up to 10mg a day or Risperdal (risperidone) or up to 20mg a day of Haldol (haloperidol) for six weeks. Both worked equally well in dealing with mania and psychotic symptoms according to the Clinician-Administered Rating Scale For Mania and The Positive and Negative Syndrome Scale. Risperdal (risperidone) worked better for depression according to the The Hamilton Rating Scale For Depression scores. And the Risperdal (risperidone) sucked a lot less.
Now for bipolar disorder:
Zyprexa vs. Risperdal vs. lithium. A small, short study sponsored by Janssen for bipolar and schizoaffective disorders. 0.25 to 7mg a day of Risperdal (risperidone) against 7.5 to 17.5mg a day of Zyprexa (olanzapine) against 600 to 900mg a day of lithium. All meds were equally effective and equally sucky during the short period of the study. In 1998 dollars the Risperdal (risperidone) cost half as much as the Zyprexa (olanzapine) at the dosages used, and that would still hold true today. I note that one of the doctors conducting the study is Dr. Sanjay Gupta of Olean hospital, not to be confused with CNN’s Dr. Sanjay Gupta. This Dr. Gupta is doing some fascinating work, though.
Risperdal vs. Seroquel – This study small, 3-week study was for 19 people who had to discontinue Risperdal (risperidone) combined with an anticonvulsant because of sucky side effects. Eighteen of the 19 completed the study, and 15 of them saw at 50% or better reduction on their Young Mania Rating Scale when taking Seroquel (quetiapine) and an anticonvulsant than an anticonvulsant alone, and 18 out of 19 had a 50% improvement on the the Clinical Global Impression.
Risperdal vs. Haldol vs. lithium – This small short study had 45 people take 6mg a day of Risperdal (risperidone), 10mg a day of Haldol (haloperidol) or 800 to 1200 mg daily of lithium. Using the Brief Psychiatric Rating Scale, Young Mania Rating Scale and Clinical Global Impression, the lithium tested best, Risperdal (risperidone) came in second and Haldol (haloperidol) brought up the rear.
For autism (mostly kids, of course):
Risperdal for autistic adults 31 adults, 17 with some form of autism, 14 with PDD got either Risperdal (risperidone) or a placebo for 12 weeks. After that everyone got the Risperdal (risperidone) for another 12 weeks, just to be fair. During the placebo phase, 14 people took Risperdal (risperidone) and 8 of them got results, while no one taking the wonder drug Placebo showed any change. You can’t fool us autistic spazzes. Dosages were pretty high, from 1.5 to 4.5mg a day, but I don’t know the severity of symptoms involved. Risperdal (risperidone) worked for reducing repetitive behavior, aggression, anxiety or nervousness, depression, irritability, and the overall behavioral symptoms of autism. Objective, measurable change in social behavior and language did not occur. Hey, nothing is going to keep me from talking like an otaku. In the following 12 weeks when the remaining people got Risperdal, nine of them got results as well. One person had to drop out for some reason. So 17 out of 31 got results.
Risperidone and explosive aggressive autism. – This study covered 11 guys with an average age of 18, so there were adults, teenagers and kids involved. They started at 0.5mg a day, and taking that much twice a day was the dosage that usually worked best, but some of the guys needed more. Within 2-3 days aggression, self-injury, explosivity, and poor sleep hygiene improved “substanially”.
A 3-year naturalistic study of 53 preschool children with pervasive developmental disorders treated with risperidone. – 45 boys and 8 girls aged 3.6 to 6.6 years taking 0.25 to 0.75mg a day of Risperdal (risperidone) for 1 to 3 years. 25 of the kids continued to the end of the study, the remaining 28 dropped out due to side effects (12), parents’ choice (10), lack of efficacy (3), and decision of the treating psychiatrist (3). Of the 25 who stayed in, it seemed to work on 22 of them. So 22 out of 53, and that’s based on both an improvement of 25% in Children’s Psychiatric Rating Scale score and a score of 1 or 2 on the Clinical Global Impressions-Improvement scale. It worked better for behavioral disorders and affect dysregulation than interpersonal functioning. Side effect most likely to cause discontinuation (and the one always to look out for in kids) – increased prolactin levels.
Will Risperdal Make Little Travis Behave? OK, the official title of this study is “Parent-defined target symptoms respond to risperidone in RUPP autism study: customer approach to clinical trials.” And the doctors basically asked, what is driving mom and dad up the wall because of their kids’ autism. The answers: tantrums, aggression, and hyperactivity. How did Risperdal (risperidone) do? It did best for self-injury. Too bad that wasn’t the parents’ main concern. Oh, it does great for tantrums, too.
Risperdal in severe autism – 51 kids with autism bad enough to warrant full-time hospitalization. Risperdal in unknown dosages worked for 38 of them, but if 4 of them came down with EPS I’m guessing it was in the 2-3mg a day range.
Risperdal and autistic irritability. Actually this study looked at serious issues – severe tantrums, aggression and self-injurious behavior. They just scored it on the Irritability subscale of the Aberrant Behavior Checklist as well as the Clinical Global Impressions – Improvement scale. While big and placebo-controlled, 101 children (82 boys and 19 girls; mostly 6-11 years old), it was really short, only 8 weeks. The kids took 0.5 to 3.5mg a day of Risperdal, and at 3.5mg a day of Risperdal, it’s no surprise that an 11 year-old cheap date of a kid (because most of us in the autistic spectrum don’t need much in the way of meds) would see “a 56.9 percent reduction in the Irritability score.” It’s hard to be too irritable when you’re asleep all day!
Tourette’s: Risperidone versus pimozide in Tourette’s disorder: a comparative double-blind parallel-group study 26 people took an average of 4mg a day of Risperdal (risperidone), while 24 people took and average of 3mg a day of Orap (pimozide). Tics improved with both meds, but overall the Risperdal worked better. Only the people taking Risperdal (risperidone) got any significant relief from OCD symptoms. EPS was an issue with 4 people taking Risperdal (risperidone) and 8 taking Orap (pimozide). Other side effects sucked less with Risperdal as well.
For depression: Seroquel vs. Risperdal vs. Zyprexa vs. Geodon to augment antidepressants for treatment-resistant depression Another antipsychotic cage match! 49 people who have ridden a total of 76 horsies on the med-go-round. Here are the results – Zyprexa (olanzapine) is the clear winner with a 57% response rate, followed by Risperdal (risperidone) with 50%, Seroquel (quetiapine fumarate) with 33% and bringing up the rear in a real shock to me, Geodon (ziprasidone) with only 10%. So if your doctor wants to try Zyprexa (olanzapine) combined with an antidepressant first to bring you out of the abyss, don’t fret the weight thing. Which sucks less, what you’re going through now or a few extra pounds?
Finally: Risperdal for just about everything! – This small study followed the treatment of 27 people with a variety of disorders for a period of up to four years (with an average of 28 months). They took anywhere from 1 to 16mg of Risperdal (risperidone) a day, just once a day. No one came down with EPS. Everyone felt better to some degree, either a little better or way better. So while the study was small, it shows that Risperdal (risperidone) does work in the long run.
How Risperdal Works In Your Brain: Like all Novel / Atypical Antipsychotics, Risperdal (risperidone) is a selective monoaminergic antagonist. It has a high affinity (Ki of 0.12-7.3 nM) for the serotonin Type 2 (5HT2), dopamine Type 2 (D2), a1 and a2 adrenergic, and H1 histaminergic receptors. It acts as an antagonist at other receptors, but with lower potency. Risperdal has low to moderate affinity (Ki of 47-253 nM) for the serotonin 5HT1C, 5HT1D, and 5HT1A receptors, weak affinity (Ki of 620-800 nM) for the dopamine D1 and haloperidol-sensitive sigma site, and no affinity (when tested at concentrations >10-5 M) for cholinergic muscarinic or b1 and b2 adrenergic receptors.
So, what does that mean in English? Well excessive dopamine in certain parts of the brain is one popular hypothesis behind the symptoms of schizophrenia. There’s also evidence that working on the muscarinic receptors makes a big difference as well, but since Risperdal doesn’t do the muscarine thing that’s a good-news / bad-news deal The good-news is that the anticholinergic side effects – dry mouth, nausea, dizziness, aren’t as big a deal and don’t last as long with Risperdal as compared with Zyprexa (olanzapine). The bad news is that Risperdal doesn’t work as well with some some forms of schizophrenia or ultradian rapid cycling bipolar disorder because of not hitting the muscarinic receptors. The effects of the other receptors on schizophrenia are less well known.
For bipolar disorder, anyone who lives in Bipolarland can tell you about getting manic from having their brain soak in serotonin for too long from an SSRI. Or perhaps the same thing happened from too long of a soak in norepinephrine and dopamine from Wellbutrin. There’s even evidence that the muscarinic receptors play a role in bipolar disorder as well.
If my unfortunate and quite accidental experience with a mushroom that had a bit too much muscarine is any indicator, I’ll go along with the hypothesis that muscarinic receptors play a big role in bipolar disorder, especially ultradian rapid cycling.
How Risperdal helps with autistic spectrum disorders is as yet unknown. Maybe it’s how it deals with the various 5HT receptors. Atypical antipsychotics in general work to turn down the volume, as it were, in the input being received. But why does Risperdal tend to work better than all the others for Asperger’s? Got me. I can find studies on how well it works (those will be in the following section), but there’s really nothing out there as to why it works.
Risperdal has one of the simplest profiles in which receptors it deals with – mainly the dopamine Type 2 (D2) and serotonin Type 2 (5HT2), it just hits them harder than any of the other Novel / Atypical Antipsychotics. In some ways it acts much like the older standard / typical antipsychotics, it just sucks less than they tend to.
Risperdal’s Half-Life: It’s half-life is complicated. It does a double metabolism and there’s a big difference between the poor and extensive metabolizers. When it comes right down to the stuff that’s working in your brain, that has a half-life of 20 hours. More or less. Here are the details:
The apparent half-life of risperidone was 3 hours in extensive metabolizers and 20 hours in poor metabolizers. The apparent half-life of 9-hydroxyrisperidone was about 21 hours in extensive metabolizers and 30 hours in poor metabolizers. The pharmacokinetics of the active moiety, after single and multiple doses, were similar in extensive and poor metabolizers, with an overall mean elimination half-life of about 20 hours.
Days to Reach a Steady State: Six days at the outside.
Comments: Risperdal (risperidone) is, milligram for milligram, the most potent of all the antipsychotics. It is also just the bomb when dealing with the combination of Asperger’s and bipolar, or just Asperger’s and other forms of autism alone. I weaned myself off of Risperdal (risperidone) and found out it was a very Bad Idea. Not even Strattera (atomoxetine) could keep me from being suicidally depressed after getting friended by a woman on the second date. Risperdal (risperidone) keeps the autistically exaggerated emotions in check, making the distorted, hyperbolic reactions of the Asperger’s-bipolar combination less distorted and hyperbolic. It was only by adding Risperdal (risperidone) back into the cocktail that I started climbing out of the depression. Yes, part of that was the combination of antipsychotic and antidepressant, but part of it was Risperdal’s toning down the exaggeration of feelings we autistic types have. Like all antipsychotics it makes Mouse severely depressed, but it is the only one she can tolerate in small doses, as required, when her autistically-exaggerated emotions or mania get out of hand. It sometimes makes her hear music in things like clothes dryers. There have been several studies done on Risperdal’s effectiveness in controlling symptoms across the autistic spectrum, in both kids and adults1 along with other antipsychotics, and Risperdal (risperidone) has tested the best. Not only that, Risperdal (risperidone) gets high marks for dealing with rage. Most everyone who can tolerate it finds it really does tone down or even eliminate the rage response from bipolar disorder and high-functioning autism. Of course there are also studies to back that up, for both children and adults. (See the How Risperdal Works & Compares with Other Meds for more details).
Although I’ve tasted far worse medications, the oral solution does taste like ass. Don’t mix it with anything, as it’ll just prolong the disgusting taste, cowboy up and swallow it as is if you’re going that route. Of course, that could be my ultra-sensitive sense of taste in action.
Risperdal (risperidone) hits a lot of dopamine receptors along with histamine and serotonin receptors, so like Abilify (aripiprazole), it can be a coin toss as to whether or not it puts you to sleep or wakes you up. It’s usually sedating, but not always. Again, refer to he How Risperdal Works & Compares with Other Meds for more details
Well, this just sucks. I’ve had to stop taking Risperdal (risperidone) because of Tardive Dyskinesia. It came on suddenly. One day Mouse noticed that my tongue seemed to be sticking out of my mouth more when I spoke certain words and that I had some minor facial tics that I wasn’t aware of. The next day my tongue had a mind of its own, I was totally aware of facial tics without having to look in a mirror, and I was blinking like a cartoon owl. Lowering my dosage of Risperdal (risperidone) from 0.5mg a night to 0.25mg reduced the symptoms, but they still flared up now and then. Eventually I had to stop taking a very effective med. The TD is gone for the most part. I had a bit of a tic in my forehead for quite some time, but I’m a really poor metabolizer of meds, so the Risperdal (risperidone) may have hung around for a lot longer than usual. Plus tics are side effects of other meds I take, and once you get a side effect going like that, it’ll just hang around if the other meds will make it easier to do so. Still, it didn’t leave until I took Seroquel (quetiapine), which is often used to get rid of TD symptoms.
Did it freak me out? Of course it did! For about an hour. I knew what was going on, I knew how to deal with it. Fortunately I have the luxury of knowing how meds work and not having to leave my house for days at a time. So if something like this happens to you, go ahead and freak out! It’s scary! And Christ on a crutch, to go out in public when that’s happening to you on top of everything else you’re dealing with? It’s one thing when you’re used to dealing with that sort of thing most of your life, but it’s something else entirely when it’s a brand new event in your life. While I personally don’t give a shit about tics and blinking and my tongue going wacky on me when I’m trying to buy groceries, I’m not the rest of the world.
However many the positive effects of Risperdal (risperidone) are gone. First and foremost I had to live in bipolar 2 hell for over a few months, cycling through various stages of depression and mixed states. See my blog for details. I’ve also been way more autistic in bad ways lately. I was in a minor auto accident, nothing really to write about. Were I not such an autistic freak it would have been a matter of exchanging information and driving off. But I froze. My car had to be pushed out of traffic because I couldn’t function. I couldn’t talk. I can’t deal with people. Selling my house and moving was really difficult my inability to deal with people and to deal with change. This lack of Risperdal (risperidone) was really, really sucking hard.
Eventually, though, I got over it. Coping skills, therapy, all that good stuff. While the discontinuation of Risperdal (risperidone) was painful in the usual way with atypical antipsychotics – a massive return of symptoms – in the long run I’m able to deal with stuff better in my life thanks to having taken Risperdal. So I’m a lot less of a jerk than I was before I took it, albeit more of a jerk than I was when I was on it. Sensory integration is weird again. But I’m much, much calmer.
Still, it was a very effective med for dealing with pesky hallucinations, and irrational thinking that plagued me back in 2002 when I was going batshit crazy. Although it didn’t do squat for me for ultradian rapid cycling or intrusive thoughts until Topamax (topiramate) was added to my cocktail.