Posted by Jota on September 13, 2003, at 17:35:16
First, a bunch of background.
I'm currently taking a heady cocktail of medicines targeting bipolar II depression: Lexapro 40mg, Straterra 80mg, Wellbutrin 300mg, Carbatrol 800 mg, Lamactil 300 mg (Carbatrol approximately halves effective dose), T3 25mg, Folate, Fish Oil, and the testosterone supplement AndroGel 10g.
I arrived at the preceding after a steep breakthrough depression this past winter. Previously I had been on Paxil 80mg plus Wellbutrin 200mg for about 18 months; and before that, Effexor 150mg rising to 300mg over the course of 5 years plus Wellbutrin 150 mg.
(All along, I have also put a lot of effort into the "psychosocial" dimension, e.g., psychotherapy, meditation, yoga, etc.)
I'm feeling way better than this winter: I'm back to work and being highly productive. Exercising several times a week; active social life. And my sleep is approximately normal: no more early-morning wakening. Sexual function is hard to judge since I'm not dating anyone at the moment. (Also making it difficult to judge is that I've been on SSRI's for most of the time since I became sexually active.)
On the other hand, I'm still having some night sweats; much less than this winter/early spring when it was 2 or 3 every night. now its more like 1 several times a week. Sometimes my sleep seems "shallow" as does my meditation. I'm still getting mild headaches several times a week (lesser versions of what I would describe as "head nausea", i.e., a feeling akin to nausea except that it originates from the head). I'm having some trouble with word retrieval. Possibly other memory and concentration deficits, though it's not obvious to me to what extent and certainly much less than this past fall, winter and spring. Also frequent mild sadness, often with a few tears. Lastly, I feel like I'm having to work harder to keep my mood up.
The testosterone supplement is the most recently added medicine. It has definitely helped restore some libido, though not as much as I would like. And the dissipation of the headaches more or less corresponded to when I started on the testosterone. The 10 g AndroGel I'm taking is the maximum recommended dose. Nevertheless, my total and free testosterone levels are just barely within the "normal" range. This is approximately 2 standard deviations below the mean associated with 10g AndroGel. For the sake of completeness, I will also mention that my sperm count is extremely low.
In addition to my regular psychiatrist, I've also been consulting with a top researcher at NIMH and with a Mass-General affiliated psychiatrist whom I saw for many years when I lived in Boston.
As I would judge that I'm still mildly depressed, I'm not satisfied with my current medicine regimen. But it's not clear what to do next.
Possibility 1: push up on the Testosterone. The Carbatrol interacts with the testosterone. As it has been explained to me, one possibility is that the blood level will read much lower than the relevant availability of testosterone. Another possibility is that the Carbatrol indeed is lowering the relevant testosterone level. So the effective supplement of testosterone I am getting is less than the nominal 10g. (Similarly, lamactil dosages need to be doubled when taking Carbatrol).
Possibility 2: taper down on the Carbatrol, possibly replacing with Trileptal. Trileptal is chemically quite similar to Carbatrol, but it doesn't induce liver enzymes and therefore has much fewer interactions with other medicines. But the NIMH researcher recommends against this saying that it's not yet clear whether Trileptal has as good antidepressant properties as Carbatrol. (I can't find anything on the web on carbamazepine's antidepressant properties; but whwn I was going through experimentation almost one year ago, my experience was that it did; also, the NIMH researcher is highly respected and follows many not-yet-published research projects).
Possibility 3: push up on the Carbatrol (my blood levels show it to be below the therapeutic range). I went up to 800 from 600 because I was getting some hypomanic mood spikes (more on the sluggish/racing thoughts dimension than on the happiness/sadness dimension). By increasing the dosage, I can see whether my mood further improves, stays the same, or goes down. If the latter, I could taper down and possibly even eliminate the Carbatrol. Analogously, during the first severe depression I had, 10 years ago, we pushed up Lithium as an augmenter and my mood plunged; we then quickly tapered off of it and my mood immediately bounced back. (Hence my resolve to avoid lithium.)
Possibility 4: add an atypical tranquilizer (probably Geodon or Abilify). My regular psychiatrist is very skeptical of doing this. But the NIMH guy is adamant (in a non pushy way) that the atypicals have excellent antidepressant properties and that I should turn to them before, for instance, trying adding or substituting in a different antidepressant (e.g., Zoloft, Remeron, or Cymbalta, if it ever is approved). And my old psychiatrist, whom I deeply respect, says that the Mass General researchers are extremely enthusiastic about using Geodon as an antidepressant, either for augmentation or even stand alone. Moreover he deeply respects the NIMH researcher, whom he feels is one of the very very best psychopharmacologists (I would also add that the NIMH guy is really nice)
I would definitely welcome people's thoughts on these another possibilities.
Jota
poster:Jota
thread:259728
URL: http://www.dr-bob.org/babble/20030912/msgs/259728.html