Posted by dewdropinn on July 31, 2007, at 11:04:57
In reply to Re: My Experience Mirrors Yours, posted by linkadge on July 31, 2007, at 8:43:48
At the risk of volunteering advise that falls in the "of course I've considered that" category, I might advise trying to arrange for a consultation with a research psychiatrist at NIMH, John's Hopkins (their really on the front lines with this stuff), or another similarly hallowed hall of psychopharm research. This is what made all the difference for me. Like you, I had a doctor who approached the bipolar -- a steady diet of mood stabilizers and anti-psychotics. Fortunately, he was good friends with an equally old school, semi-retired, big time researcher who initiated some of the groundbreaking research at NIMH back in the 60's, 70's and 80's -- it was truly a situation where I was literally talking to one of the gods in psychiatry.
He started out by drawing this squiggly line diagram that was his cosmos of medications, including all the experimental ones and drugs of lore like Largactil and Dilantin -- he noted neurotransmitters, drew up and down lines depending upon whether a med increased or decreased neurotrasmitter activity, and he made a bunch of marvelous conceptual comments -- next to Lamictal he wrote "take your foot off the gas!" He was generally of the "psychopharm as art rather than science" -- it's not that there isn't a great deal of science, study and research involved with every drug, it's that it's very easy to get lost in the infinite minutia of known, unknown, possible activity of a given drug -- if you view it as an art, you prescribe drugs based on a conceptual understanding of how each drug works and interacts with other drugs -- it makes the whole cosmos of possibilities managable. Thin slicing at it's finest.
As for the bipolar issue, he was in generally in agreement with the treatment guidelines for classic bipolar, but he indicated that it wasn't uncommon to prescribe antidepressants in difficult cases -- I believe Wellbutrin and the MAOIs were the preferred options of choice. With softer bipolar, antidepressants were definitely a viable option, and commonly used, but almost always with some kind of mood stabilizer. So, he affirmed general accepted theories on the treatment of bipolar, but readily acknowledged that there are a whole lot of exceptions to the rule -- and many more with bipolar 2 and soft bipolar.
He came up with an A-H treatment algorithm, and sent me on my way. Option C turned out to be the winner -- Lamictal, up symbol + EMSAM or similiar up symbol. Fortunately, I had taken just about every antidepressant -- I knew what might work and what definitely didn't work -- I knew for instance that I could take wellbutrin, so long as I had a mood stabilizer onboard; I had a lot of success with selegiline, but only in combination with a mood stabilizer. I also knew what mood stabilizers worked, kind of worked, and definitely didn't work -- Lamictal was at the top of the list, Tegretol came in second, so long as it was taken with some kind of antidepressant, Trileptal came in third; and very low dose Depakote was the final viable option -- anything over 125mg was just brutal, but about 1/4 of the sprinkle cap was tolerable and beneficial. Note -- none of these mood stabilizers were effective by themselves, and most of them made depression worse without some kind of antidepressant add-on. The other thing that I knew from experience is that I couldn't take antidepressants without a mood stabilizer -- they were either totally ineffective, or they lost their efficacy over time, or they made me more anxious and made sleep virtually impossible. I was in a very similar situation to yours -- antidepressants and mood stabilizers didn't work by themselves, but when combined good things began happening.
One final note and then I'll then I'll stand back and say -- "I look forward to seeing how everything goes" -- because honestly, there's very little I could add. Finding a true research doc for a consultation appointment would be ideal, but may not be feasable due to financial and geographical issues -- my second suggestion would be to either work with your doctor to at least give antidepressants w/ mood stabilizers a try or to find one who's willing to explore alternatives -- mood stabilizers alone clearly isn't an option. As far as possible drug options to explore or at least inquire about, I would suggest discussing Tegretol and Trileptal with your doctor -- alone these drugs will make almost certainly make things worse, but in combination with Wellbutrin, Tricyclic or even an SSRI they may improve things tremedously (sadly, you can't take Tegretol with an MAOI.) One of the interesting aspects of Tegretol was it's effect on cognition -- I suddenly started thinking musically again, re-gained my writing chops, and re-gained much of the creativity that I thought I'd lost -- it made me more depressed, but it gave me something as well. Depakote sprinkles are another option well worth exploring, again make sure to take with an antidepressant, because I can almost assure you it will increase depression to some degree -- Depakote doesn't improve cognition, but it does have a noticable anti-anxiety component -- the key for me was pouring out a tinsy tiny amout from the 125mg sprinkle cap -- for me, the 250mg pills were a one way trip to total, complete and utter misery in every way imaginable. I think you've actually made some real discoveries -- recognizing that antidepressants and mood stabilizers alone are not beneficial may be a real insight into your particular condition, and may lead the way to finding an optimal combination -- I'm also guessing that you've had some positive responses to select antidepressants, so you may have already sorted out the most viable add-on options. I have a feeling that you're going to hit upon a combination that leads to improvement, if not total remission -- unfortunately, you've still got to go through the trial and error rodeo, but I think some pieces of the puzzle may already be on the board.
Best of luck -- and I look forward to hearing how everything goes.
Drew
> >think you're right on all counts -- and I >definitely empathize with your frustrations and >hope you can find a solution.
>
> >I can't tell you how much suffering I had to >endure after a doc determined that under no >circumstances could I take an antidepressant -- >I spent about a year in mood stabilizer induced >suspended animation. I've definitely taken my >share of "magig bullits" (I love that one by the >way.)
>
> Yeah, that was a typo. I hope that pointing this out wasn't an attempt to rectify my accusations on the propensity of mood stabilizers to cause "dumb as a bag of nails syndrome". :)
>
>
> >Thankfully, I was able to consult with someone >who had a contrary opinion regarding >antidepressants and the treatment of soft >bipolar spectrum disorders.
>
>
> Thats it. There is no conscensious on how antidepressants should be used to treat bipolar. I think they are afraid to say that it really depends on the patient. I think they're afraid to admit they don't have a solid answer. Some bipolars simply won't get well unless they are on an antidepressant. They might have some intracellular issues as well as monoamine issues.
>
>
> >Ultimately, I don't think it's a question of >believing or not believing a given theory. A >theory is simply a construct that provides a way >of explaining larger phenomena -- theories can >suggest answers that lead to constructive >solutions, but they can also be incredibly >dangerous when people begin treating them as >scientific facts rather than simply as a model >for future investigation. And it seems like you >are contending with the application of theories >that are presented as "the answer" even >though "the answer" clearly isn't "the answer." >I lost many years contending with answers that >weren't.
>
> I can agree with that.
>
> Although it makes it difficult when all you have available is the type of doctor that believes in the hardcore heuristics.
>
> >Ultimately, I think you seem to have a fairly >reasonable immediate term solution. If the >effect of a given treatment doesn't result in >net benefits after a reasonable trial -- e.g. >you felt better before taking it -- then it >stands to reason that you're better off without it.
>
> Thanks for the post.
>
> Linkadge
>
>
poster:dewdropinn
thread:772375
URL: http://www.dr-bob.org/babble/20070730/msgs/773075.html