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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 16 of 16. This is the beginning of the thread.
Posted by Noa on March 24, 2000, at 14:00:36
I need advice on how to taper off of lithium. Am currently taking 1200 mg/day---600 in am, 600 in pm.
Posted by Anna P. on March 24, 2000, at 14:37:14
In reply to Tapering off Lithium, posted by Noa on March 24, 2000, at 14:00:36
> I need advice on how to taper off of lithium. Am currently taking 1200 mg/day---600 in am, 600 in pm.
Sorry, I didn't follow your whole story, but is lithium not helpful anymore?
Anna P.
Posted by Chris A. on March 24, 2000, at 14:59:08
In reply to Tapering off Lithium, posted by Noa on March 24, 2000, at 14:00:36
Best done only under the close supervision of a pDoc who knows you. Can't emphasize the doctor/patient relationship enough here.
Chris A.
Posted by Noa on March 24, 2000, at 15:24:39
In reply to Re: Tapering off Lithium, posted by Chris A. on March 24, 2000, at 14:59:08
Yes, I feel it is not helping enough to outweigh the negative effects. When I started taking it in December, I did notice some improvement for about 6 weeks, and then things went downhill. The lithium worsened my hypothyroidism, and I started having both mood problems and problems with low energy, fatigue, difficulty managing things, mental slowness, etc. I believe the mental fogginess I feel has only been a problem since the lithium. It was added in hopes of helping my mood (difficult to treat depression). And, it causes me to have to urinate all the time, and to feel thirsty all the time, which are bothersome, but which I would tolerate if the lithium were helping, but since it is not, well, you see where I'm going....
I am frustrated with trying to get a conversation with my pdoc about this. He doesn't return phone messages. He has told me to page him, but when I do, he is with a patient and says he will call back but doesn't. I have an appointment in mid-April, and if I could, I would just make an appointment sooner in order to speak with him, but when I call his office staff, they tell me the next available appointment is in one month.
I have made a tentative appointment with a new doc for the first week in April, but this involves a financial problem, as he doesnt participate in my insurance plan (hardly any psychiatrists do anymore, and it seems the ones that do run their practices like my pdoc does--chaotically and with no time for the patients). But I need someone who won't just be seeing me for 15 minutes (among the dozens of patients seen each day).
I just want to hear from anyone who has tapered off of lithium--the pace that you did it and what I might expect in terms of any withdrawal symptoms.
Obviously, I am frustrated not only with my illness and the lack of sufficient help from the medications I am on, but also with the quality of care I have been receiving. I respect my doc's knowledge, but the way he runs his practice stinks. I am also frustrated an wanting to figure out how the hypothyroid figures in to the mix, why am I having these physical symptoms with this round of depressionl, is it the lithium, etc etc?
Posted by Scott L. Schofield on March 24, 2000, at 15:28:33
In reply to Re: Tapering off Lithium, posted by Anna P. on March 24, 2000, at 14:37:14
> > I need advice on how to taper off of lithium. Am currently taking 1200 mg/day---600 in am, 600 in pm.
>
> Sorry, I didn't follow your whole story, but is lithium not helpful anymore?
>
> Anna P.Dear Noa,
I would like to echo Anna's question.
- Scott
Posted by dove on March 24, 2000, at 16:10:52
In reply to Re: Tapering off Lithium, posted by Scott L. Schofield on March 24, 2000, at 15:28:33
(((Noa)))
My thoughts are with you as always, and I have no advice to give you in regard to tapering the Lithium. Aside from getting a new p-doc. You really need a doc that'll give you the time of day, the doc *must* return your calls, your pages, and *must* be willing to give out urgent-care appointments, aside from critical-care, where someone is sent to inpatient.You need respect, and your questions answered. My thoughts, prayers, and best wish vibes are with you Noa! Keep us updated, and thank you for all the wonderful things you are and the gracious gift you give by giving of yourself, my children even know of your fame :-)
dove
Posted by Dr. Bob on March 25, 2000, at 14:30:44
In reply to (((Noa))), posted by dove on March 24, 2000, at 16:10:52
> You need respect, and your questions answered...
This is maybe a shot in the dark, but could you send him an email?
Bob
Posted by grace b on March 26, 2000, at 12:10:54
In reply to Re: Tapering off Lithium, posted by Noa on March 24, 2000, at 15:24:39
I was on lithium and had to come off of it because it no longer worked for me. I was taking 900 mg. daily when a new doc that I stated with, (my old on retired), wanted to try depakote. The way he weaned me lithium was to replace a pill for a pill. In other words I stopped taking one lithium at a time and replaced it with a depakote. this process took a week at a time for eack lithium I dropped. I had no side effects. It took three weeks to be off the lithium totally. I now take 1500mg. of depakote daily and I am making out fine. I do take effexor and respirdal as well as the depakote but I am stable for the time being and have been since November of last year. Good Luck, Grace
Posted by Noa on March 26, 2000, at 13:36:40
In reply to Re: Tapering off Lithium, posted by grace b on March 26, 2000, at 12:10:54
Thanks, all.
Dr. Bob, I had thought of emailing him, but was too frustrated with him for not calling back. Maybe I will try it.
Grace, thanks. The thing is, I won't be adding another mood stabilizer, at least for a while. I haven't had any mania or hypomania, so I am not really worried about that happening, but wonder if there are other types of withdrawal effects.
Dove, thanks for the support. It helps.
Posted by Noa on March 27, 2000, at 7:00:07
In reply to Re: Tapering off Lithium - Longish, posted by Scott L. Schofield on March 26, 2000, at 19:58:07
Scott, thank you for your concern.
I have what probably is best described as "double depression". I have been taking more and more medication over the years, and after another episode in November, my pdoc recommended lithium as an augmentation strategy. I started it in December, began to notice gradual improvement over six weeks, and then a sudden worsening of my depression, with physical symptoms of fatigue and slowness. My pdoc adjusted my thyroid medication, with the idea that the lithium made me more hypothyroid. Since then, it has been frustrating. I feel a bit better for a few days, then worse. Overall, my energy level is terrible, my mind feels like it is filled with fuzzballs, and I feel demoralized. On top of that, the lithium causes me to have to urinate extremely frequently, and to be voraciously thirsty all the time. Between the lithium and the effexor, my bladder control is inconsistent, which is annoying and embarrassing. If I felt the lithium were making me feel better, perhaps I would tolerate the urinary problems, but it is not making me feel better. I feel tired, listless, unmotivated, exhausted, uncoordinated, disorganized, mentally slow, and demoralized. One thing the lithium has done for me is to get me to think more directly about the hypothyroidism and to sort that out from the other depressive issues. And I feel strongly that for me, it is counterproductive to stay on lithium and have to constantly deal with the push and pull of lithium vs. thyroid meds.
Finally, Scott, although my pdoc conceptualizes my depressive disorder as a bipolar depression (a la Akiskal's bipolar III), I have never had any manic or hypomanic symptoms. The closest I can say I have come to hypomania is to have had moods that for me, in comparison with my depression, were ultramicrominihypomanic. Certainly not sufficient for the diagnostic criteria.
So, I haven't taken lithium for long, it hasn't shown itself to be that helpful for my depression, it seems to worsen some aspects of my depression associated with hypothyroid, and the side effects are, to say the least, bothersome.
Posted by Cam W. on March 27, 2000, at 7:08:07
In reply to Re: Tapering off Lithium - Longish, posted by Scott L. Schofield on March 26, 2000, at 19:58:07
Scott - I have seen many people who have not responded to lithium after several discontinuations, but also some who have after a few discontinuations. There seems to be a trend (conjecture only) in which people who have had more than 10 (approx.) manic episodes do not respond as well to lithium upon re-introduction. This could be due to induction of rapid cycling (antidepressant-induced or naturally-induced), as those with rapid cycling do not respond as well to lithium's effects. People who have stopped lithium on only a couple of occasions, and have had only a few manic episodes in their life, seem to respond as well the second and third time that lithium is introduced. I have seen the lithium work upon re-introduction, especially in those who have recently had their first break at a later age (eg mid-twenties) and who were still in denial of the disorder. I have no proof of this, it is just something a doc and I have mused about over coffee a couple of times. For what it's worth - Cam W.
Posted by Phil on March 27, 2000, at 7:13:17
In reply to Re: Tapering off Lithium - Scott, posted by Noa on March 27, 2000, at 7:00:07
Good luck with dropping Lithium, Noa. From reading your posts, it seems the right thing to do.
Phil
Posted by Noa on March 27, 2000, at 7:20:58
In reply to Re: Li-induced-Li-discontinuation, posted by Cam W. on March 27, 2000, at 7:08:07
For more on this subject, see the following article:
Am J Psychiatry 1998 Jul;155(7):895-8
Lithium discontinuation and subsequent effectiveness.
Coryell W, Solomon D, Leon AC, Akiskal HS, Keller MB, Scheftner WA, Mueller T
The authors conclude:
"These findings provide no evidence that lithium discontinuation results in treatment resistance when lithium is resumed."
Posted by Scott L. Schofield on March 27, 2000, at 10:42:54
In reply to Re: Li-discontinuation--more, posted by Noa on March 27, 2000, at 7:20:58
Hi Noa.
After reading your reply, I can see why you want to discontinue lithium. I think it was worth a shot at trying to treat your dysthymia. The side effects you experience really suck, and if you are receiving no benefit from it, I can't see any reason to stick with it. I don't think you should forever banish lithium from your medicine chest of artillery, though. That it may have produced a positive response early in treatment may indicate that it may be useful in future combinations. I'm not trying to sell the stuff. I hate it (for me).Depakote?
Lamictal?
How about Parnate + (Wellbutrin or desipramine) + Ritalin?
As far as the discontinuation-induced refractoriness to lithium is concerned, I think my treatment of it in my prior post was well-balanced. The details of Cam's contribution echo that which I had already stated. I am not convinced that discontinuation-induced refractoriness exists as a discreet phenomenon. I have no emotional stake in this. However, one study of a mere 28 people in the absence of life-charting and without correlating the type and course of illness for each case is, for me, far from being a well designed investigation. Why did they not include the rest of their "large, naturalistic follow-up of patients"? I'm sure I could reproduce these results if I were to choose 28 24-year olds who presented with their index episode of mania.
It has been my personal experience that I tend to find what I'm looking for. I am not a well-disciplined Ph.D. who is supposedly trained to approach an issue with impeccable objectivity. I'm getting better, though. If I want to cruise Medline to prove that lithium-discontinuation-induced lithium-refractoriness exists, voila... (see below)
The anecdotal reports are there, a few multiple-case studies are there, and only one contradictory citation showed-up - yours, although I'm sure there are more. What does this prove? Not a whole hell of a lot. No intelligent investigation of this issue exists. I will say that there is enough stuff here to persuade me to consider the possibility. There is certainly enough stuff here to give evidence that it does happen, regardless of how frequently or infrequently. If I were to find myself in a pair of shoes of roughly the same style as my friend was wearing, I would definitely place a weight on the balance scale on the side of caution.
None of this applies to you anyway.
===========================================================
This is the abstract you cited in its entirety:
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1 : Am J Psychiatry 1998 Jul;155(7):895-8 Related Articles, Books, LinkOut
Lithium discontinuation and subsequent effectiveness.Coryell W, Solomon D, Leon AC, Akiskal HS, Keller MB, Scheftner WA, Mueller T
University of Iowa College of Medicine, Iowa City 52242-1000, USA. william-coryell@uiowa.edu
OBJECTIVE: Several reports have raised concern that the discontinuation of lithium may result in treatment resistance following recurrence of affective disorder. This report explores this possibility. METHOD: The data derive from a large, naturalistic follow-up of patients with major depressive disorder or mania. Twenty-eight of the patients in the study were free of lithium and experiencing an episode of mania or schizoaffective mania diagnosed according to Research Diagnostic Criteria when they entered the study, recovered while taking lithium, later experienced a recurrence while not taking lithium, and then resumed lithium treatment. Survival analyses of time to recovery and, subsequently, time to recurrence, used continued lithium treatment as an additional censoring variable. RESULTS: Patients given lithium recovered no more quickly from their index episode than they did from their first prospectively observed episode. Moreover, lithium prophylaxis appeared no less effective after the first prospectively observed episode than after the index episode. CONCLUSIONS: These findings provide no evidence that lithium discontinuation results in treatment resistance when lithium is resumed.
===========================================================
1 : Am J Psychiatry 1992 Dec;149(12):1727-9 Related Articles, Books
Lithium-discontinuation-induced refractoriness: preliminary observations.Post RM, Leverich GS, Altshuler L, Mikalauskas K
Biological Psychiatry Branch, National Institute of Mental Health, Bethesda, MD 20892.
The authors used a systematic life-chart methodology to observe four patients with bipolar disorder in whom long periods (6-15 years) of effective lithium prophylaxis were followed by relapses on lithium discontinuation. Once the drug was reinstituted, it was no longer effective. The incidence, predictors, and mechanisms underlying this phenomenon all require further systematic study. The current preliminary observations suggest an additional reason for caution when lithium discontinuation in the well-maintained patient is considered.
-------------------------------------------------
Ned Tijdschr Geneeskd 2000 Feb 26;144(9):401-4 Related Articles, Books
[No title available].[Article in Dutch]
Oostervink F, Nolen WA, Hoenderboom AC, Kupka RW
Academisch Ziekenhuis, Utrecht.
[Medline record in process]
Three man, aged 66, 60 and 26 years with bipolar disorder and long periods (20-5 years) of effective lithium prophylaxis had relapses on lithium discontinuation. Once the drug was reinstituted, it was no longer effective. Combinations of lithium with a classical MAO inhibitor or a second mood stabilizer (valproic acid and carbamazepine, respectively) ultimately proved to be successful. The risk of refractoriness should be kept in mind before considering to stop lithium therapy. A better compliance can be achieved by informing patients about the risks of discontinuing lithium, by maintaining a minimal maintenance dose and by adequately coping with possible side effects.
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2 : Am J Psychiatry 1994 Oct;151(10):1522 Related Articles, Books
Refractoriness induced by lithium discontinuation despite adequate serum lithium levels.Bauer M
Publication Types:
Comment
LetterComments:
Comment on: Am J Psychiatry 1992 Dec;149(12):1727-9
Comment on: Am J Psychiatry 1993 Nov;150(11):1756
---------------------------------------------------------
Am J Psychiatry 1993 Nov;150(11):1756 Related Articles, Books
Refractoriness induced by lithium discontinuation.Terao T, Terao M
Publication Types:
Comment
LetterComments:
Comment on: Am J Psychiatry 1992 Dec;149(12):1727-9
Comment in: Am J Psychiatry 1994 Oct;151(10):1522
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Nonresponse to reinstituted lithium prophylaxis in previously responsive bipolar patients: prevalence and predictors.Maj M, Pirozzi R, Magliano L
Department of Psychiatry, First Medical School, University of Naples, Italy.
OBJECTIVE: The authors explored the prevalence and predictors of nonresponse to reinstituted lithium prophylaxis in bipolar patients who had relapsed after discontinuation of successful lithium treatment. METHOD: The study was conducted with 54 bipolar patients for whom lithium had been reintroduced after one or more recurrences following discontinuation of successful prophylaxis. They were followed up, through bimonthly personal interviews, for 1 year after recovery from the episode during which lithium treatment had been resumed, or up to the first recurrence with onset after lithium reinstitution. RESULTS: During the follow-up period, 44 patients did not have any affective episodes, whereas 10 had at least one recurrence. The only significant difference between the two patient groups was the longer duration of prediscontinuation lithium treatment for the patients who relapsed. CONCLUSIONS: Nonresponse to reinstituted prophylaxis should be considered among the possible risks of the interruption of effective long-term lithium treatment.
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: Psychol Rep 1994 Apr;74(2):355-61 Related Articles, Books
Lithium maintenance therapy for bipolar I patients: possible refractoriness to reinstitution after discontinuation.Murray JB
Psychology Department, St. John's University, Jamaica, NY 11439.
Publication Types:
Review
Review, tutorial
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94 : Neuropsychobiology 1993;27(3):132-7 Related Articles, Books, LinkOut
New developments in the use of anticonvulsants as mood stabilizers.Post RM, Ketter TA, Pazzaglia PJ, George MS, Marangell L, Denicoff K
Biological Psychiatry Branch, National Institute of Mental Health, Bethesda, MD 20892.
There is increasing recognition that lithium is inadequate in the treatment of up to 50% of bipolar patients. In addition to subgroups that are nonresponsive from the outset, loss of efficacy (tolerance) and discontinuation-induced refractoriness have recently been observed. The anticonvulsants carbamazepine and valproate are effective alternative or adjunctive treatments, but tolerance can also occur during their long-term prophylactic use. New treatment algorithms for this loss of efficacy, including combination therapies, require further systematic study. Preliminary data suggesting that some patients with extremely rapid and chaotic mood fluctuations may respond to the L-type calcium channel blocker nimodipine are presented, and the theoretical implications discussed.
----------------------------------------------------
There are more.
Posted by Noa on March 28, 2000, at 9:51:17
In reply to Re: Tapering off Lithium , posted by Phil on March 27, 2000, at 7:13:17
Finally spoke with my pdoc last night. He wasn't thrilled with the idea of giving up on lithium, but said he trusts my judgment. He said to taper by 300 mg every week, which was my plan anyway.
Posted by KELLYR. on March 28, 2000, at 20:40:56
In reply to Re: Tapering off Lithium , posted by Noa on March 28, 2000, at 9:51:17
> Finally spoke with my pdoc last night. He wasn't thrilled with the idea of giving up on lithium, but said he trusts my judgment. He said to taper by 300 mg every week, which was my plan anyway.
NOA,I hope that you find the right meds.I know that it gets very upsetting when it seems like you find the right meds & they stop working,(been there).Do you know what his is going to put you on now?My thoughts & prays are w/ you.
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