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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 10 of 10. This is the beginning of the thread.
Posted by SLS on April 4, 2001, at 12:06:21
Two new anticonvulsants are being investigated through preliminary studies for their potential to be of benefit to people suffering from bipolar disorder, including those who have not adequately responded to current available treatments. Their mechanisms of action appear to be very different from the other anticonvulsants.
levetiracetam (Keppra)
zonisamide (Zonegan)Another relatively new anticonvulsant, tiagabine (Gabitril), has been used from time to time for bipolar disorder, but I haven't seen anyone on Psycho-Babble describe their experience with it.
- Scott
Posted by cole on April 4, 2001, at 20:49:01
In reply to New mood-stabilizers ?, posted by SLS on April 4, 2001, at 12:06:21
I wanted to thank you for your response re: serzone and my boyfriend, I read him all the responses and he liked your explanation the most. He seems to be doing pretty well on
the stuff now & has adjusted to the urge to express himself.
I have a question regarding my own med happenings, and it relates to the mood stabilizer business. In an earlier post I was wondering why I've kept crashing on remeron every few months and requiring an increase in my dosing to restabilize. I've gone from 45 in october to 60 in january, and needed to take it up to 75 a little over a week ago. My pdoc mentioned that my depression is "cyclic" in my last visit when I was asking about the problem. Loosmrbls responded to the earlier post suggesting that I was actually bipolar II and needed a mood stabilizer. I've never experienced true mania, unless you consider the agitation/aggression I experienced from zoloft. My depression is very strong though, and I suffer from significant anxiety (I do drive like a bat out of hell when anxious)with the depression. Should I look into a mood stabilizer? What would work with remeron, ritalin (as needed to study), and small amts of trazodone? Provigil and wellbutrin made me feel completely disconnected, if that lends any clues. I do have a box of adrafinil that I haven't tried either, but that's more of a stimulant. Any ideas would be much appreciated, I want some good ideas before I talk to my doctor.
:) cole
Posted by SLS on April 4, 2001, at 23:09:35
In reply to Re: New mood-stabilizers ? » SLS, posted by cole on April 4, 2001, at 20:49:01
> I wanted to thank you for your response re: serzone and my boyfriend, I read him all the responses and he liked your explanation the most. He seems to be doing pretty well on the stuff now & has adjusted to the urge to express himself.
I'm glad that the situation was "simple" enough to resolve itself. Wonderful.
> I have a question regarding my own med happenings, and it relates to the mood stabilizer business. In an earlier post I was wondering why I've kept crashing on remeron every few months and requiring an increase in my dosing to restabilize. I've gone from 45 in october to 60 in january, and needed to take it up to 75 a little over a week ago.
I think it is reasonable to try 75mg of Remeron for a few weeks. I cannot comment on the probability of your responding to it, but you are almost done completely exploring it. Did it help at all at any point?
> My pdoc mentioned that my depression is "cyclic" in my last visit when I was asking about the problem.
What is it about your case that is cyclic?
> Loosmrbls responded to the earlier post suggesting that I was actually bipolar II and needed a mood stabilizer. I've never experienced true mania, unless you consider the agitation/aggression I experienced from zoloft.
Loosmrbls could be right. However, agitation is listed as a possible side effect of Zoloft.
Sometimes, when someone is just beginning to respond to an antidepressant, irritability and anger can emerge. However, if your reaction to Zoloft included impatience with people, constant movement, rapid or pressured speech, fits of rage, and reduced need for sleep, then a diagnosis of bipolar II needs to be considered.
> My depression is very strong though, and I suffer from significant anxiety (I do drive like a bat out of hell when anxious) with the depression.
I don't know what to make of this. The driving while anxious thing is suspicious as being consistent with a mixed-state hypomania, a type of bipolar II in which depression and hypomania occur simultaneously. However, I don't know how often this sort of driving thing can happen with unipolar depression. I don't experience it, but my depression is very anergic - I don't have enough energy to be anxious and drive fast.
Do you ever get an acid-stomach?
> Should I look into a mood stabilizer?
I don't know.
If it is determined that you have a bipolar-type disorder, a mood-stabilizer would probably be an important part of your treatment. Some people have symptoms that are similar to bipolar disorder but do not meet the strict criteria established for this diagnosis. Recently, the term "soft-bipolar" has emerged to describe these otherwise undefined bipolar-type presentations.
What other drugs have you tried?
> What would work with remeron, ritalin (as needed to study), and small amts of trazodone? Provigil and wellbutrin made me feel completely disconnected, if that lends any clues.
I think these clues would ring a bell with somebody here, but I can't come up with anything concrete. If you decide to try a mood stabilizer, I would recommend Lamictal (lamotrigine). It has significant antidepressant effects and is claimed to be effective for treating rapid-cyclicity. It has few side effects at the dosages used for depression and bipolar disorder. The one very important thing to remember is to start Lamictal at a low dosage and increase it very gradually. Doing so will prevent a rash-reaction that occurs infrequently but that can be serious. I currently take 300mg of Lamictal. I find it helpful. You will probably be recommended every possible drug except those you have already tried, but Effexor or Parnate sound good to me. Parnate is an MAO-inhibitor, a drug that is better left for later because it requires a special diet. There are numerous eligible alternatives. It might make sense to add Effexor to Remeron at this point, as it is considered a potent combination. You might be able to lower the dosage of Remeron if it works. Just keep an eye out for mania (or have others keep an eye out for you), just in case you have the potential for it. I'm not saying that you do.
> I do have a box of adrafinil that I haven't tried either, but that's more of a stimulant.
A great many people have had success with adrafinil. It really cannot be lumped into the same category as the convential "stimulants", and does not seem to act identically to its sister drug, Provigil.
> Any ideas would be much appreciated, I want some good ideas before I talk to my doctor.
Oh, I wish you would have specified "good" ideas before I wrote anything. I'll have to leave that for someone else.
Sincerely,
Scott
Posted by SalArmy4me on April 5, 2001, at 2:42:34
In reply to New mood-stabilizers ?, posted by SLS on April 4, 2001, at 12:06:21
Tiagabine is mentioned in the Tips, but I personally don't believe that anything other than gabapentin, lamotrigine, or topiramate will be needed for bipolar disorder (I have taken them all and they are all good).
> Two new anticonvulsants are being investigated through preliminary studies for their potential to be of benefit to people suffering from bipolar disorder, including those who have not adequately responded to current available treatments. Their mechanisms of action appear to be very different from the other anticonvulsants.
>
> levetiracetam (Keppra)
> zonisamide (Zonegan)
>
> Another relatively new anticonvulsant, tiagabine (Gabitril), has been used from time to time for bipolar disorder, but I haven't seen anyone on Psycho-Babble describe their experience with it.
>
>
> - Scott
Posted by loosmrbls on April 5, 2001, at 7:35:45
In reply to Re: New mood-stabilizers ? » SLS, posted by cole on April 4, 2001, at 20:49:01
Cole:
I forgot to post the name of a great website for the latest info on bipolar II. You don't need true mania to be Bipolar II (you would be Bipolar I if you had full mania) and people with bipolar II often don't think they've ever had a hypomanic episode. It takes a skilled psychiatrist to tease out the history -- although in my case it was pretty obvious.
I would recommend reading the website and see if what they talk about "feels right" to you. It may, it may not. You'll probably know after reading the website if Bipolar II sounds right for you, especially if you've lived with your illness for a while.
When I first found Dr. Bob's forum, I was both relieved and horrified to find so many people with "treatment resistant depression."
I'm becoming more convinced that "depression" is the final common symptom(s) of vastly different mental illnesses -- just as stomach pain, or fever, can be casued by many, very different illnesses.
After all, bipolar and unipolar depression look identical, and can be treated almost identical (although I think this will change) even though the illnesses are very different.
I think the small group of people who "get depressed" and recover after antidepressants are the exception and not the rule, and usually you can find a cause (so they would be adjustment disorder with depressed mood, or "situational depression.")
This forum obviously represents the people who do not fall into that category. I think many people are misdiagnosed with "depression" because depression is a common presentation for a variety of different mental illnesses. I was treated as "depressed" for over two years -- thankfully, the hypomania began to rear it's head more strongly and I found a great doctor, and I was diagnosed. I am now finding out the two years of being on antidepressants may have been worse for me -- not neutral, or simply delaying adequate treatment.
My point here? It's not the label or diagnosis that matters, it is finding the right drug(s) that work for you and make you better. If you (like me) have been on numerous trials of AD's and it didn't help (or makes you worse) it's time to maybe consider another diagnosis, or at least another type of medication.
Mood stabilizers are also used as an adjunct with AD's for refractory depression, so even if bipolar II doesn't seem like you, a trial of these drugs may be helpful.
Posted by SLS on April 5, 2001, at 10:05:55
In reply to Re: New mood-stabilizers ?, posted by SalArmy4me on April 5, 2001, at 2:42:34
Sal,
> Tiagabine is mentioned in the Tips, but
> I personally don't believe that anything other than gabapentin, lamotrigine, or topiramate will be needed for bipolar disorder
I am curious what would motivate you to make such an assertion. It is rather bold.
If medical science had thought this way twenty years ago about its armamentarium of tricyclics and MAO-inhibitors, we would not have Prozac, Serzone, Remeron, Wellbutrin, etc. The clinicians at that time felt that they could help 85% of people using those two classes of antidepressants. (The 85% number was quoted me by Michael Liebowitz in 1982). Those odds really aren't so bad. Why look for new drugs?
As far as my position in life is concerned, I can't afford to concur with your opinion. Besides, it doesn't seem to be an opinion shared by clinical and research psychopharmacologist. I am happy about that. :-) Hell, even Robert M. Post can't juggle those three drugs and successfully treat all of his patients at the NIMH.
> (I have taken them all and they are all good).
If you have found your answer within the boundaries of the current pharmacopoeia, I am happy for you. There are others who haven't. In addition, it would be nice to produce other mood-stabilizers without the side effects associated with those you have mentioned.
What about Tegretol or Depakote? I am sure you can find things about these drugs that are not desirable, but some people rely on them to remain a member of society, often without experiencing significant side effects. Does lithium still occupy a unique niche in pharmacotherapy, or can everyone currently taking it just replace it with one of the three you have suggested and remain well? Personally, I would be scared to tell anyone that.
- Scott
P.S. I hope you are right.
>
> > Two new anticonvulsants are being investigated through preliminary studies for their potential to be of benefit to people suffering from bipolar disorder, including those who have not adequately responded to current available treatments. Their mechanisms of action appear to be very different from the other anticonvulsants.
> >
> > levetiracetam (Keppra)
> > zonisamide (Zonegan)
> >
> > Another relatively new anticonvulsant, tiagabine (Gabitril), has been used from time to time for bipolar disorder, but I haven't seen anyone on Psycho-Babble describe their experience with it.
> >
> >
> > - Scott
Posted by SalArmy4me on April 5, 2001, at 12:56:47
In reply to Re: New mood-stabilizers ? » SalArmy4me, posted by SLS on April 5, 2001, at 10:05:55
Some thoughts: I tried tiagabine. Hell, I tried everything whether orthodox or experimental. I couldn't remember who I was on tiagabine.
My father does not prescribe nor has he ever heard of tiagabine for epilepsy or mania.
> Sal,
>
> > Tiagabine is mentioned in the Tips, but
>
> > I personally don't believe that anything other than gabapentin, lamotrigine, or topiramate will be needed for bipolar disorder
>
> I am curious what would motivate you to make such an assertion. It is rather bold.
>
> If medical science had thought this way twenty years ago about its armamentarium of tricyclics and MAO-inhibitors, we would not have Prozac, Serzone, Remeron, Wellbutrin, etc. The clinicians at that time felt that they could help 85% of people using those two classes of antidepressants. (The 85% number was quoted me by Michael Liebowitz in 1982). Those odds really aren't so bad. Why look for new drugs?
>
> As far as my position in life is concerned, I can't afford to concur with your opinion. Besides, it doesn't seem to be an opinion shared by clinical and research psychopharmacologist. I am happy about that. :-) Hell, even Robert M. Post can't juggle those three drugs and successfully treat all of his patients at the NIMH.
>
> > (I have taken them all and they are all good).
>
> If you have found your answer within the boundaries of the current pharmacopoeia, I am happy for you. There are others who haven't. In addition, it would be nice to produce other mood-stabilizers without the side effects associated with those you have mentioned.
>
> What about Tegretol or Depakote? I am sure you can find things about these drugs that are not desirable, but some people rely on them to remain a member of society, often without experiencing significant side effects. Does lithium still occupy a unique niche in pharmacotherapy, or can everyone currently taking it just replace it with one of the three you have suggested and remain well? Personally, I would be scared to tell anyone that.
>
>
> - Scott
>
>
> P.S. I hope you are right.
>
>
> >
> > > Two new anticonvulsants are being investigated through preliminary studies for their potential to be of benefit to people suffering from bipolar disorder, including those who have not adequately responded to current available treatments. Their mechanisms of action appear to be very different from the other anticonvulsants.
> > >
> > > levetiracetam (Keppra)
> > > zonisamide (Zonegan)
> > >
> > > Another relatively new anticonvulsant, tiagabine (Gabitril), has been used from time to time for bipolar disorder, but I haven't seen anyone on Psycho-Babble describe their experience with it.
> > >
> > >
> > > - Scott
Posted by cole on April 5, 2001, at 16:56:13
In reply to Re: New mood-stabilizers ?, posted by SLS on April 4, 2001, at 23:09:35
Thank you both for your responses. Here's a little more of my hx if it lends any clues/ ideas.
> I think it is reasonable to try 75mg of Remeron for a few weeks. I cannot comment on the probability of your responding to it, but you are almost done completely exploring it. Did it help at all at any point?
>
*Yes, in fact when it's working it is the best med I've ever tried. I sleep more than I would like at night, but I don't need to take naps, I have energy, I am motivated, and I am not at all depressed. I do maintain some of my anxiety, but nothing like the anxiety when severely depressed. The problem is, the best response occurs about 2-3 weeks after increasing the dose, then starts to drop off and I begin moving towards depression. So I guess I'm chasing after that initial response when I up my dose.
> What is it about your case that is cyclic?*I definitely progress through the year, my worst time is usually feb- april, best is summer. Additionally I go through periods of waxing and waning depression within a time span of days/weeks.
> Loosmrbls could be right. However, agitation is listed as a possible side effect of Zoloft.
>
> Sometimes, when someone is just beginning to respond to an antidepressant, irritability and anger can emerge. However, if your reaction to Zoloft included impatience with people, constant movement, rapid or pressured speech, fits of rage, and reduced need for sleep, then a diagnosis of bipolar II needs to be considered.*I was on zoloft all through high school, and I can't believe how much nicer I am off the stuff. On zoloft I was always starting fights with people, I was violent towards my parents, & I was always breaking things. I was so keyed up I was always bouncing my leg if seated, and I couldn't sleep at night (had to take trazodone), ground my teeth (even during the day!). . .basically I was a pain in the ass. I still had periods where I would sleep most of the afternoon despite all the anxiety the med produced/ then would be up all night without the trazodone.
> I don't know what to make of this. The driving while anxious thing is suspicious as being consistent with a mixed-state hypomania, a type of bipolar II in which depression and hypomania occur simultaneously.* One thing that I experience that makes me think mixed state is when I am depressed, and something upsets me. I get into a really dissociative state, and I usually end up slicing my arm with a knife or hurting myself somehow. I also feel this way when I get suicidal, which is a significant side to my depression. The state ends after I hurt myself, and later when the wound hurts I wonder what the hell I was thinking, but I kind of break from reality when I do that sort of thing. I self mutilated constantly on zoloft, it's very infrequent now.
> Do you ever get an acid-stomach?
*I've been diagnosed with acid reflux, does this count?> What other drugs have you tried?
* here's a an abridged list: celexa-- same rxn as zoloft; trazodone-- only helps me sleep; serzone-- only slight antianxiety effects; wellbutrin and provigial-- no AD effect, both caused serious brain lag; reboxetine-- made me suicidal; ritalin-- only helps me concentrate & stay out of bed; prozac-- no noticeable response that I recall, but that was over 10 yrs ago.
>
> A great many people have had success with adrafinil. It really cannot be lumped into the same category as the convential "stimulants", and does not seem to act identically to its sister drug, Provigil.*I might give the adrafinil a shot, but if it is metabolized like provigil, it will make my birthcontrol pills ineffective.
> Oh, I wish you would have specified "good" ideas before I wrote anything. I'll have to leave that for someone else.
You were rather helpful-- you gave me some things to think about, I really appreciate your input. I'll look into the lamictal.
Thanks!
cole
Posted by SLS on April 5, 2001, at 20:44:02
In reply to Re: New mood-stabilizers ? SLS, loosmrbls, posted by cole on April 5, 2001, at 16:56:13
Hi Cole.
> * One thing that I experience that makes me think mixed state is when I am depressed, and something upsets me. I get into a really dissociative state, and I usually end up slicing my arm with a knife or hurting myself somehow. I also feel this way when I get suicidal, which is a significant side to my depression. The state ends after I hurt myself, and later when the wound hurts I wonder what the hell I was thinking, but I kind of break from reality when I do that sort of thing. I self mutilated constantly on zoloft, it's very infrequent now.
Your description does not really strike me as being at all manic. You seem to be suffering from an agitated depression that a tricyclic antidepressant might help. You might also benefit from a low dosage of Zyprexa. The other thing that might be important to consider is the seasonal course of your illness. When you speak to your doctor next, ask him if he has ruled-out seasonal affective disorder (SAD). This type of depression is often best treated with light-therapy.
- Scott
Posted by judy1 on April 6, 2001, at 15:20:15
In reply to Re: New mood-stabilizers ? SLS, loosmrbls, posted by cole on April 5, 2001, at 16:56:13
Hi,
Craig sent me over here (I'm over on the other board posting about my dissociation and self-injury problems) Anyway, it sounds like we share some common symptoms- I'm dxed with bipolar 1, rapid cycling, panic disorder, PTSD and some sort of dissociative disorder that may be a result of everything else going on. I also have a lot of problems with dissociation when depressed, and it usually ends in self-injury (cutting). I'm working with a therp who just deals with this (DBT). I'm also on lamictal, klonopin, xanax and just stopped risperdal (none of these messed with my birth control pills). I can't take any AD's because my cycling worsens, and SSRI's were the worst offenders. Sorry I don't have the concentration to read the thread, just thought my experiences may help. take care, judy
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