![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 45. This is the beginning of the thread.
Posted by colin wallace on February 24, 2003, at 13:40:48
Hi guys,I need some innovative ideas here. I have my (BP11 type) depression pretty much under control right now, with Lamictal at 225mg.My experience with Lamictal has surpassed my most optimistic expectations, but it’s been a bit of a cat ‘n mouse affair all along- excellent results within three months or so and a complete normalizing of mood and temperament. Then, very suddenly the cracks start to appear, and the AD effect just ‘cuts-out’.When this happens, I immediately start to relapse into a dysphoric hypomania(angry, bitter, helter-skelter runaway depressive thoughts- reckless actions etc.).
What cures this very quickly is raising the Lamictal dose by 25mg or so, although this too tends to wane over time. I had hoped(prayed) that I would reach an optimum dose where the mood stabilization and depression would be taken care of- at least for some considerable period of time. This may yet happen. However, my track record and the experiences of others suggest that at some point (possibly sooner than I’d anticipated)my underlying illness will finally outpace any viable Lamictal dosage.I say this because I am now forced to rely on an uniformed, overcautious GP. who just won’t raise my dose high enough or quickly enough .I’m only supposed to be taking 150mg as it is.
If I start to slide again, I’d like to be prepared. I intend to pre-empt this by choosing a suitable mood stabilizer to fortify the Lamictal(I only ever experience dysphoric hypomania-never euphoric, sadly).At that point, I’ll also need to aggressively tackle my depression, with a serious AD, where all else has failed.
My current thoughts are along the lines of Topomax or Carbemazapine for stabilization, with a last attempt at Prozac, before trying. Selegiline or another MAOI as a last resort.A lithium or Valproate re-trial are possibilities although I hated both without an AD first time around).
If my Lamictal does finally poopout(God forbid), I know I’ll very quickly become badly unstable and depressed, and I want to be prepared should it happen.
Any ideas would be appreciated here, so I can bounce them around with a psych.(assuming I can find/afford one).Col. The eternal pessimist.
Posted by Ron Hill on February 24, 2003, at 15:10:52
In reply to Lamictal and Pre-emptive Strikes , posted by colin wallace on February 24, 2003, at 13:40:48
Colin,
Have you read the most recent (Spring 2002) edition of the American Psychiatric Association's "Practice Guideline for the Treatment of Patients With Bipolar Disorder (Revision)"? If not, here is a link to the document:
http://www.psych.org/clin_res/bipolar_revisebook_1.cfm#parta-1
May I give you my opinion? If yes, keep reading. If no, STOP HERE!
This is just my two cents and as such it could be completely incorrect. If I were in your situation, I'd leave the Lamictal in place and add a time-release lithium product (e.g.; Lithobid) at a low dose, shooting for a Li blood level of about 0.4 micromol/l (I think I’ve got the units correct).
My second choice would be to add-on Trileptal to your existing Lamictal. As you probably know, Trileptal is Tegretol with an extra oxygen molecule tagged on. Trileptal works similarly to Tegretol but with fewer side effects.
As you likely know, using Depakote and Lamictal concurrently can be a little risky because Depakote influences the blood levels of Lamictal and, therefore, the patient can be put at higher risk of rash and/or Steven's Johnson Syndrome.
Once you have enough mood stabilization on board, if you still struggle with depressive episodes, then add-on a MAOI like Parnate, Nadil, or (maybe) Selegiline.
That's my opinion, but you know what they say? Opinions are like butt-holes; everybody has one!
Quick questions: Do you think the nine cans of beer contributed to your current "eternal pessimist" mind set? Could alcohol be destabilizing you? Do you think that your brief sampling of Enada NADH was destabilizing for you?
I care about you as a friend.
-- Ron
-----------------------------------
> Hi guys,
>
> I need some innovative ideas here. I have my (BP11 type) depression pretty much under control right now, with Lamictal at 225mg.My experience with Lamictal has surpassed my most optimistic expectations, but it’s been a bit of a cat ‘n mouse affair all along- excellent results within three months or so and a complete normalizing of mood and temperament. Then, very suddenly the cracks start to appear, and the AD effect just ‘cuts-out’.When this happens, I immediately start to relapse into a dysphoric hypomania(angry, bitter, helter-skelter runaway depressive thoughts- reckless actions etc.).
> What cures this very quickly is raising the Lamictal dose by 25mg or so, although this too tends to wane over time. I had hoped(prayed) that I would reach an optimum dose where the mood stabilization and depression would be taken care of- at least for some considerable period of time. This may yet happen. However, my track record and the experiences of others suggest that at some point (possibly sooner than I’d anticipated)my underlying illness will finally outpace any viable Lamictal dosage.I say this because I am now forced to rely on an uniformed, overcautious GP. who just won’t raise my dose high enough or quickly enough .I’m only supposed to be taking 150mg as it is.
> If I start to slide again, I’d like to be prepared. I intend to pre-empt this by choosing a suitable mood stabilizer to fortify the Lamictal(I only ever experience dysphoric hypomania-never euphoric, sadly).At that point, I’ll also need to aggressively tackle my depression, with a serious AD, where all else has failed.
> My current thoughts are along the lines of Topomax or Carbemazapine for stabilization, with a last attempt at Prozac, before trying. Selegiline or another MAOI as a last resort.A lithium or Valproate re-trial are possibilities although I hated both without an AD first time around).
> If my Lamictal does finally poopout(God forbid), I know I’ll very quickly become badly unstable and depressed, and I want to be prepared should it happen.
> Any ideas would be appreciated here, so I can bounce them around with a psych.(assuming I can find/afford one).
>
> Col. The eternal pessimist.
>
>
Posted by Ron Hill on February 24, 2003, at 15:44:31
In reply to Lamictal and Pre-emptive Strikes , posted by colin wallace on February 24, 2003, at 13:40:48
Colin,
I was trying to provide you a link to the entire APA document. Let me try again:
http://www.psych.org/clin_res/bipolar_revisebook_index.cfm
-- Ron
------------------------
> Hi guys,
>
> I need some innovative ideas here. I have my (BP11 type) depression pretty much under control right now, with Lamictal at 225mg.My experience with Lamictal has surpassed my most optimistic expectations, but it’s been a bit of a cat ‘n mouse affair all along- excellent results within three months or so and a complete normalizing of mood and temperament. Then, very suddenly the cracks start to appear, and the AD effect just ‘cuts-out’.When this happens, I immediately start to relapse into a dysphoric hypomania(angry, bitter, helter-skelter runaway depressive thoughts- reckless actions etc.).
> What cures this very quickly is raising the Lamictal dose by 25mg or so, although this too tends to wane over time. I had hoped(prayed) that I would reach an optimum dose where the mood stabilization and depression would be taken care of- at least for some considerable period of time. This may yet happen. However, my track record and the experiences of others suggest that at some point (possibly sooner than I’d anticipated)my underlying illness will finally outpace any viable Lamictal dosage.I say this because I am now forced to rely on an uniformed, overcautious GP. who just won’t raise my dose high enough or quickly enough .I’m only supposed to be taking 150mg as it is.
> If I start to slide again, I’d like to be prepared. I intend to pre-empt this by choosing a suitable mood stabilizer to fortify the Lamictal(I only ever experience dysphoric hypomania-never euphoric, sadly).At that point, I’ll also need to aggressively tackle my depression, with a serious AD, where all else has failed.
> My current thoughts are along the lines of Topomax or Carbemazapine for stabilization, with a last attempt at Prozac, before trying. Selegiline or another MAOI as a last resort.A lithium or Valproate re-trial are possibilities although I hated both without an AD first time around).
> If my Lamictal does finally poopout(God forbid), I know I’ll very quickly become badly unstable and depressed, and I want to be prepared should it happen.
> Any ideas would be appreciated here, so I can bounce them around with a psych.(assuming I can find/afford one).
>
> Col. The eternal pessimist.
>
>
Posted by colin wallace on February 24, 2003, at 15:59:02
In reply to Re: Lamictal and Pre-emptive Strikes » colin wallace, posted by Ron Hill on February 24, 2003, at 15:10:52
Hi Ron,
Actually I was thinking along exactly the same lines as you-I'd probably opt for the Carbemazapine/Trileptal over lithium, based on my previous reaction to lithium.I intend leaving the Lamictal in place anyhow(I've just hit 250mg, and will aim for 300mg within 2weeks).
The occasional booze session doesn't really destabilize me on Lamictal , other than leaving me generally ill and hung over for days(that's why I rarely drink).The NADH isn't in the frame either- fact is I've been having 'warning shots across the bows' for at least a month.
I became hypomanic around 5weeks ago, when I wasn't allowed to raise my dose quickly enough.I jumped into my car in the middle of the night, drove over 300miles(with no clue where I was going),ran out of petrol and started wandering aimlessly.I really didn't know what I was doing.
I only came to my senses when I went to a hotel, and took an additional 50mg Lamictal(luckily I always carry meds with me).I was fine three days later.
It's just that my screwy neurons are a bit like the Borg(?!).... Whatever you throw at the f***ers, they tend to adapt and overcome eventually.
I'm keeping ahead of the game for the moment, and will see a psych. next month if I can.
I just have a gut instinct that I'll need something else in place, because if I'm honest with myself, I'm slowly losing ground.
Being under huge stress is of course my biggest bane right now, but that's an inescapable fact.
It just saps and erodes my gains.
We'll see how things pan out as I ramp up my dosage.
Thanks for your friendship Ron.
>>>That's my opinion, but you know what they say? Opinions are like butt-holes; everybody has one<<<Well Ron, your opinions are always welcome, but your butt-hole isn't too appealing at all.At least, that's what JohnJ tells me!!!
Posted by Ritch on February 24, 2003, at 22:25:26
In reply to Lamictal and Pre-emptive Strikes , posted by colin wallace on February 24, 2003, at 13:40:48
>
> Hi guys,
>
> I need some innovative ideas here. I have my (BP11 type) depression pretty much under control right now, with Lamictal at 225mg.My experience with Lamictal has surpassed my most optimistic expectations, but it’s been a bit of a cat ‘n mouse affair all along- excellent results within three months or so and a complete normalizing of mood and temperament. Then, very suddenly the cracks start to appear, and the AD effect just ‘cuts-out’.When this happens, I immediately start to relapse into a dysphoric hypomania(angry, bitter, helter-skelter runaway depressive thoughts- reckless actions etc.).
> What cures this very quickly is raising the Lamictal dose by 25mg or so, although this too tends to wane over time. I had hoped(prayed) that I would reach an optimum dose where the mood stabilization and depression would be taken care of- at least for some considerable period of time. This may yet happen. However, my track record and the experiences of others suggest that at some point (possibly sooner than I’d anticipated)my underlying illness will finally outpace any viable Lamictal dosage.I say this because I am now forced to rely on an uniformed, overcautious GP. who just won’t raise my dose high enough or quickly enough .I’m only supposed to be taking 150mg as it is.
> If I start to slide again, I’d like to be prepared. I intend to pre-empt this by choosing a suitable mood stabilizer to fortify the Lamictal(I only ever experience dysphoric hypomania-never euphoric, sadly).At that point, I’ll also need to aggressively tackle my depression, with a serious AD, where all else has failed.
> My current thoughts are along the lines of Topomax or Carbemazapine for stabilization, with a last attempt at Prozac, before trying. Selegiline or another MAOI as a last resort.A lithium or Valproate re-trial are possibilities although I hated both without an AD first time around).
> If my Lamictal does finally poopout(God forbid), I know I’ll very quickly become badly unstable and depressed, and I want to be prepared should it happen.
> Any ideas would be appreciated here, so I can bounce them around with a psych.(assuming I can find/afford one).
>
> Col. The eternal pessimist.
>
>Colin, I would go with the Tegretol add since you haven't tried that one yet. Teg is sometimes used successfully for treatment-resistant bipolar depression. I tried Trileptal recently and I felt a definite antidepressant effect from it, but I have a weak stomach and the stuff nauseated me badly. Just a tip-don't take much of it-it seems like if you take very much you dull out-just a little seemed to help with the "black-anergia" I can get from Depakote. Kind of similar to Wellbutrin, but much milder without any hostility or grouchiness. Oh, another idea here-what about some thyroid supplementation? I have yet to try it-pdoc is scared of it-I think it would be perfect for me (rapid cycling).
Posted by colin wallace on February 25, 2003, at 0:21:00
In reply to Re: Lamictal and Pre-emptive Strikes » colin wallace, posted by Ritch on February 24, 2003, at 22:25:26
> >
> Colin, I would go with the Tegretol add since you haven't tried that one yet. Teg is sometimes used successfully for treatment-resistant bipolar depression. I tried Trileptal recently and I felt a definite antidepressant effect from it, but I have a weak stomach and the stuff nauseated me badly. Just a tip-don't take much of it-it seems like if you take very much you dull out-just a little seemed to help with the "black-anergia" I can get from Depakote. Kind of similar to Wellbutrin, but much milder without any hostility or grouchiness. Oh, another idea here-what about some thyroid supplementation? I have yet to try it-pdoc is scared of it-I think it would be perfect for me (rapid cycling).Thanks Mitch,
I'm glad you chimed in here, because your symptoms seem very similar to mine(as do your med. reactions).I think I'll try asking for Trileptal, but I won't hold my breath(dealing with a UK psych.- he'll probably prescribe 350mg Effexor for hypomania..)
It seems Trileptal has less of a likelihhood for causing med. interactions(than Carbemazapine) too.Have you compared the two, or do they just 'feel' like identical meds??
Can I ask what doses you took, and at what point did you become nauseated?I never tried Wellbutrin-it's not available as an AD here in UK anyway, but I'm almost certain it would zap me with more irritability.
Thyroid supplementation interests me too,but I haven't looked into it in detail yet.
What meds are you currently taking Mitch anyway, and how do you feel yourself these days?Cheers,
Col.ps.Any thoughts on Topomax?
Posted by colin wallace on February 25, 2003, at 0:24:03
In reply to Re: Let me try that link again » colin wallace, posted by Ron Hill on February 24, 2003, at 15:44:31
Posted by Ritch on February 25, 2003, at 9:46:21
In reply to Re: Lamictal and Pre-emptive Strikes, posted by colin wallace on February 25, 2003, at 0:21:00
> > >
> > Colin, I would go with the Tegretol add since you haven't tried that one yet. Teg is sometimes used successfully for treatment-resistant bipolar depression. I tried Trileptal recently and I felt a definite antidepressant effect from it, but I have a weak stomach and the stuff nauseated me badly. Just a tip-don't take much of it-it seems like if you take very much you dull out-just a little seemed to help with the "black-anergia" I can get from Depakote. Kind of similar to Wellbutrin, but much milder without any hostility or grouchiness. Oh, another idea here-what about some thyroid supplementation? I have yet to try it-pdoc is scared of it-I think it would be perfect for me (rapid cycling).
>
> Thanks Mitch,
>
> I'm glad you chimed in here, because your symptoms seem very similar to mine(as do your med. reactions).I think I'll try asking for Trileptal, but I won't hold my breath(dealing with a UK psych.- he'll probably prescribe 350mg Effexor for hypomania..)
> It seems Trileptal has less of a likelihhood for causing med. interactions(than Carbemazapine) too.Have you compared the two, or do they just 'feel' like identical meds??
> Can I ask what doses you took, and at what point did you become nauseated?I never tried Wellbutrin-it's not available as an AD here in UK anyway, but I'm almost certain it would zap me with more irritability.
> Thyroid supplementation interests me too,but I haven't looked into it in detail yet.
> What meds are you currently taking Mitch anyway, and how do you feel yourself these days?
>
> Cheers,
> Col.
>
> ps.Any thoughts on Topomax?
>
Hi Colin, I took Tegretol once a long time ago as a switch from lithium-but I only tried it a few days because it didn't seem to help me that much (didn't give it a fair trial). I knew a Navy vet in college (on disability) that was BPI who had been on high dose lithium for probably 20 years and he switched to it and liked it a lot because he said his "memory came back". Trileptal, I tried for the first time a couple of years ago when it first came out. I get an AD effect from it but I got the nausea when I hit 225mg and when I went up to 300mg it became intolerable. I retried it again at the start of my seasonal blue spell back in December and I got the AD effect again-and got the nausea again. But I still got some benefit from 150mg/day as tiny as that sounds. I tried it on its own (w/o Depakote) for a couple of weeks very recently and the Dep. removal made me VERY uptight. Couldn't handle it. So, I just quit the Trileptal and went back on Dep., anxiety went way down, but now I am feeling off/on black/blue spells again and my cycling is aggravated a little more but I'm NOT angry. OK-I know this is complicated! The Depakote seems to defnitely help anxiety and REALLY gets rid of my temper spells. The Trileptal seems to be more effective for depression and reducing *CYCLING*, but it makes me want to barf! So, right now I'm on Depakote 250mg, Klonopin .5mg, and a *pinch* of Effexor in the morning (prob. about 9mg or so), with 500mg of L-tyrosine and about .7G of EPA. The Effexor quashes the Depakote induced black spells (always in the evenings-mornings are great) to some extent, but for it to work well I have to take a little more and that *little* extra will wreck my sleep and upset my stomach. I haven't heard of anybody else complaining about nausea from Trileptal-I'm just stomach sensitive to any med it seems. Topamax? I found it great for sleep and pretty decent for anxiety, but I had a major problem with forming thoughts and forgetting people's names. I would be talking to somebody I knew rather well for about ten minutes and spend half the time trying to remember what their name was! I know this doesn't sound that positive, but everybody reacts to a lot of this stuff so differently.---Mitch
Posted by catmint on February 25, 2003, at 15:42:48
In reply to Re: Lamictal and Pre-emptive Strikes, posted by colin wallace on February 25, 2003, at 0:21:00
Colin, Ron, and Ritch,
I have had a mini breakdown, but it's nothing unusual. I am feeling at my wits end on Lamictal, I have had to increase the dose weekly, only to have any effects wear off. I am moody all the time, I'm pretty sure it's lack of Seratonin,
Like Colin, I have tried the SSRIs and would only take them as a last resort.
I am having a lot of thoughts running through my head about adding Lithium or Trileptal as well. Ron, please, I like your opionion. Have you gained any weight on the low dose of Lithium? I am meeting with my pdoc on Thursday and will mention both to him. I was a lot less irritable on Depakote, but I don't want to combine it with Lamictal.
Ritch, does Trileptal work for irritability?
I am really having a bad day-life, whenever I tell someone I have bipolar, they are like, Ohhhh...(feel sorry for me).
Last night I was so fragile, I get so hopeless. Col, I can totally relate to how you feel, I sometimes want to run away, but I have a child. By the way, I have been so judgemental of myself
and can't even feel love for him. I wake up really irritable, and send him off to school,feeeling guilty about my feelings.
I upped my dose to 50 mg. and yes, am feeling that Lamictal buzz, headachy, energy, slightly more optimistic, racing thoughts, but hey, it's the best AD so far.
I am so glad I have you guys to talk to about this.
Hope to hear from you,
::Amy
Posted by Ron Hill on February 25, 2003, at 18:34:31
In reply to Re: Lamictal and Pre-emptive Strikes, posted by catmint on February 25, 2003, at 15:42:48
Hi Amy,
Sorry to hear that you are having trouble. Hang in there. There's an answer out there for you; the trick is finding it.
>Have you gained any weight on the low dose of Lithium?
Nope. Nada. Zippo. But, YMMV. However, I gained 30 pounds on Depakote (not to mention the hair loss, rash, and worsened depression). Depakote is a good medicine for a lot of people, but it was not a good fit for me. The only side effect I've had with Lithobid (600 mg/day) was frequent urination for the first couple of weeks when I first started the med.
>I am meeting with my pdoc on Thursday and will mention both to him. I was a lot less irritable on Depakote, but I don't want to combine it with Lamictal.
Amy, your dx is BP II, right? What moodstabilizers have you tried besides Lamictal and Depakote? Why did you discontinue the Depakote, weight gain? What other meds are you currently taking?
Clearly, the 50 mg/day of Lamictal is not providing enough mood stabilization, which is not surprising at that low dosage. Where is your pdoc going with this? Is it his/her plan to gradually ramp up the Lamictal until the dose is finally substantial enough to function as a mood stabilizer?
Amy, have you ever tried to add a low dose of an atypical antipsychotic to a moodstabilizer? I bring this up because of what you told me last week about the one hallucination episode.
I posted the following link earlier in this thread, but I'll place it here as well. If you can, scan over the relevant portions of the document before your pdoc appointment. Make sure your pdoc fully understands the difficulty you are having. Insist that he/she gives you the time needed to talk through your symptoms and possible remedies. Who cares if you go over the allotted fifteen minute appointment time limit!
http://www.psych.org/clin_res/bipolar_revisebook_index.cfm
Amy, keep us informed regarding your progress. Also, let me know what your pdoc says.
-- Ron
Posted by Ritch on February 25, 2003, at 23:20:27
In reply to Re: Lamictal and Pre-emptive Strikes, posted by catmint on February 25, 2003, at 15:42:48
> Colin, Ron, and Ritch,
>
> I have had a mini breakdown, but it's nothing unusual. I am feeling at my wits end on Lamictal, I have had to increase the dose weekly, only to have any effects wear off. I am moody all the time, I'm pretty sure it's lack of Seratonin,
> Like Colin, I have tried the SSRIs and would only take them as a last resort.
> I am having a lot of thoughts running through my head about adding Lithium or Trileptal as well. Ron, please, I like your opionion. Have you gained any weight on the low dose of Lithium? I am meeting with my pdoc on Thursday and will mention both to him. I was a lot less irritable on Depakote, but I don't want to combine it with Lamictal.
> Ritch, does Trileptal work for irritability?
> I am really having a bad day-life, whenever I tell someone I have bipolar, they are like, Ohhhh...(feel sorry for me).
> Last night I was so fragile, I get so hopeless. Col, I can totally relate to how you feel, I sometimes want to run away, but I have a child. By the way, I have been so judgemental of myself
> and can't even feel love for him. I wake up really irritable, and send him off to school,feeeling guilty about my feelings.
> I upped my dose to 50 mg. and yes, am feeling that Lamictal buzz, headachy, energy, slightly more optimistic, racing thoughts, but hey, it's the best AD so far.
> I am so glad I have you guys to talk to about this.
> Hope to hear from you,
> ::Amy
Amy, feeling "moody all the time" is a drag. It seems unfortunate that Lamictal may not work well "on its own". No news flash here-because I can't see Depakote working "on its own" for me either (for depression). Lithium thus far, has been the only one that comes close to accomplishing that, but it also has its shortcomings. I hate AP's, so they are OUT, too. So, the "two mood stabilizer combo" or 2 AED's comes to mind. I found Trileptal to be helpful only for depression and reduced cycle frequency (that's it). Depakote wins hands down for irritablity over anything else (even AP's). I still am convinced that thyroid augmentation (T3+T4) would work greatly (but can't get my pdoc to overcome paranoia about it). I read a poster here (I hope they jump in and help out) that mentioned being very stable on low-dose Depakote with low-dose Lamictal +thyroid. That's what has got my interest, I must admit.
Posted by catmint on February 25, 2003, at 23:51:50
In reply to Re: Lamictal and Pre-emptive Strikes » catmint, posted by Ron Hill on February 25, 2003, at 18:34:31
> Amy, your dx is BP II, right? What moodstabilizers have you tried besides Lamictal and Depakote? Why did you discontinue the Depakote, weight gain? What other meds are you currently taking?>Yes, I am BP II. I have tried Neurontin, Depakote and Lamictal. I discontinued the Depakote b/c it made my depression a lot worse and add on SSRI's did not help at all. Right now I only take Lamictal.
> Clearly, the 50 mg/day of Lamictal is not providing enough mood stabilization, which is not surprising at that low dosage. Where is your pdoc going with this? Is it his/her plan to gradually ramp up the Lamictal until the dose is finally substantial enough to function as a mood stabilizer?> I have only met with the psychiatric nurse and haven't talked with the doctor since I started 8 weeks ago. I suspect on Thursday he will have a plan for me as to what dose I should be at.
> Amy, have you ever tried to add a low dose of an atypical antipsychotic to a moodstabilizer? I bring this up because of what you told me last week about the one hallucination episode.
> Yes, I have taken olanzapine and hate it. It makes me gain weight and I feel like a major zombie. I do keep it on hand but I don't ever take it. And I don't even want TD even though the risk is slim.
> I posted the following link earlier in this thread, but I'll place it here as well. If you can, scan over the relevant portions of the document before your pdoc appointment. Make sure your pdoc fully understands the difficulty you are having. Insist that he/she gives you the time needed to talk through your symptoms and possible remedies. Who cares if you go over the allotted fifteen minute appointment time limit!
> Thanks Ron, that is a good site. My pdoc is pretty good about listening.
> Amy, keep us informed regarding your progress. Also, let me know what your pdoc says.> I will, thanks again.
::Amy
Posted by catmint on February 25, 2003, at 23:52:56
In reply to Re: Lamictal and Pre-emptive Strikes » catmint, posted by Ritch on February 25, 2003, at 23:20:27
Posted by catmint on February 25, 2003, at 23:57:13
In reply to Re: Lamictal and Pre-emptive Strikes » catmint, posted by Ritch on February 25, 2003, at 23:20:27
Ritch,
Thanks for your post.
Did Trileptal help at all with irritability?
I really did not get irritable on Depakote, it works wonders for that. No fights with anyone while on it! But, it made my depression way worse, so I switched to Lamictal.
Talk to you soon.
::Amy
Posted by KrissyP on February 26, 2003, at 1:01:16
In reply to Lamictal and Pre-emptive Strikes , posted by colin wallace on February 24, 2003, at 13:40:48
Good for you in wanting to be prepared! I truly hope that the Lamictal doesn't fall short for you as it sounds like it does work well for you. I hear you when you say "very suddenly the cracks start to appear, and the AD effect just ‘cuts-out’.When this happens, I immediately start to relapse into a dysphoric hypomania(angry, bitter, helter-skelter runaway depressive thoughts- reckless actions etc." Prozac was the first AD I went on in 1995. I am a big believer in Effexor-only because it has helped me and works on more than just the Serotonin. I wish you the best. Just wanted to reply
Posted by colin wallace on February 26, 2003, at 7:50:31
In reply to Re: Lamictal and Pre-emptive Strikes, posted by catmint on February 25, 2003, at 15:42:48
> Colin, Ron, and Ritch,
>
> I have had a mini breakdown, but it's nothing unusual. I am feeling at my wits end on Lamictal, I have had to increase the dose weekly, only to have any effects wear off. I am moody all the time, I'm pretty sure it's lack of Seratonin,
> Like Colin, I have tried the SSRIs and would only take them as a last resort.
> I am having a lot of thoughts running through my head about adding Lithium or Trileptal as well. Ron, please, I like your opionion. Have you gained any weight on the low dose of Lithium? I am meeting with my pdoc on Thursday and will mention both to him. I was a lot less irritable on Depakote, but I don't want to combine it with Lamictal.
> Ritch, does Trileptal work for irritability?
> I am really having a bad day-life, whenever I tell someone I have bipolar, they are like, Ohhhh...(feel sorry for me).
> Last night I was so fragile, I get so hopeless. Col, I can totally relate to how you feel, I sometimes want to run away, but I have a child. By the way, I have been so judgemental of myself
> and can't even feel love for him. I wake up really irritable, and send him off to school,feeeling guilty about my feelings.
> I upped my dose to 50 mg. and yes, am feeling that Lamictal buzz, headachy, energy, slightly more optimistic, racing thoughts, but hey, it's the best AD so far.
> I am so glad I have you guys to talk to about this.
> Hope to hear from you,
> ::Amy
Amy,Here's the good news.The first 50mg of Lamictal is by far the hardest to cope with.When I crept up to 50mg,I thought the world had collapsed onto my head.The anger, racing thoughts,bitterness etc were just awful, and I came so close to throwing in the Lamictal towel.
But 50mg was something of a turning point;after cautiously creeping up the dose ladder in tiny increments,I suddenly thought(at 50mg)...well, to hell with it-lets try moving up by a whopping 25mg-things can't get any worse.
Then,as if by magic, the 25mg dose made me feel normal within a day or so.Such a smooth transition,no irritability whatsoever.It's almost as if you have to prep. your brain for the 'normal' therapeutic 25mg increases, and curiously, when your small gains stop dead in their tracks and things start tumbling quickly-that's the time to hit it hard- your brain signals its readiness.And it happened to me too, bang on the 50mg mark.You've got so much mileage left in Lamictal Amy, believe me.Start going up now by 25mg weekly if you can handle it, and it should be be plain sailing.
I wouldn't even contemplate add-ons yet if I were you-not untill I'd reached 200mg or so, and even then only as a contingency in case things look as if they may just fade out by 300mg.
I often feel like running away too(sometimes I actually do!!)If you decide to make a duck for it, give me a shout and I'll come along-somewhere hot though!!!
Seriously,I can relate to the way you react to your son too-the snapping followed by the guilt.
I have this with my(very sick dad).
Sometimes when my mind is racing, I feel as though I hate him for destroying all my gains.What right has he got to get terminally ill, right!?
However, I don't blame myself for this at all anymore.I love him dearly, and realize that this is just the stress and my illness talking.And it soon passes.
So don't panic, you'll pass through this-Lamictal will take you many more miles before you weigh in there with other meds.(which could well screw things up for you at this stage).Keep cool- we're fighting a long haul strategic battle here.Let's keep ahead.
Col.
Posted by colin wallace on February 26, 2003, at 7:52:36
In reply to Re: Lamictal and Pre-emptive Strikes, posted by colin wallace on February 26, 2003, at 7:50:31
Posted by Ron Hill on February 26, 2003, at 9:42:11
In reply to Re: Lamictal and Pre-emptive Strikes, posted by catmint on February 25, 2003, at 23:51:50
Amy,
>Yes, I am BP II. I have tried Neurontin, Depakote and Lamictal. I discontinued the Depakote b/c it made my depression a lot worse and add on SSRI's did not help at all. Right now I only take Lamictal.
What did the Neurontin feel like? Did it help your irritability? What was your highest dose?
> I have only met with the psychiatric nurse and haven't talked with the doctor since I started 8 weeks ago.Do you mean that you started going to this particular pdoc's office 8 weeks ago, or that you started treatment for your BP II for the very first time 8 weeks ago? If not the latter, how long have you been taking psychotropic medication and what prompted you to seek a dx and treatment initially?
> > Amy, have you ever tried to add a low dose of an atypical antipsychotic to a moodstabilizer? I bring this up because of what you told me last week about the one hallucination episode.> Yes, I have taken olanzapine and hate it. It makes me gain weight and I feel like a major zombie. I do keep it on hand but I don't ever take it. And I don't even want TD even though the risk is slim.
I hear you, Amy. And I hear what Mitch is saying also. It was just a thought.
-- Ron
Posted by Ritch on February 26, 2003, at 10:16:12
In reply to Re: Lamictal and Pre-emptive Strikes » Ritch, posted by catmint on February 25, 2003, at 23:57:13
> Ritch,
> Thanks for your post.
> Did Trileptal help at all with irritability?
> I really did not get irritable on Depakote, it works wonders for that. No fights with anyone while on it! But, it made my depression way worse, so I switched to Lamictal.
> Talk to you soon.
> ::AmyAmy, it (Trileptal) didn't seem to help much on the irritability issues (just depression and cycling). Depakote looks like a for sure keeper for me despite being a little depressogenic. I have to combine it with other stuff to level that out.
Posted by colin wallace on February 26, 2003, at 11:18:32
In reply to Re: Lamictal and Pre-emptive Strikes » catmint, posted by Ritch on February 26, 2003, at 10:16:12
Hi there Ritch,
Cheers for your previous response by the way- you're a good man to share ideas with.
You mentioned that someone had posted previously on some success with a low dose combo.of Lamictal/Valproate/thyroid.
I think at first I'm going to opt for the Trileptal to augment my Lamictal(if necessary).
That extra oxygen molecule makes Trileptal seem far superior to plain Tegretol in terms of tolerability and side-effects.
If that bottoms out(or I'm refused the med.,as seems more likey!)then my options may be limited to a cautious trial of Divalproex(seems to be better tolerated than Valproate)and an AD.
I wondered have you heard of any other reasons not to combine Lamictal/Valproate(apart from the obvious decreased clearance of Lam. and increased risk of rash).
I'm sure that these risks can be greatly reduced by dose adjustment and a very cautious introduction of Depakote anyhow(seeing as I'm already past the LAM. rash risk).Waddaya reckon??
Posted by Ritch on February 26, 2003, at 13:29:31
In reply to Rich..., posted by colin wallace on February 26, 2003, at 11:18:32
> Hi there Ritch,
>
> Cheers for your previous response by the way- you're a good man to share ideas with.
> You mentioned that someone had posted previously on some success with a low dose combo.of Lamictal/Valproate/thyroid.
> I think at first I'm going to opt for the Trileptal to augment my Lamictal(if necessary).
> That extra oxygen molecule makes Trileptal seem far superior to plain Tegretol in terms of tolerability and side-effects.
> If that bottoms out(or I'm refused the med.,as seems more likey!)then my options may be limited to a cautious trial of Divalproex(seems to be better tolerated than Valproate)and an AD.
> I wondered have you heard of any other reasons not to combine Lamictal/Valproate(apart from the obvious decreased clearance of Lam. and increased risk of rash).
> I'm sure that these risks can be greatly reduced by dose adjustment and a very cautious introduction of Depakote anyhow(seeing as I'm already past the LAM. rash risk).
>
> Waddaya reckon??Colin,
From what I understand the rash thing is associated much more frequently with coadministration with valproate period. I *suspect* it has to do with both meds having a tendency to double each other's levels. So, if you are already on Lamictal and you add some Depakote (i.e.), your Lamictal blood level should jump up considerably (similar to a too quick dose titration of the Lamictal), thereby bringing on the increased risk of the rash due to a sudden lurch in the Lamictal blood levels. That's just my hunch though. There may be some oddball interaction that has nothing to do with the relative change in either blood levels of valproate or lamotrigine that increases the risk of TEN or SJS. ??? I would give the Trileptal a shot because 1) You haven't tried it yet, and 2) There isn't a contraindication of taking it with the Lamictal. I always will save the scary sh*t for last! I just read that post about the VPA+LTG+thyroid working well and it seemed to make pretty good sense. The VPA works good for hostility/mania, the LTG for depression, and the thyroid is good for the cycling. Yet another thing that sounds good on paper, though.....
Posted by Ritch on February 26, 2003, at 13:52:25
In reply to Re: Rich... » colin wallace, posted by Ritch on February 26, 2003, at 13:29:31
> > Hi there Ritch,
> >
> > Cheers for your previous response by the way- you're a good man to share ideas with.
> > You mentioned that someone had posted previously on some success with a low dose combo.of Lamictal/Valproate/thyroid.
> > I think at first I'm going to opt for the Trileptal to augment my Lamictal(if necessary).
> > That extra oxygen molecule makes Trileptal seem far superior to plain Tegretol in terms of tolerability and side-effects.
> > If that bottoms out(or I'm refused the med.,as seems more likey!)then my options may be limited to a cautious trial of Divalproex(seems to be better tolerated than Valproate)and an AD.
> > I wondered have you heard of any other reasons not to combine Lamictal/Valproate(apart from the obvious decreased clearance of Lam. and increased risk of rash).
> > I'm sure that these risks can be greatly reduced by dose adjustment and a very cautious introduction of Depakote anyhow(seeing as I'm already past the LAM. rash risk).
> >
> > Waddaya reckon??
>
> Colin,
>
> From what I understand the rash thing is associated much more frequently with coadministration with valproate period. I *suspect* it has to do with both meds having a tendency to double each other's levels. So, if you are already on Lamictal and you add some Depakote (i.e.), your Lamictal blood level should jump up considerably (similar to a too quick dose titration of the Lamictal), thereby bringing on the increased risk of the rash due to a sudden lurch in the Lamictal blood levels. That's just my hunch though. There may be some oddball interaction that has nothing to do with the relative change in either blood levels of valproate or lamotrigine that increases the risk of TEN or SJS. ??? I would give the Trileptal a shot because 1) You haven't tried it yet, and 2) There isn't a contraindication of taking it with the Lamictal. I always will save the scary sh*t for last! I just read that post about the VPA+LTG+thyroid working well and it seemed to make pretty good sense. The VPA works good for hostility/mania, the LTG for depression, and the thyroid is good for the cycling. Yet another thing that sounds good on paper, though.....
>
>OH, just wanted to add something if you aren't aware of this already, but maximum dosage of Lamictal isn't supposed to exceed 150mg/day (75mg bid) if you take VPA with it. This would approximate a 300mg dose of Lamictal without the VPA. Your doc doesn't want to exceed 150mg of Lamictal anyhow... so you could get yourself under med. *supervision* and ask them about adding some 100mg Epilim to that dose level and watch things closely. If you want to try that down the road. Just some thoughts.... That way let the NHS pay for all of your meds.
Posted by catmint on February 26, 2003, at 14:36:29
In reply to Re: Lamictal and Pre-emptive Strikes, posted by colin wallace on February 26, 2003, at 7:50:31
Thanks Col. I am feeling much better on day two at 50 mg. Titrating 25 a week only leaves me 10 weeks until I reach 300 though. Might try to stretch it out to every 2 weeks? Are our brains just becoming tolerant to the stuff?
I'ts great to have been keeping in touch with you all this time.
Good luck on going back to work. Keep riding your bike for sure no matter what.
Talk to you soon!
::Amy
Posted by catmint on February 26, 2003, at 15:10:53
In reply to Re: Lamictal and Pre-emptive Strikes » catmint, posted by Ron Hill on February 26, 2003, at 9:42:11
> What did the Neurontin feel like? Did it help your irritability? What was your highest dose?
>The Nuerontin felt good at first, like a kind-of buzzed, ralaxed feeling, but it had no mood stabilizing effects whatsoever. I also was taking Wellbutrin and Prozac with it, and began to fall apart after a year. I ended up smoking a lot of pot to try to help with the irritability, but it only ended up messing me up even worse, I was in a perpetual mixed state, smoking cigarretes, not sleeping well, having those night terrors I told you about, and occasional auditory hallucinations. I quit my job right after 9/11, and in a manic state, went out and bought a bunch of batteries,and film, and packed my backpack. I was paranoid that my boyfriend was going to be drafted and I wanted to get ready to move to Canada. Needless to say, I was going bonkers. I then became severely depressed and agitated and literally began tearing my hair out in an attempt to end the pain I felt. At the time I was in an outpatient program for mentally ill people who were on sick leave from work, it did help somewhat, but I mostly was either hyper and agitated or lying on the floor crying. My pdoc and I talked about hospitalization, which she told my I did not want to do unless I felt that I needed someone to watch me in case I was suicidal. Well, I had my boyfriend to take care of me and my son, so I rode it out at home, I quit all meds, still smoked pot, which I later quit, and somehow stabilized. That didn't last long, I then became euphiorically manic, over the summer and thought I was cured! LOL. THe depression inevitably hit hard in the fall and I started Depkote, tried to add Wellbutrin (no go), then Prozac(terrible).I then had my first trial of Lam. which gave me a rash. I then quit all meds again, convinced that psychiatry was ruining my life and there was no hope for me. After more misery, I opted to give Lamictal a second chance which brings us up to date.
I should add that I wasn't diagnosed until I was 32, after many years of illness. I knew I was depressed but not bipolar, the mania I had was mostly dysphoric, but occasionally I would freak out and think I was someone I wasn't, invite complete strangers into my home, spend lots of money I didn't have, drive recklessly, have delusions, and so on.
Ron, thanks for your interest.
::Amy
Posted by Ron Hill on February 26, 2003, at 20:52:51
In reply to Re: Lamictal and Pre-emptive Strikes » Ron Hill, posted by catmint on February 26, 2003, at 15:10:53
Amy,
Thanks for taking time to tell me some of your dx and Rx background.
May I be bold and tell you what I would do if I were in your shoes? What follows is merely my opinion. Please treat it as such. Obviously, I’m not a pdoc. I’m only a peer offering my opinion.
It seems clear to me that the first order of business should be to get an effective moodstabilizer on board ASAP. I would choose a first line moodstabilizer (see the APA document “PRACTICE GUIDELINE FOR THE TREATMENT OF PATIENTS WITH BIPOLAR DISORDER (Revision)), and since Depakote does not agree with you, that leaves lithium. Please beware; I have a personal bias in favor of lithium because it has worked well for me. However, it may or may not work well for you. If it were me, I'd choose a slow-release brand of lithium (I like Lithobid). Further, I'd start out in the low-to-mid dose range shooting for a blood level around 0.6 mEq/l. Side effects are less likely at the lower dose levels, but if it does not provide enough mood stabilization, the dosage may need to be increased.
If it were me, I'd keep the Lamictal in place and continue to ramp it up slowly. If your irritability is causing irreparable damage to your relationships, perhaps your pdoc would be willing to prescribe a benzo to get you by until the lithium and Lamictal get you stabilized. However, I’d try to avoid the benzo if you can get by without it. If you still have trouble with depression after the lithium is on board and the Lamictal is ramped up, then it might be time to investigate the feasibility of adding an MAOI. If it were me, I would not add an SSRI, SNRI, or TCA.
The material contained herein is provided for informational purposes only and should not be considered as medical advice or instruction. Consult your health care professional for advice relating to a medical problem or condition.
Best wishes, Amy, and let me know how it goes.
-- Ron
-----------------------------------------
> > What did the Neurontin feel like? Did it help your irritability? What was your highest dose?
>
> >The Nuerontin felt good at first, like a kind-of buzzed, ralaxed feeling, but it had no mood stabilizing effects whatsoever. I also was taking Wellbutrin and Prozac with it, and began to fall apart after a year. I ended up smoking a lot of pot to try to help with the irritability, but it only ended up messing me up even worse, I was in a perpetual mixed state, smoking cigarretes, not sleeping well, having those night terrors I told you about, and occasional auditory hallucinations. I quit my job right after 9/11, and in a manic state, went out and bought a bunch of batteries,and film, and packed my backpack. I was paranoid that my boyfriend was going to be drafted and I wanted to get ready to move to Canada. Needless to say, I was going bonkers. I then became severely depressed and agitated and literally began tearing my hair out in an attempt to end the pain I felt. At the time I was in an outpatient program for mentally ill people who were on sick leave from work, it did help somewhat, but I mostly was either hyper and agitated or lying on the floor crying. My pdoc and I talked about hospitalization, which she told my I did not want to do unless I felt that I needed someone to watch me in case I was suicidal. Well, I had my boyfriend to take care of me and my son, so I rode it out at home, I quit all meds, still smoked pot, which I later quit, and somehow stabilized. That didn't last long, I then became euphiorically manic, over the summer and thought I was cured! LOL. THe depression inevitably hit hard in the fall and I started Depkote, tried to add Wellbutrin (no go), then Prozac(terrible).I then had my first trial of Lam. which gave me a rash. I then quit all meds again, convinced that psychiatry was ruining my life and there was no hope for me. After more misery, I opted to give Lamictal a second chance which brings us up to date.
>
> I should add that I wasn't diagnosed until I was 32, after many years of illness. I knew I was depressed but not bipolar, the mania I had was mostly dysphoric, but occasionally I would freak out and think I was someone I wasn't, invite complete strangers into my home, spend lots of money I didn't have, drive recklessly, have delusions, and so on.
>
> Ron, thanks for your interest.
>
> ::Amy
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