Shown: posts 1 to 5 of 5. This is the beginning of the thread.
Posted by Peter on October 25, 2003, at 19:34:02
Hi everyone:
I need some help at clarification:
Quick background info: Starting taking meds 8 years ago; my pdoc initially diagnosed me with 'mild' bipolar disorder, took me off the paxil that my GP had precribed me, and started me up on Depakote. He has 'updated' my diagnosis numerous times over the years to the point that his judgments have seemed outright contradictory. After being on depakote for a while, I just became very depressed and tired all the time, and my anxieties were becoming more apparent. So my new diagnosis became 'mild' bipolar/panic disorder/social anxiety. He started me on klonopin 5 years ago and I still take it. He began to try a number of different SSRI's on me, as well as effexor, moclobemide, and wellbutrin, but he never used to allow me to take these antidepressants without my also taking a mood-stabilizer. So I've also taken a number of different anticonvulsant mood-stabilizers aside from depakote (neurontin, lamictal) and also Lithium. His initial reason for not allowing me to take AD's without an MS was for fear of my having a hypomanic episode, which, to this day, neither my family, friends, nor myself have been aware of any sign of in me. He thought that his diagnosis of 'mild bipolarity' was proven by my reactions to SSRI's; they would help for a while, but then they would induce alcohol/drug cravings in me and my overall anxiety levels would increase. At first, he said this was proof that I am bipolar, because these cravings and the drug/alcohol sprees that would result were indicative of a type of SSRI-induced hypomania. But then things began to changed; about 2 years ago, we reviewed my history, and he said it is likely that I have a form of adult ADHD on top of everything else. So he put me on various stimulants, sometimes combined with mood-stabilizers and/or AD's. Then he went thru a sort of 'experimental' stage with me and put me on various other meds like dopamine-agonists, beta-blockers, strattera, u name it. During this time, I decided to get some second opinions from other good pdocs: some told me I DO in fact fall somewhere within the bipolar spectrum ('otherwise unspecified'), others told me there are no signs of my being bipolar in any way but that I have an extreme case of 'depressive-anxiety.' Some said I have ADHD, others said I don't. So I decided to just stick with my original pdoc since he knows me the best; but he seemed to begin to be less adamant about my needing a mood-stabilizer. So we kept trying to find the right combo.
My latest combo was: lexapro+adderall+klonopin+restoril(for sleep). I began lexapro about 8 weeks ago, went through a slew of side-effects, and am currently unsure as to whether it has really helped my fundamental depression and anxiety. Whenever it seems like it has begun to work, I end up crashing into depression, getting socially withdrawn again, etc. So, first he thought the adderall was masking possible lexapro benefits and had me taper off the adderall; but i was completely lethargic/depressed/unable to follow through on any tasks. So he switched me to a few long-acting stimulants until we found the one that seems to have the least negative effects on me - dexadrine spansules. So now I'm taking everything I listed above, except dex instead of adderall.
Then I started feeling physically ill - my ears kept getting blocked up and I felt gross and tired all the time. I went to a GP, who said he didn't see any signs of infection, but he put me on a week-long trial of antibiotics to treat and prevent any possible underlying, chronic sinus condition.
My pdoc, meanwhile, has proposed to me a game plan which I find very confusing. He said that usually when someone taking a fixed dose of an SSRI for many weeks only responds partially (feels only slight, sporadic improvements), a higher dose is called for. But, he said that many people suffer underlying chronic sinus disorders that could also make them depressed and cause low energy. He proposed that we first wait for a few days of my taking the antibiotic to see if I begin to feel more consistently better; if so, that would tell us that a sinus condition was indeed to some degree responsible for my continued depression. If I do not feel better, we could increase the lexapro dose. Ok, so it all makes sense so far. But then he said something that I can't wrap my head around: he said that if I find that I feel better for 3-4 days in a row and then my mood switches to depression/anxiety for another 3-4, then that is a sign of bipolar cycling and would call for my adding some depakote to the regime. On the other hand, if my moods are variable every day, that is a sign that I am on too low a dose of lexapro. In other words, the answer lies in the AMPLITUDE of my mood swings - if it is very large, it is more likely that I have bipolar cycling and need to add a mood-stabilizer, but if it is shallow, I might just need a lexapro increase. But then he said we might end up adding depakote AND increasing both the lexapro AND the dexedrine - that sort of confused me. He said the next 3-4 days on the antibiotic will make everything more clear.
Here is where I have difficulties: I can see how 3-4 days on the antibiotic will tell us whether an underlying sinus condition has been contributing to my mood lability. But how on earth will another 3-4 days tell us the the general amplitude of my mood inconsistencies?? Furthermore, I would think he would have already figured out if I am bipolar or not after 8 years of seeing him.
I try to keep a daily mood journal, and I've found it very hard to pinpoint if I go thru overarching bipolar mood-cycling, or if my moods are variable each day. Then there's the synergy between the stim and the SSRI, which adds a whole new factor that could be contributing to my mood lability. There are just too many factors at work here, and it is overwhelming. I don't want to do the wrong thing because I've misinterpreted the nature of my moods; it's almost as if it is all being left up to me! I don't want to increase the lexapro unless I 'need' to, because this would undoubtedly result in an increase of SE's, like sexual dysfunction and apathy. And I do not want to unecessarily add depakote again to my regime, as it has never done anything but given me a lethargic, 'wet-blanket' effect.
I'm very sorry for the length of the post, but I'm really frustrated and would very much appreciate any feedback. Thanks a lot,
Peter
Posted by galkeepinon on October 25, 2003, at 21:22:44
In reply to HELP: Very Confused, posted by Peter on October 25, 2003, at 19:34:02
Hi Peter, I am so very sorry that you are going through this. I went through the exact same thing for years. God, I know it feels AWEFUL feeling *somewhat* like a 'guinea pig'!
It sounds to *me* that you have 'rapid cycling'. I was diagnosed with it in 1997 after I went through pretty much of what you post here regarding yourself.
It seems that mania induced by SSRI's is something researchers and physicians alike are trying to 'solve' Most of the currently available antidepressant drugs appear able to induce hypomanic and manic reactions, but still, this is a serious concern for people taking the serotonin reuptake inhibitor group of antidepressants which includes the SSRI's such as fluoxetine but also the antidepressants such as nefazodone that have a combined effect on serotonin and norepinephrine reuptake. This reaction can be severe having psychotic features or requiring patients to be secluded for extreme agitation.
*The problem is that antidepressants are given together with mood stabilizers to prevent an 'overshoot' from occurring in the patient, for if used on their own in the treatment of bipolar disorder, antidepressants can push moods up too high causing hypomania, mania, or rapid cycling. IMHO,the following two types of antidepressants are pretty effective for bipolar patients: Wellbutrin, Prozac, Luvox, Paxil, and Zoloft. There are many other choices if these do not work, or if they cause unpleasant adverse effects, Remeron, Nardil (talk to ace) :-), Parnate, Serzone, and tricyclic antidepressants such as Elavil, Norpramin, Tofranil, Pamelor, and Effexor.
In 1999, I started my first trial of Lamictal and it did wonders for *me* How much were you taking?
*You would think that your pdoc in this case would have already figured out if you're bipolar or not after 8 years of seeing him~But doctors aren't gods and there is no magic wand unfortunately.
I wonder if your pdoc was or is trying to treat you from a psychiatrist's perspective when really, you need to see a psychiatrist?
Sometimes bipolars cannot take SSRI's for the mere fact of causing more mania.
*Re: chronis sinus infections: I get them a lot and the meds sometimes seem to make them worse.
Sounds like the Dx of bipolar NOS, seems about the only thing docs can determine when all this is going on with us.
The journal idea is a great idea, you're doing YOUR part, now you hopefully can concentrate on finding a psychiatrist that can help you. I know, it's such a drag going through all that searching, emotionally AND physically, but you need to get better and quit having all this stuff hanging over your head, it's not fair to you!
Yes, it is overwhelming~you are not alone on that one! It shouldn't ALL be left up to you, a good psychiatrist will work with you, but it sounds as if you haven't had much success with your pdoc.
*Re: the increase in Lexapro, it's a catch 22 for sure. It works well for some, but then some have the SE of sexual dysfunction and apathy, which I have found passed for me, as well as others who are taking Lexparo here on the message board. **Ironically, one of the kinds of depression that should not be treated with drugs is depression caused by other kinds of drugs. If someone is depressed and the depression started after beginning a new drug, it may well be drug-caused.
I need to go make dinner, but I wanted to reply to your post.
I hope this helped a little and I wish you all the best, if you have any more questions for me, I would be happy to try and help.
Hang in there and use the board as part of support for yourself if you want, it has helped many a people:-)
Best wishes:-)
======================================================================
Hi everyone:
> I need some help at clarification:
> Quick background info: Starting taking meds 8 years ago; my pdoc initially diagnosed me with 'mild' bipolar disorder, took me off the paxil that my GP had precribed me, and started me up on Depakote. He has 'updated' my diagnosis numerous times over the years to the point that his judgments have seemed outright contradictory. After being on depakote for a while, I just became very depressed and tired all the time, and my anxieties were becoming more apparent. So my new diagnosis became 'mild' bipolar/panic disorder/social anxiety. He started me on klonopin 5 years ago and I still take it. He began to try a number of different SSRI's on me, as well as effexor, moclobemide, and wellbutrin, but he never used to allow me to take these antidepressants without my also taking a mood-stabilizer. So I've also taken a number of different anticonvulsant mood-stabilizers aside from depakote (neurontin, lamictal) and also Lithium. His initial reason for not allowing me to take AD's without an MS was for fear of my having a hypomanic episode, which, to this day, neither my family, friends, nor myself have been aware of any sign of in me. He thought that his diagnosis of 'mild bipolarity' was proven by my reactions to SSRI's; they would help for a while, but then they would induce alcohol/drug cravings in me and my overall anxiety levels would increase. At first, he said this was proof that I am bipolar, because these cravings and the drug/alcohol sprees that would result were indicative of a type of SSRI-induced hypomania. But then things began to changed; about 2 years ago, we reviewed my history, and he said it is likely that I have a form of adult ADHD on top of everything else. So he put me on various stimulants, sometimes combined with mood-stabilizers and/or AD's. Then he went thru a sort of 'experimental' stage with me and put me on various other meds like dopamine-agonists, beta-blockers, strattera, u name it. During this time, I decided to get some second opinions from other good pdocs: some told me I DO in fact fall somewhere within the bipolar spectrum ('otherwise unspecified'), others told me there are no signs of my being bipolar in any way but that I have an extreme case of 'depressive-anxiety.' Some said I have ADHD, others said I don't. So I decided to just stick with my original pdoc since he knows me the best; but he seemed to begin to be less adamant about my needing a mood-stabilizer. So we kept trying to find the right combo.
> My latest combo was: lexapro+adderall+klonopin+restoril(for sleep). I began lexapro about 8 weeks ago, went through a slew of side-effects, and am currently unsure as to whether it has really helped my fundamental depression and anxiety. Whenever it seems like it has begun to work, I end up crashing into depression, getting socially withdrawn again, etc. So, first he thought the adderall was masking possible lexapro benefits and had me taper off the adderall; but i was completely lethargic/depressed/unable to follow through on any tasks. So he switched me to a few long-acting stimulants until we found the one that seems to have the least negative effects on me - dexadrine spansules. So now I'm taking everything I listed above, except dex instead of adderall.
> Then I started feeling physically ill - my ears kept getting blocked up and I felt gross and tired all the time. I went to a GP, who said he didn't see any signs of infection, but he put me on a week-long trial of antibiotics to treat and prevent any possible underlying, chronic sinus condition.
> My pdoc, meanwhile, has proposed to me a game plan which I find very confusing. He said that usually when someone taking a fixed dose of an SSRI for many weeks only responds partially (feels only slight, sporadic improvements), a higher dose is called for. But, he said that many people suffer underlying chronic sinus disorders that could also make them depressed and cause low energy. He proposed that we first wait for a few days of my taking the antibiotic to see if I begin to feel more consistently better; if so, that would tell us that a sinus condition was indeed to some degree responsible for my continued depression. If I do not feel better, we could increase the lexapro dose. Ok, so it all makes sense so far. But then he said something that I can't wrap my head around: he said that if I find that I feel better for 3-4 days in a row and then my mood switches to depression/anxiety for another 3-4, then that is a sign of bipolar cycling and would call for my adding some depakote to the regime. On the other hand, if my moods are variable every day, that is a sign that I am on too low a dose of lexapro. In other words, the answer lies in the AMPLITUDE of my mood swings - if it is very large, it is more likely that I have bipolar cycling and need to add a mood-stabilizer, but if it is shallow, I might just need a lexapro increase. But then he said we might end up adding depakote AND increasing both the lexapro AND the dexedrine - that sort of confused me. He said the next 3-4 days on the antibiotic will make everything more clear.
> Here is where I have difficulties: I can see how 3-4 days on the antibiotic will tell us whether an underlying sinus condition has been contributing to my mood lability. But how on earth will another 3-4 days tell us the the general amplitude of my mood inconsistencies?? Furthermore, I would think he would have already figured out if I am bipolar or not after 8 years of seeing him.
> I try to keep a daily mood journal, and I've found it very hard to pinpoint if I go thru overarching bipolar mood-cycling, or if my moods are variable each day. Then there's the synergy between the stim and the SSRI, which adds a whole new factor that could be contributing to my mood lability. There are just too many factors at work here, and it is overwhelming. I don't want to do the wrong thing because I've misinterpreted the nature of my moods; it's almost as if it is all being left up to me! I don't want to increase the lexapro unless I 'need' to, because this would undoubtedly result in an increase of SE's, like sexual dysfunction and apathy. And I do not want to unecessarily add depakote again to my regime, as it has never done anything but given me a lethargic, 'wet-blanket' effect.
> I'm very sorry for the length of the post, but I'm really frustrated and would very much appreciate any feedback. Thanks a lot,
> Peter
Posted by wsj on October 26, 2003, at 2:59:17
In reply to HELP: Very Confused, posted by Peter on October 25, 2003, at 19:34:02
your pdoc suggesting bipolar for the first time after seeing you for 8 yrs seems ludicrous to me. im having mixed signals from my lex & dex & klon. im actually thinking about washing out for 2 weeks starting next week and then goin to parnate. this might give me a chance to have a decent christmas. last year i couldnt partake in family functions because of how bad i felt. was on effexor at the time.
i don't know how bad withdrawal from lex will be or wether or not to taper.wsj
Posted by Peter on October 26, 2003, at 5:40:12
In reply to Re: HELP: Very Confused » Peter , posted by galkeepinon on October 25, 2003, at 21:22:44
> Hi Peter, I am so very sorry that you are going through this. I went through the exact same thing for years. God, I know it feels AWEFUL feeling *somewhat* like a 'guinea pig'!
>>Exactly.
> It sounds to *me* that you have 'rapid cycling'. I was diagnosed with it in 1997 after I went through pretty much of what you post here regarding yourself.
>>But why doesn't my doctor just tell me that's what I have? The wierd thing about him is that he's considered one of the best and he sure acts and talks like he knows what he's doing. But every new med regime is like a 'TEST' to try to clarify my diagnosis. I realize that psychopharmacology requires a certain extent of trial and error. But THIS MUCH!? 8 years of putting my body through so many pharmacological roller-coasters? Hearing different things from different doctors. One very good doc even said I definitely do not have any bipolar disorder and recommended a TCA for what she called 'depressive anxiety' (and the TCA's are supposedly the worst in terms of inducing mania in BP patients).
> It seems that mania induced by SSRI's is something researchers and physicians alike are trying to 'solve' Most of the currently available antidepressant drugs appear able to induce hypomanic and manic reactions, but still, this is a serious concern for people taking the serotonin reuptake inhibitor group of antidepressants which includes the SSRI's such as fluoxetine but also the antidepressants such as nefazodone that have a combined effect on serotonin and norepinephrine reuptake. This reaction can be severe having psychotic features or requiring patients to be secluded for extreme agitation.
>>Well, that's the thing. My close family and friends have told me they have never seen me in a manic state. If I do have some form of Bipolar disorder, it is not severe; if it were, it would probably be easier for my doc to diagnose and treat.
> *The problem is that antidepressants are given together with mood stabilizers to prevent an 'overshoot' from occurring in the patient, for if used on their own in the treatment of bipolar disorder, antidepressants can push moods up too high causing hypomania, mania, or rapid cycling. IMHO,the following two types of antidepressants are pretty effective for bipolar patients: Wellbutrin, Prozac, Luvox, Paxil, and Zoloft.
>>I tried all of the above; they worked minimally for a while and then left me too emotionally numb and craving alcohol (probably due to dopamine-downregulation, which is 1 of the reasons we now combine stimulants with SSRI's). Why didn't you mention lexapro; is it not as good for bipolar patients?
There are many other choices if these do not work, or if they cause unpleasant adverse effects, Remeron, Nardil (talk to ace) :-), Parnate, Serzone, and tricyclic antidepressants such as Elavil, Norpramin, Tofranil, Pamelor, and Effexor.
>>My doc told me TCA's are the worst for bipolar patients. As for the MAOI's, well, yes, I have been considering Nardil or Parnate for a long time, but can't seem to get over the anxiety about tyramine and emergency rooms. My pdoc seeems to change his mind constantly about my tring an MAOI. One day, he'll say yes, definitely, they are the best, let's go for it; another day, he will say that it will be very difficult for me to adjust to a whole new set of side-effects and to deal with the anxiety of avoiding certain foods, etc. (I do have a hypochondriacal element to my anxiety). And last thing he said was that we should just stick with the lexapro and adjust things as needed instead of doing an entire new drug overhaul and getting me on an MAOI. I'm just sick of deciding what to do. I just don't know anymore.
> In 1999, I started my first trial of Lamictal and it did wonders for *me* How much were you taking?
>>Well Lamictal was interesting; of course we had to titrate it VERY SLOWLY because of the rash risk. I got up to 100-150mg after many months. But the problem is that my pdoc never gives a single med a sufficient trial, and he always combines multiple meds so that we end up having no idea what meds are working and what meds are not. When I was taking lamictal, he also had me taking adderall, prozac, strattera, and klonopin. It became a nightmare; I started getting anxious again, so he had me come off each med, 1 at a time, since he had no idea which was causing the problem. I really don't mean to talk negatively about him; he's a great guy and a great doc, but I just sometimes wonder if we are going about things in the right ways. Anyway, he used to be all enthusiastic about lamictal as being the ideal med for me, and now when I ask him how he thought it was for me, he says he has no idea.
> I wonder if your pdoc was or is trying to treat you from a psychiatrist's perspective when really, you need to see a psychiatrist?
>>True. He is purely a 'psychopharmacologist,' and he has recommended that I also see a therapist, which I plan to do ( I have seen many therapists, but have not found the right one for me).
> Sometimes bipolars cannot take SSRI's for the mere fact of causing more mania.
> *Re: chronis sinus infections: I get them a lot and the meds sometimes seem to make them worse.
> Sounds like the Dx of bipolar NOS, seems about the only thing docs can determine when all this is going on with us.
> The journal idea is a great idea, you're doing YOUR part, now you hopefully can concentrate on finding a psychiatrist that can help you. I know, it's such a drag going through all that searching, emotionally AND physically, but you need to get better and quit having all this stuff hanging over your head, it's not fair to you!
> Yes, it is overwhelming~you are not alone on that one! It shouldn't ALL be left up to you, a good psychiatrist will work with you, but it sounds as if you haven't had much success with your pdoc.
> *Re: the increase in Lexapro, it's a catch 22 for sure. It works well for some, but then some have the SE of sexual dysfunction and apathy, which I have found passed for me, as well as others who are taking Lexparo here on the message board. **Ironically, one of the kinds of depression that should not be treated with drugs is depression caused by other kinds of drugs. If someone is depressed and the depression started after beginning a new drug, it may well be drug-caused.
> I need to go make dinner, but I wanted to reply to your post.
> I hope this helped a little and I wish you all the best, if you have any more questions for me, I would be happy to try and help.
> Hang in there and use the board as part of support for yourself if you want, it has helped many a people:-)
> Best wishes:-)
>>> Thank you for all your support,
Peter
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Posted by Miky on January 11, 2005, at 16:49:52
In reply to Re: HELP: Very Confused » galkeepinon, posted by Peter on October 26, 2003, at 5:40:12
Hello Peter,
In response to your problem, I am not a doctor, but I've seen many cases like yours. First, when a diagnosis is so unclear, it would be best to consult an expert in bipolarity, and not just a good psychiatrist. You've tried the conventional treatment algorythm for depression and anxiety with no results. It seems to me as if all the treatments you've tried have not addressed effectively your depresssion, anxiety, or mood lability. A diagnosis of treatment-resistant depression, bipolar disorder NOS or rapid cyclig are better addressed by an expert in bipolarity. The only one I know of lives in La Hoya, California. His name is Hagop Akiskal. If you can't afford to get to to CA to see him, he may be able to recommend another specialist or mood clinic in your area.
Second, do not underestimate the role of psychotherapy. Therapy can teach you coping skills to better address your reaction to the triggers of your symptoms, and to recognize and manage your difficulties. Education can only empower you instead of leaving you at the mercy of various physicians, whom are by no means perfect, as you have discovered after 8 years. Their impefection is understandable though, when they{re trying to treat conditions that no one completely understands, as the research is on-going.
I hope all will en up well with you and those like you who are searching for emotional balance and peace of mind.
This is the end of the thread.
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