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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 24 of 24. This is the beginning of the thread.
Posted by BearNCrow on August 5, 2009, at 21:55:28
so i'm currently hypomanic and super depressed. overall symptoms include: initial sleeplessness turning into over sleeping, irritability, agitation, high energy, obsessiveness, impulsivity, sadness, suicidal ideation, feeling out of control, racing thoughts, feeling unsafe, cognitive mud and i feel like i'm in this extended dissociative state.
current meds: lithium 1500mg, risperdal 6 mg, klonopin 2mg, my doctor just took me off of paxil 40mg to try and abort the hypomania.
this is killing me. i am super scared of feeling suicidal and being impulsive, as are my doctor and therapist. i don't actually want to kill myself, i just don't have a lot of control right now. my doctor says this kind of mixed episode is dangerous for this very reason and she wants me to feel better (preferable) or at least just be depressed.
i was down to 900 mg of lithium and went up to 1500 mg very quickly. going off paxil was sudden. the risperdal has been increasing from 2 to 4 to now 6 mg. i'm just not feeling my meds.
anyone have any experience with this kind of a mood state and these meds?
i have no idea if this made any sense. this was really hard to write. i'm just looking for advice, support, experience, a hello...whatever.
Posted by morganpmiller on August 5, 2009, at 22:07:32
In reply to Mixed Hypomanic Episode + Medication Changes, posted by BearNCrow on August 5, 2009, at 21:55:28
I am really sorry you are going through this.
I'm not sure how suddenly getting off paxil will help with your mixed state.I think the most common way of treating a mixed state is with Depakote and Zyprexa.
Have you ever gone to the hospital? The only reason I ask is that going to an inpatient or partial patient facility might be the best way to get you stabilized. You will find doctors that are well equipped to deal with what you are experiencing.
Posted by morganpmiller on August 5, 2009, at 22:10:39
In reply to Mixed Hypomanic Episode + Medication Changes, posted by BearNCrow on August 5, 2009, at 21:55:28
Did your symptoms get worse after jumping up to 1600mgs of Lithium and getting off Paxil?
I think your meds are doing something, just not the things you are needing at the moment.
Posted by BearNCrow on August 5, 2009, at 22:20:51
In reply to Re: Mixed Hypomanic Episode + Medication Changes, posted by morganpmiller on August 5, 2009, at 22:07:32
yeah, my doctor took me off paxil hoping it would help but not really being that sure. i consider depakote and zyprexa to be evil. depakote is the first drug i was ever on and i'm still fat from it. zyprexa oddly enough gives me anxiety and ocd symptoms. i loathe and despise hospitals. i've had some bad experiences in the past and my doctor and therapist know to try everything before going that route. it just means more frequent appointments and check ins...i.e. more money that i don't have. sigh. oh well. if my life isn't worth it then what is?
Posted by BearNCrow on August 5, 2009, at 22:23:44
In reply to Re: Mixed Hypomanic Episode + Medication Changes, posted by morganpmiller on August 5, 2009, at 22:10:39
i just went up to 1500mg of lithium last night, and last night is the first night i didn't take the paxil. so this is all very new.
Posted by morganpmiller on August 5, 2009, at 22:31:24
In reply to Re: Mixed Hypomanic Episode + Medication Changes » morganpmiller, posted by BearNCrow on August 5, 2009, at 22:20:51
I am right there with you on being hospitalized.
The only reason I mention depakote is because it is often better than lithium at treating mixed states. Would you consider it just for a few months? Then maybe go down to a low dose(it does have neuroprotective properties and a low dose may not give you the side effects while still helping to maintain mood).
How long have you been on paxil? I'm just trying to make sense of him taking you off it so abruptly.
Posted by morganpmiller on August 5, 2009, at 22:34:55
In reply to Re: Mixed Hypomanic Episode + Medication Changes » morganpmiller, posted by BearNCrow on August 5, 2009, at 22:23:44
> i just went up to 1500mg of lithium last night, and last night is the first night i didn't take the paxil. so this is all very new.
>
>
I guess you don't notice anything from the increase in lithium yet?Maybe he thinks the increase in lithium will counterbalance any negative effects you might feel by getting off paxil so fast.
Posted by Phillipa on August 6, 2009, at 0:03:20
In reply to Re: Mixed Hypomanic Episode + Medication Changes, posted by morganpmiller on August 5, 2009, at 22:34:55
Welcome to babble sorry things are horrible right now. I'm with morganmiller with a short term hospitalization as you said your're life is worth it. Please consider it? Same question here how come paxil abruptly? Lithium will probably take a few days to kick in at the higher dose. Also were your lithium levels within normal before increasing lithium? We're with you here. Any antipsychotic? Love Phillipa
Posted by Phillipa on August 6, 2009, at 0:04:20
In reply to Mixed Hypomanic Episode + Medication Changes, posted by BearNCrow on August 5, 2009, at 21:55:28
I see you are on resperidol sorry about that. Phillipa
Posted by Justherself54 on August 6, 2009, at 0:30:04
In reply to Mixed Hypomanic Episode + Medication Changes, posted by BearNCrow on August 5, 2009, at 21:55:28
I'm so sorry you're going through this. Stopping Paxil "cold turkey" is no easy ride. I'd discuss this with your pdoc..if possible, perhaps a slower reduction of the paxil will ease some of your symptoms. Keep posting..you'll get lots of support here.
Posted by atypical on August 6, 2009, at 4:09:15
In reply to Mixed Hypomanic Episode + Medication Changes, posted by BearNCrow on August 5, 2009, at 21:55:28
I truly hope this mood passes over for you. I was where you were last Monday-Thursday, except it was more of a depressive episode than anything. I went to work and when I got home stuck it out on my couch/bed and eventually got through it. But it was horrible. Well, this is my case. The question about Lithium levels was good -- were your levels therapeutic before your increase? There are also lots of other meds (Lamictal?) to consider. Of course, this all takes time. Ugh.
Regarding hospitalization, next time I feel I did last week way I will do one of those day programs at the hospital maybe. I do feel the same way as you about hospitals -- I've only been once for three days. Why do they have to generally be unpleasant environments? Is there another way? Perhaps investment in wonderful, cozy interior design so that people in trouble might actually say, "hey, I WANT to go there" because it's so cozy? I mean this kind of seriously. Better environment = more patients, which equals more money, right? And perhaps more lives saved or suffering reduced.
Posted by SLS on August 6, 2009, at 7:14:56
In reply to Re: Mixed Hypomanic Episode + Medication Changes, posted by morganpmiller on August 5, 2009, at 22:34:55
Trileptal, the sister drug of Tegretol, might be an interesting choice here. There is some evidence that it can quell the SSRI discontinuation withdrawal sydrome. Of course, it is a mood stabilizer as well. That said, I think there is more evidence for Depakote being used in mixed-states. This might, however, reflect a bias towards not studying Tegretol as closely because of the necessity for taking regular blood tests to screen for agranulocytosis while taking it.
With Depakote, you can start with loading doses of 1000mg or higher, then change to the target dosage. For me, I found that I needed 1000-1500mg of Depakote to treat mania. I thus used a loading dose of 2000mg (1000mg b.i.d.) to get started. I don't recommend doing this unless your doctor is familiar with this dosing strategy.
Although Depakote has not received as much attention to treat SRI withdrawal, it still might work given that it, like Tegretol and Trileptal, inhibits sodium channels and potentiates GABA neurotransmission, abeit through different mechanisms; the effects of which are to reduce the excitability of glutamate neurons.
- Scott
Posted by SLS on August 6, 2009, at 7:44:38
In reply to Re: Mixed Hypomanic Episode + Medication Changes, posted by atypical on August 6, 2009, at 4:09:15
> There are also lots of other meds (Lamictal?) to consider. Of course, this all takes time. Ugh.
Lamictal is a great choice when an antidepressant effect is needed. However, it makes a poor anti-manic drug to be used acutely. It does make for a good combination with lithium, IF lithium were to treat the mania successfully. For right now, the fire must be put out, and the lithium doesn't seem to be helping. I would think drugs like Depakote would be indicated, perhaps using Zyprexa temporarily.
Just as a reminder, if Depakote and Lamictal are to be combined, the dosage of Lamictal must be cut in half. Depakote reduces the clearance of Lamictal by inhibiting glucuronidation.
- Scott
Posted by Frustratedmama on August 6, 2009, at 8:06:19
In reply to Re: Mixed Hypomanic Episode + Medication Changes, posted by SLS on August 6, 2009, at 7:44:38
This is exactly the experience I had! Dropping the paxil quickly will likely help after the withdrawal subsides but you will likely need something to STOP the irritability. Depakote is a great suggestion if you can tolerate it! I highly recommend it in the XR version...easier to tolerate....also neurontin (short term!) may help coming off the paxil...some people try prozac but with irritability I would guess that would worsen it..... I am doing better with pristiq....never would have thought it true....but it is helping..... good luck and keep us posted....!
Posted by Frustratedmama on August 6, 2009, at 8:12:51
In reply to Re: Mixed Hypomanic Episode + Medication Changes, posted by Frustratedmama on August 6, 2009, at 8:06:19
Another helpful med might be risperdal - I found it to work quickly when I was more hypomanic than depressed.
Posted by sam K on August 6, 2009, at 13:12:42
In reply to Mixed Hypomanic Episode + Medication Changes, posted by BearNCrow on August 5, 2009, at 21:55:28
you just described the exact exact same thing I experience. exact. One med that helps for this for me is lamictal/lamotrigine. It works perfectly, it has a mild/moderate antidepressant effect, while stopping mania/hypomania. So basically right as I take it, the mixed state is gone. As well as the diassociated feeling.
I also get dysphoria during the mixed states. I just feel terrible, yet wired with racing thoughts, and icredibly suicidal. And you said you dont want to commit suicide, same here, your mind is just flooded with sucicidal thoughts though.
My mind just runs in circles about how Im going to get out of it, at 100 mph. And then I feel helpless and hopeless, but Im wired so its really really uncomfortable.
seroquel, abilify, lamictal in my experience are good for this. But i dont like antipsychotics at all.
Posted by SLS on August 6, 2009, at 13:17:59
In reply to Re: Mixed Hypomanic Episode + Medication Changes, posted by sam K on August 6, 2009, at 13:12:42
> you just described the exact exact same thing I experience. exact. One med that helps for this for me is lamictal/lamotrigine. It works perfectly, it has a mild/moderate antidepressant effect, while stopping mania/hypomania.
That's interesting. Do you ever get floridly or psychotically manic, or are you exclusively hypomanic?
- Scott
Posted by alchemy on August 6, 2009, at 21:19:56
In reply to Mixed Hypomanic Episode + Medication Changes, posted by BearNCrow on August 5, 2009, at 21:55:28
Mixed states suck, and they are the most dangerous. Is it worth it at this point to take a little bit of paxil to taper? Your dr sounds stupid to go cold turkey. Antipsychotics like Zyprexa are of course good to help the agitation, but they make mine worse. I would probably need a benzo to get through it. But that's me. I agree some of the Lamictal posts, for my semi-stabilizer.
Posted by linkadge on August 7, 2009, at 7:09:55
In reply to Re: Mixed Hypomanic Episode + Medication Changes, posted by alchemy on August 6, 2009, at 21:19:56
I agree with the above posts. See if you can taper off paxil. You may want to jump down to 20mg, but no lower than that for a first step.
Paxil withdrawl could very likely magnify the instability you are feeling. Paxil withdrawl itself is associated with the induction of mixed states.
Linkadge
Posted by BearNCrow on August 7, 2009, at 13:30:49
In reply to Re: Mixed Hypomanic Episode + Medication Changes, posted by linkadge on August 7, 2009, at 7:09:55
thanks everyone for your responses. i've been so depressed i haven't felt like writing anything. this feels like climbing mt everest. i was on a low dose of paxil (40mg), so the jump wasn't outrageous, although i just woke up and am feeling withdrawal symptoms for the first time. it's definitely uncomfortable. i will have to get my lithium level checked on monday i assume. i may go back up to 1800mg which is where i was at a year ago before i began tapering down to 900mg. i see my pdoc in an hour. my wife is going with me for support. my therapist and pdoc are talking hospitilization, but i am just so against it. i'd rather take it an hour at a time of making contracts for safety until i'm at a place where i don't need to be hospitalized. the last and only time i was in the hospital was a horrific experience. i took today off and now it's the weekend. i just want to lay low and see if this improves by monday. my wife can be with me all weekend, but if it doesn't improve and i still feel suicidal, monday will be a new story because i will be left alone to drive to work and be on my own. so it's just a waiting game right now. hopefully something good will come from my pdoc appointment. thanks for listening everyone.
Posted by Phillipa on August 7, 2009, at 19:55:04
In reply to Re: Mixed Hypomanic Episode + Medication Changes, posted by BearNCrow on August 7, 2009, at 13:30:49
How did the doc's appointment go? Love Phillipa
Posted by BearNCrow on August 7, 2009, at 20:12:00
In reply to Re: Mixed Hypomanic Episode + Medication Changes » BearNCrow, posted by Phillipa on August 7, 2009, at 19:55:04
it went well. she is starting me on a low dose of lexapro. i already took 5mg and it has helped some with the paxil withdrawal symptoms. i'm not as dizzy, fuzzy and electrified. i will stay at 5mg until i check in with my pdoc on monday and will go up to 10mg then.
getting my lithium level checked monday morning. there may be room to increase from 1500mg to 1800mg. have to wait and see about that. am staying at 6mg of risperdal.
my pdoc commented on how quickly i moved from a mixed hypomanic episode to full blown depression. she took me off 40mg of paxil cold turkey because she was really afraid of the fact that i was feeling highly impulsive and suicidal -- she wanted to end the hypomania. i think she did the right thing. i really trust her. now she just wants to get me to a place where i can contract for safety for longer than a few hours at a time. and believe me i want to be there too.
my wife is "babysitting" me this weekend, meaning i am not to be left alone. i am okay with that because my pdoc, my wife and i decided together that as long as my wife is okay with it, then it will keep me out of the hospital for the next few days, and hopefully by sunday night and monday i will be feeling more in control, more like myself and more safe.
one foot in front of the other....
Posted by Phillipa on August 7, 2009, at 20:45:36
In reply to Re: Mixed Hypomanic Episode + Medication Changes » Phillipa, posted by BearNCrow on August 7, 2009, at 20:12:00
That's great response so soon? Wow. Baby Steps. Love Phillipa have a great weekend and post your progress daily so we know how your're doing.
Posted by morganpmiller on August 7, 2009, at 22:26:11
In reply to Re: Mixed Hypomanic Episode + Medication Changes » Phillipa, posted by BearNCrow on August 7, 2009, at 20:12:00
Seems like you are doing better..good to hear
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