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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 6 to 30 of 42. Go back in thread:
Posted by SLS on October 11, 2010, at 1:34:11
In reply to going back to bipolar medications, posted by linkadge on October 10, 2010, at 18:29:52
> ok, so I don't know if I am bipolar or not.
What makes you think that you have bipolar disorder?
> mood stabilizers like lithium and tegretol have been helping me more than other treatments lately.
You have some experimenting to do, then. Tegretol can produce some cognitive impairment, unlike its cousin drug, Trileptal. Tegretol has, of course, been studied more with evidence demonstrating its effectiveness. However, I have seen Trileptal be just as effective in treating aggression and impulsivity. I don't know about mania. For depression, I felt that Trileptal gave me more energy and reduced negative thinking. Unfortunately, these effects were far from being robust enough to justify its continuation.
Combining lithium with valproate might fit the bill. Valproate can be calming. I would add lithium first as monotherapy to evaluate its clinical effect and dosage range. Once you have found a dosage that suits you - hopefully between 300-600mg You can then add valproate in several ways. You can start low and go slow, start right at the target dosage, or start above the target dosage using loading doses. I lithium and valproate provide a hint of improvement, I would then add Trileptal. If these three drugs don't work, I would then swap valproate for lamotrigine. You can combine valproate with lamotrigine, but using only half the dosage of lamotrigine when used as monotherapy. I think that valproate inhibits the glucuronidation of lamotrigine. To confound the evaluation of lamotrigine further, Tegretol accelerates the metabolism of lamotrigine, thus shortening its half-life. I don't know what would be the net effect on lamotrigine kinetics when Tegretol and valproate are both added.
Don't neglect Topamax. If you start real low and go real slow, you can actually prevent the occurrence of cognitive impairments. Maybe titrate starting at 25mg. I liked the idea of being at 100mg rather than 200mg because 200mg provided no greater benefit than 100mg. In addition, the risk of forming kidney stones is reduced at the lower dosage (carbonic anhydrase inhibition). The most robust and consistent clinical response I have seen to Topamax was to bring to remission a woman with mixed-state mania (or manic dysphoria). She discontinued it for reasons of insufficient finances and relapsed until the Topamax was restarted. It was a striking response.
Gabitril - I don't like this drug as it can be unpredictable and produce dysphoria and seizures.
Keppra - I'm not sure about this drug. It has a high therapeutic index to play with, but it seems to have little or no evidence for effectiveness in bipolar disorder. Kenneth Kaufman at Robert Wood Johnson Medical Center wrote up a case history, if you are interested. The only other case I know of where Keppra proved helpful was with a friend of mine who has an ultra-rapid cycling bipolar II presentation.
- Scott
Posted by Maxime on October 11, 2010, at 2:16:04
In reply to Re: going back to bipolar medications » stargazer2, posted by morgan miller on October 10, 2010, at 23:56:11
You wrote: "mind, numbing glucose metabolism wrecking antipsychotics for off-label uses."
Do you know how the metabolims are wrecked? And does it only happen with APs or with other psych meds?
Posted by polarbear206 on October 11, 2010, at 7:18:31
In reply to going back to bipolar medications, posted by linkadge on October 10, 2010, at 18:29:52
I hope during your trial, you will stick it out. As I recall, you give up too fast out of frustration.
Posted by Maxime on October 11, 2010, at 8:54:35
In reply to going back to bipolar medications, posted by linkadge on October 10, 2010, at 18:29:52
I agree with Polarbear. You do very short trials. Also you seem to be able to feel an effect of a drug within a couple of days. I don't think that happens to anyone here. You are really lucky.
Posted by linkadge on October 11, 2010, at 8:54:49
In reply to Re: going back to bipolar medications, posted by morgan miller on October 10, 2010, at 23:51:18
I'm not sure what it is about antidepressants. I have never really had a manic episode eiter but..
I don't get the same problem with the ritalin at all. If I was true bipolar, wouldn't a potent psychostimulant like ritalin cause mania?Its the feeling of losing control I hate the most. I don't know what it is, dopamine supression in the frontal cortex? I don't know.
Linkadge
Posted by linkadge on October 11, 2010, at 8:56:22
In reply to Re: going back to bipolar medications » stargazer2, posted by morgan miller on October 10, 2010, at 23:56:11
I think that seroquel is about as safe an any other antidepressant out there. If you can keep the dose below 100mg I'd think the risks are justified.
paxil and sertraline have been shown to induce insulin resistance too.
Linkadge
Posted by linkadge on October 11, 2010, at 8:59:46
In reply to Re: going back to bipolar medications » linkadge, posted by SLS on October 11, 2010, at 1:34:11
>What makes you think that you have bipolar >disorder?
I don't think I do, but the mood stabilizers do produce an improvement in my anxiety. Lately the SSRIs have been producing a massive increase in anxiety, panic, etc. etc.
Thanks for the run down SLS, but I have been on most of the mood stabilizers mentioned before.
I think the problem was that the doses were too high for the problems I have.I'm thinking of trying 50-100mg of tegretol or 300mg of lithium and see if that takes the edge off the anxiety.
Linkadge
Posted by linkadge on October 11, 2010, at 9:03:35
In reply to Re: going back to bipolar medications, posted by polarbear206 on October 11, 2010, at 7:18:31
>As I recall, you give up too fast out of >frustration.
I think we can skip the subjective qualifying remarks.
Linkadge
Posted by SLS on October 11, 2010, at 9:32:43
In reply to Re: going back to bipolar medications, posted by linkadge on October 11, 2010, at 8:59:46
> I think the problem was that the doses were too high for the problems I have.
The lithium sounds like a drug not to overlook if you have first-degree relatives who respond to it. Valproate at dosages between 125mg and 500mg might serve the purpose.
- Scott
Posted by ed_uk2010 on October 11, 2010, at 14:34:42
In reply to Re: going back to bipolar medications, posted by linkadge on October 11, 2010, at 8:59:46
>I'm thinking of trying 50-100mg of tegretol or 300mg of lithium and see if that takes the edge off the anxiety.
Link,
I get the impression that you prefer meds to take 'when needed' rather than all the time. Which mood stabiliser do you find best to take just when required? I think that would be the best type of med for you.
Posted by morgan miller on October 11, 2010, at 21:55:42
In reply to Re: going back to bipolar medications, posted by linkadge on October 11, 2010, at 8:54:49
There really is not a "true" bipolar. The spectrum is wide and varied and each individual is different. Heck, in 20 years they may not be calling some of us bipolar anymore.
As far as seroquel or any other AP is concerned, I think there is far more potential for insulin resistance and other metabolic issues than most SSRIs. But that's just my opinion. I'd have to do more research to come to any solid conclusion, which at this point is likely impossible anyway. In my experience, APs like seroquel and zyprexa, even at low doses, noticeably impacted my metabolism in a very short period of time. With Prozac and Zoloft, I do think there was an impact, but it felt much slighter and it took much longer to notice it.
Posted by bleauberry on October 12, 2010, at 5:36:52
In reply to going back to bipolar medications, posted by linkadge on October 10, 2010, at 18:29:52
One of my doctors is trained in naturopathy. In her psych office she prescribes small amounts of lithium very frequently. We're not talking the usual therapeutic doses. Things like 25mg to 300mg. That dose range seems to be helpful for a wide range of psych problems regardless of whatever other meds or chronic illnesses are happening. Without going into the complicated genetic stuff she was talking about, it also helps to bridge some of the roadblocks, snippets, and morphs in genetic flaws. Lithium in small amounts is neuro-helpful, protective, and healing. All this in addition to whatever benefits you happen to feel when taking it.
I'm not a fan at all of lamictal. It seldom seems to lead to any of kind of lasting benefit, not even in clinical trials, and has none of the benefits of the natural salt of the earth lithium. It certainly has a place in the arena of seizure disorders though, for which it is intended.
Posted by SLS on October 12, 2010, at 7:36:53
In reply to Re: going back to bipolar medications, posted by morgan miller on October 11, 2010, at 21:55:42
> There really is not a "true" bipolar. The spectrum is wide and varied and each individual is different. Heck, in 20 years they may not be calling some of us bipolar anymore.
Hopefully, it will be within man's ability to diagnose bipolar disorder using biological markers.
"True" bipolar disorder is sometimes referred to as manic depression, and was first described by Emil Kraeplin a hundred years ago, noting the recurrent course of the illness. The classically described bipolar I is sometimes referred to as Cade's Disease.
How common is bipolar I? Probably 1.5 - 3.0 percent of the population. My guess is that the higher number begins to reflect the inclusion of bipolar II and bipolar NOS.
- Scott
Posted by SLS on October 12, 2010, at 7:57:08
In reply to Re: going back to bipolar medications, posted by bleauberry on October 12, 2010, at 5:36:52
> I'm not a fan at all of lamictal. It seldom seems to lead to any of kind of lasting benefit,
not even in clinical trials,How do you account for the people who do respond well to lamotrigine treatment for depression, especially in polypharmacy? That would include me. Are the antidepressant effects of lamotrigine limited to bipolar disorder? Perhaps not. I think there needs to be more study in this area to characterize lamotrigine therapeutically, and to elucidate its mechanisms of action. Whenever I try to lower the dosage or discontinue lamotrigine, I feel significantly worse. In other words, repeated challenges with the higher dosages of lamotrigine procuced therapeutically measurable improvements in my depression. It is difficult to completely ignore real-life anecdotal experiences.
I would like to see how well unipolar depressives respond to a combination of lamotrigine with either Wellbutrin or Parnate.
- Scott
Posted by Dr. Bob on October 12, 2010, at 14:42:27
In reply to Re: going back to bipolar medications » stargazer2, posted by morgan miller on October 10, 2010, at 23:56:11
> what a bunch of ... a-ss-holes we were back then
Please don't use language that could offend others.
But please don't take this personally, either, this doesn't mean I don't like you or think you're a bad person, and I'm sorry if this hurts you.
More information about posting policies is in the FAQ:
http://www.dr-bob.org/babble/faq.html#civil
http://www.dr-bob.org/babble/faq.html#enforceFollow-ups regarding these issues should be redirected to Psycho-Babble Administration. They, as well as replies to the above post, should of course themselves be civil.
Thanks,
Bob
Posted by linkadge on October 12, 2010, at 14:55:30
In reply to Re: going back to bipolar medications, posted by morgan miller on October 11, 2010, at 21:55:42
>As far as seroquel or any other AP is concerned, >I think there is far more potential for insulin >resistance and other metabolic issues than most >SSRIs.
The atypical with the most pronounced metabolic side effects is olanzapine. There is some evidence that seroquel can have similar effects, but the evidence is much less clear.
For some people, seroquel is a lifesaver. As noted in the studies of seroquel for GAD, seroquel provided relief from core symptoms within one week. This was in contrast to the SSRI arms which needed about 6 weeks for effects to become pronounced.
Metabolic concerns are just one side effect, are are probably minimal with doses below 75mg. All medications have side effects. If paxil makes you an insomniac that just wants to veg out all day, this too will take a metabolic toll.
For me, seroquel (an antipsychotic) produced much less apathy than any SSRI. On paper, this should not happen, but its really an individual balanace of benefits and risks.
I have a suspicion that TCAs like doxapin and amitriptyline probably have a very similar metabolic risk (weight gain, hyperlipidemia, glucose issues) (as most potent 5-ht2c antagonists seem to have), but they have not been studied as closely as the atypicals.
Linkadge
Posted by linkadge on October 12, 2010, at 15:07:00
In reply to Re: going back to bipolar medications, posted by SLS on October 12, 2010, at 7:36:53
The reason things like mood stabilizers, magnesium, omega3 etc. are appealing (to me) is because some of the mounting evidence that recurrent mood disorders are more than just disorders involving neurotransmitters.
With first episode disorders, perhaps there is enough neuronal integrety that a simple neurotransmitter boost is able to get things going.
For me now, SSRI's just produce the opposite effect to what they once did (massive excitory effect rather than inhibitory). Mind you, citalopram worked for about a year and a half with no major problems.
The anticonvulsants, benzos, mangesium and lithium seem like the only things that can help tame down the anxiety and hyperemotional moods.
Linkadge
Posted by morgan miller on October 12, 2010, at 15:23:13
In reply to Re: going back to bipolar medications, posted by linkadge on October 12, 2010, at 14:55:30
Seroquel at 25 mg put me into a acid trip like coma for 3 or 4 hours, then just left me feeling agitated. I think you are one of the positive responders to Seroquel. I hear of many people feeling drained and lifeless on it. A customer at work was only taking 50 and he said it makes him sleep for 12 hours and leaves him incoherent for several hours after he wakes up. But you are right that many other people have benefited from Seroquel. I would personally prefer waiting 6 weeks to get relief than to get immediate relief from a drug that I and I know many others believe is more invasive than most SSRIs, specifically Lexapro and Zoloft. I think Paxil is poison, at least from me it was. It turned me into a zombie for 10 days before I decided I would rather be an unstable mess instead of take it.
Posted by linkadge on October 12, 2010, at 17:34:40
In reply to Re: going back to bipolar medications » linkadge, posted by morgan miller on October 12, 2010, at 15:23:13
>I think you are one of the positive responders >to Seroquel.
I'm not going to get into an argument about how many people do well on seroquel and who don't, thats beyond the scope of anybody here. With any psychiatric medication, there will be those who respond well and those who don't.
>I hear of many people feeling drained and >lifeless on it. A customer at work was only >taking 50 and he said it makes him sleep for 12 >hours and leaves him incoherent for several >hours after he wakes up.
Well, I personally don't recomend more than 25mg but, whatever works (or doesn't for ya).
>But you are right that many other people have >benefited from Seroquel. I would personally >prefer waiting 6 weeks to get relief than to get >immediate relief from a drug that I and I know >many others believe is more invasive than most >SSRIs, specifically Lexapro and Zoloft.
Well thats great. If you can manage to wait 6 weeks than you're not dealing with severe GAD IMHO.
There really are no safe meds. My neighbours endo said that zoloft long term use w. weight gain probably caused her diabetes. I didn't sleep more than 2 hours at a time for a month on zoloft. The relative safety margin is largely dependant on your own individual reaction to a medication.Linkadge
Posted by Phillipa on October 12, 2010, at 19:54:46
In reply to Re: going back to bipolar medications, posted by linkadge on October 12, 2010, at 17:34:40
That's why I like the benzos. I did a google search on them and only negatives could find was tolerance or falls in elderly. Could be more but didn't find any. Phillipa and the work right away. 12.5 of seroquel put me out and I almost fainted.
Posted by morgan miller on October 12, 2010, at 21:12:53
In reply to Re: going back to bipolar medications, posted by linkadge on October 12, 2010, at 17:34:40
I agree with everything you said. I do think there are things we can do on some of these meds that can reduce or maybe eliminate the risk of issues like diabetes developing, exercise and diet are the main ones.
Posted by Jay_Clockwork_Angels on October 13, 2010, at 1:09:05
In reply to going back to bipolar medications, posted by linkadge on October 10, 2010, at 18:29:52
> ok, so I don't know if I am bipolar or not.
>
> However, lately it seems that any kind of antidepressant just makes things worse --> ssris making anxiety worse, causing insomnia, TCAs just plain being intollerable etc. etc.
>
> mood stabilizers like lithium and tegretol have been helping me more than other treatments lately. They seem to be able to produce a calming effect without inducing all forms of insanity that I get from antidepressants. Basically, I just want something that will help my brain shut/calm down without a kazillion week "waiting period" of worsened symptoms, and all manners of akathesia.
>
> I guess the bottom line is that with antidepressants I just feel *much less* in control. I can't stand the feeling of being out of control. They are so unpredictable. Ritalin is predictable for me (just up and down --> not all around). Mood stabilizers are more predictable too.
>
> Linkadge
>
>
>
>Hey Link, I know what you mean, man. I also wanted to add my support to your above post about coming up with new *mixes* using old scripts and such. The only reason I ever got any better on medications is because I took some unconventional (but safe) moves and juggled around some of my meds.
But, about this post, I'd like to add a few things. A couple of meds you may have not tried...but most of these aren't covered by Trillium or most public health plans.
-Trileptal seems to be a very interesting med on it's own, as supposedly in it's formula (difference from Tegretol) it hits the dopamine in the brain. Good anti-anxiety, and anti-depressant. I've tried it, but it was too expensive for me way back when it first came out.
-Abilify. Though it is as expensive as hell here in Canada, I've been on it for awhile, and found it has a combo of mood-brightening and anti-anxiety properties. You still have to take all of the precautions as you do with other 3rd Gen AP's. The blood sugar risk seems to be as problematic as on any of these meds.
-Dexidrine (IR) This is the only version covered by public health plans, but I have found this med incredible. Soooooo smooth, as I had tons of ups and downs on Ritalin. But, I know Ritalin has been good to you.
-Lyrica Again it is pricey, but even after a year on it, I can still feel it's anti-anxiety effect.
Just some ideas....hope you are feeling better soon.
Jay
Posted by linkadge on October 13, 2010, at 16:26:51
In reply to Re: going back to bipolar medications » linkadge, posted by Jay_Clockwork_Angels on October 13, 2010, at 1:09:05
Yeah, thanks for the recomendations.
Some of the meds mentioned are in the pool of ones I'd like to try.
Something like, low dose perhpenazine and tegretol/trileptal might help.
Linkadge
Posted by Maxime on October 13, 2010, at 21:59:26
In reply to Re: going back to bipolar medications, posted by Phillipa on October 12, 2010, at 19:54:46
> That's why I like the benzos. I did a google search on them and only negatives could find was tolerance or falls in elderly. Could be more but didn't find any. Phillipa and the work right away. 12.5 of seroquel put me out and I almost fainted.
Hi Phillipa, I'm surprised that you didn't find anything about benzos causing depression to worsen or that congnitive functions are impaired.
Posted by Phillipa on October 13, 2010, at 22:06:57
In reply to Re: going back to bipolar medications » Phillipa, posted by Maxime on October 13, 2010, at 21:59:26
Not on the search engines I used. And I figure after 40 years I'd see it in me? Phillipa
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