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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 7 of 7. This is the beginning of the thread.
Posted by sheilac on May 18, 2012, at 14:36:46
My sister who is a pharmacy tech couldn't believe the meds I was on. She thinks I should taper off of everything and just take Tramadol and Klonopin as needed.
I am beginning to wonder. My therapist isn't so sure about the BPII diagnosis. She thinks I have more anxiety/depression issues with some agraphobia issues.
Plus, why am I so super, ridiculously sensitive to meds? Maybe because I really don't need them?
Maybe less is more and I should try the Tramadol, it takes away the depression without making me dopey or euphoric or manic.
New doc wants me to add Abilify to my low dose Trileptal and Lithium to help with the depression. The Trileptal and Lithium have me so flat and depressed (maybe some would say stable?). So is Abilify supposed to perk me up and be the magic pill to get rid of the depression?
I'm not sure anymore and am reaching the end of my medication rope.
Posted by SLS on May 18, 2012, at 15:32:19
In reply to Dump everything?, posted by sheilac on May 18, 2012, at 14:36:46
You must be feeling like hell that you should consider doing something so extreme. I am dubious of the advice you have been given.
I am sure that you want to feel better immediately, regardless of what it takes to do it. However, to do what has been suggested might set you back months. I don't believe that tramadol is enough of an antidepressant to treat your present condition. Wellbutrin seems like the wrong drug for you at any dosage. I can't be absolutely sure, though. I suppose being absolutely sure of anything with these brain disorders is elusive, especially for laymen like me. So, I will just say that I feel mood stabilizers are important for you if you are to ever see stability and achieve a depression-free life for yourself. Treating with a combination of Lithium + (anticonvulsant) is sometimes necessary, expecially when ultra-rapid cycling is present. Perhaps trying drugs that are not standard antidepressants makes sense to do first. I should think that Lamictal and Abilify would be effective for your bipolar depression, especially when used together. Both of these drugs have antidepressant properties. The NIH has published an article indicating that the combination of these two drugs reduces the odds of relapse.
If your doctor prescribes Abilify, be prepared for the possible emergence of anxiety, restlessness, and insomnia at the beginning of treatment. It looks like a mild form of akathisia, but usually disappears in a week or so. The Klonopin might help prevent this. I can't tell you what percentage of people experience this with Abilify. As with all antipsychotics, true akathisia is a possible adverse event, so I would work closely with your doctor to work through startup side effects and evaluate the more persistent ones.
The following article evaluates the potential for the combination of aripiprazole (Abilify) and lamotrigine (Lamictal) to prevent future episodes of depression in bipolar disorder, especially for patients with mixed-states. Terrence Ketter trained under Robert Post at the NIH, and is considered to be an expert in the use of mood stabilizers in bipolar disorder and is a pioneer in brain imaging.
- Scott
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Aripiprazole Plus Lamotrigine May Prevent Depressive Relapse in Patients With Bipolar DisorderPresented at ECNP
Tags:
aripiprazole
Depression
lamotrigine
Schizophrenia and Bipolar DisorderRead/Add Comments | Email This | Print This
By Shazia Qureshi
AMSTERDAM, the Netherlands -- September 1, 2010 -- Combination treatment with
aripiprazole plus lamotrigine reduced the rate of relapse to a depressive
episode in patients with bipolar I disorder who had had a recent mixed episode,
researchers reported here at the 23rd Congress of the European College of
Neuropsychopharmacology (ECNP).Terence A. Ketter, MD, Department of Psychiatry and Behavioral Sciences,
Stanford University, Stanford, California, and colleagues compared treatment
with aripiprazole plus lamotrigine (n = 178) with placebo plus lamotrigine (n =
173) in 351 randomised patients.We think that these are the first data showing that aripiprazole might have
something to do with preventing depression after a mixed episode, said Dr.
Ketter during a poster presentation on August 31.Treatment was double-blind for aripiprazole and placebo, but open-label for
lamotrigine, and lasted for up to 1 year.Patients entering the study had to have bipolar I disorder plus a recent manic
or mixed episode as defined by a total score >=16 on the Young Mania Rating
Scale (YMRS). Fewer patients in the aripiprazole group presented with a mixed
episode compared with the placebo group (43.8% vs 54.9%).Before randomisation, all patients had received single-blind treatment with
aripiprazole 10 to 30 mg/day plus open-label treatment with lamotrigine 100 to
200 mg/day and had to maintain stability for 8 consecutive weeks, with 1
excursion allowed, except for the second-to-last and last visits. Stability was
defined as a YMRS score <=12 plus a Montgomery-Åsberg Depression Rating Scale
(MADRS) score <=12. An excursion was defined as a YMRS and/or MADRS score of
>12.The researchers looked at the Kaplan-Meier relapse rate into a manic or mixed
episode over the 1 year of randomised therapy. They found that the relapse rate
was lower with aripiprazole plus lamotrigine treatment (11%) than with placebo
plus lamotrigine treatment (23%), although the difference was not significant
(P =.058).When relapse into a depressive episode was evaluated, however, a post hoc
analysis showed a difference between treatment groups among patients who had
entered the study with an initial mixed episode. A significantly longer time to
depressive relapse was seen with aripiprazole plus lamotrigine treatment than
with placebo plus lamotrigine treatment (P =.041). This difference
was however not significant among patients who had entered the study with an
initial manic episode.One of the best predictions of failure, i.e. relapse, seems to be the initial
mixed episode, said Dr. Ketter.With the adverse event profiles, there were no surprises, said Dr. Ketter. No
new or unexpected adverse events were seen, and all adverse events that
occurred were consistent with the known profiles of aripiprazole monotherapy
and lamotrigine monotherapy, the researchers noted in their poster.Funding for this study was provided by Bristol-Myers Squibb and Otsuka
Pharmaceuticals.[Presentation title: Aripiprazole in Combination With Lamotrigine:
Long-Term Treatment of Patients with Bipolar I Disorder (Manic or Mixed).
Abstract P.2.e.021]
- Scott
Posted by SLS on May 18, 2012, at 15:36:18
In reply to Dump everything?, posted by sheilac on May 18, 2012, at 14:36:46
If Abilify is not tolerable, ask your doctor about using Saphris (asenapine) in its place.
- Scott
Posted by sheilac on May 18, 2012, at 15:44:33
In reply to Re: Dump everything? » sheilac, posted by SLS on May 18, 2012, at 15:32:19
I can't take Lamictal. But the low dose of Trileptal and low dose of Lithium is probably ok, right?
I guess if those meds are keeping me from tearing someone's head off, that is a good thing.
I just need to address the depression side. Which is why the doc today suggested low dose Abilify.
Do you think this combo could help?
300mg Trileptal
300mg Lithium
Klonopin as needed
2mg AbilifyWhat do you think?
Posted by Phillipa on May 18, 2012, at 17:30:34
In reply to SLS - Re: Dump everything?, posted by sheilac on May 18, 2012, at 15:44:33
I think get a second opinion first. Phillipa
Posted by bleauberry on May 20, 2012, at 5:25:03
In reply to Dump everything?, posted by sheilac on May 18, 2012, at 14:36:46
If tramadol works then I would think take it. It comes with dependence issues and if you ever have to stop it the withdrawals are nasty. But what are the choices? Years of trying other stuff you have no idea will work or not? Years of wasted life? Go with what works for now, and then try to make more sense out of things and make any other changes later on after being stable for a while.
Abilify is best for depression when it is combined with SSRIs. As with the other mood stabilizers you have experience with, it will tend to dull emotions. That is less of a problem at very low doses.
The sensitivity thing I understand. That seems very common in the Lyme, Lyme-like, MS, post-SSRI, etc groups. To me it means there is something else going on besides just the psychiatric stuff. Whatever that something else going on is, is probably also causing the psychiatric symptoms.
Most of my Lyme doc's patients had similar sensitivities. Not hard to deal with however, you just have to grasp the fact that the commonly accepted dosing guidelines do not apply to you. Your doses will be far lower, even lower than the lowest dose. My doc's starting point, for example, for a patient with lexapro is one drop....that is 1/10th of a mg. It was not unusual to have patients on 1mg of lexapro and it was working. Higher doses, bad news.
So it's just a different ballgame. If any doctor tries to apply normal doses to you, in my opinion that is a mistake and sets you up for failure.
There is a good side to the sensitivities. That is, while you are super sensitive to the negative effects of meds, you are also super sensitive to the positive effects....which means the dose that will do good for you is likely a very very low one.
You might have to get good at making custom doses. Lots of us have to do that because they don't manufacture doses small enough. There are easy ways to do this with either capsules or tabs, extended release or not, doesn't matter. Not hard.
Posted by SLS on May 20, 2012, at 7:12:32
In reply to Re: Dump everything?, posted by bleauberry on May 20, 2012, at 5:25:03
Bleauberry:
Dump everything? Dump Trileptal and lithium?
> If tramadol works then I would think take it.
What is this "if" stuff?
What if I were to tell you that we don't know that tramadol will work? We don't. It has not been established. So, then, your if statement is conditional upon the establishment of its efficacy.
How would you go about establishing that tramadol works in this case? Initial dosage? Titration schedule? Length of trial? You know - stuff like that. How long would you allow SC to suffer if it didn't work immediately?
Remember your admonishment to me regarding depression and suicide? What makes you think that tramadol has a better chance of working than Abilify in the treatment of bipolar depression? Would you say that there is a sense of urgency here?
You say that Abilify works best with a SSRI. Upon what do you base this statement? It has been helping me achieve remission, and I am not taking a SSRI for BIPOLAR DEPRESSION. However, I am taking it with a MAOI and lithium. It doesn't give me the slightest hint of cognitive dulling or affective flattening at 10 mg.
I agree that tramadol is not to be excluded from consideration for treating the depression.
I don't know how one would justify removing Trileptal when it extinguished the mania and allowed SC to pass through a zone of euthymia after starting it. I don't know if removing it was what you had in mind. After some experimentation with dosages, it seems that a dosage of 600 mg produces affective flattening for SC, but not a dosage of 300 mg. It has been established that Trileptal at 300 mg is effective in treating the mania in this case.
By the way, do you postulate that tramadol would be effective for depression because it is an SNRI like Effexor, in addition to being an opioid receptor agonist? Isn't there more of a chance that it would be maniagenic than Abilify? I don't know. Abilify can cause mania, but this is a rare event. Zyprexa can cause mania, too, as can Geodon. Only a handful of cases for each drug has been reported to Medline and other medical databases.
http://www.ncbi.nlm.nih.gov/pubmed/22122647
You might be right about everything you have to say. I am just curious what you took into consideration when you made your recommendations.
SeilaC:I am sorry to talk about you in the third person.
- Scott
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