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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 11 of 11. This is the beginning of the thread.
Posted by Quietly_Existing on February 15, 2014, at 13:55:47
Hello,
Enjoy the boards here thoroughly and am seeking some answers.
I'm currently up to 137.5mgs of Lamictal for Bipolar. The initial lower doses pulled me out of a deep depression as they were abit activating. But after each increase the activation only lasted about four days and then my mood dropped back down. So I kept titrating up to where I currently am - 137.5mgs.
The problem is around 100mgs I began to feel more depressed, tired and lethargic to the point of just laying in bed most of the day. I have also gained weight. And now anger seems to making it's way outward as well. I am confused as what to do next. I am concerned I may be in a bit of a mixed state..? I am not quite certain what my next step would be.
I see a Dr. at a clinic and she isn't that educated or up to par on treatments. Plus, simply put, it's clear she just doesn't give a $hi*..she sees patients back to back and each for only a few minutes at a time. Most of her clients are obese and over-medicated.
My previous 6 minute appointment with her I expressed my concerns and was clearly depressed as I sobbed. She immediately and very quickly said "Well I can give you zoloft." I stated I would like to try and get to a higher dose of Lamictal as it would provide more stabilization. Deep down I knew zoloft would be a poor choice as it's one of the most activating ssri's out there. Also I have a terrible history with antidepressants- casuing hypomania, to mixed state, to full-blown psychotic mania in which how I didn't kill myself I'll never know. It was truly awful. Needless to say I am my own advocate as it has proven to be much safer.
She's very lax and could care less either way..working in a clinic with mostly the indigent and poor. Not a very empathetic person if you will.
Anyhow to get to it I am uncertain if I should continue up with the Lamictal with a goal dose of 200mgs then add something for the severe depression. Lamictal doesn't offer much in terms of antimanic either. I have had poor response to numerous medications. For example Lithium made me an angry rage filled person, which immediately went away upon removal of it. I've tried the no medication route as well, but the depression is just too overpowering and is consuming my entire well-being.
Any thought/ideas? I could really use some support and advice. As it is I truly have an absolute zero support system. It's difficult.
Thank you,
Quietly_Existing
Posted by Tomatheus on February 15, 2014, at 15:13:13
In reply to Lamictal Higher dose causing anger and depression, posted by Quietly_Existing on February 15, 2014, at 13:55:47
Hello Quietly_Existing, and welcome to Psycho-Babble. It sounds like your experience with the trial-and-error approach that modern psychiatry uses in the treatment of mental illness has been largely unsuccessful, at least so far. Unfortunately, I can relate, as I believe some others here can. It's got to be frustrating to experience depressive symptoms that you find to be overpowering when you're not taking any medication only to find the medications that are typically prescribed for those sorts of symptoms (antidepressants) to not only be unhelpful but to cause all sorts of other problems (mania, mixed states, psychosis).
With the problems that you've had with antidepressants, your decision to try Lamictal seemed sensible, given reports that the medication seems to be helpful for bipolar patients that struggle to a large extent with depression. Unfortunately, medications don't always affect people in the ways that the experts would expect that they would, and it sounds like this is the case with you and Lamictal. So, should you try increasing your dose? I tend to think that as long as you find the medication tolerable and that your depression and anger aren't too overwhelming that it would make sense to work your way up to 200 mg, just to see how it will affect you. I tend to think that in all likelihood, you'll probably notice the same sorts of effects that you're experiencing now, only more intensely, on higher doses of Lamictal, but sometimes pleasant surprises can happen with dose increases.
If Lamictal doesn't work out for you, there are probably other medications that you can try, and my guess is that other members here will be more than willing to give you suggestions on which medications might be the best ones to try next. One of the other anticonvulsant mood stabilizers would probably be what I would suggest trying next, as far as psychiatric medications are concerned.
But what I would like to stress more than anything else is that even though psychiatric medications help a lot of people, I think that others (meaning those who aren't largely helped by psychiatry) need to explore options outside of the psychiatric medication box if they want to get truly well. If you haven't already done so, I would recommend getting some blood-work done to see if perhaps treating something that can be detected with a blood test might improve your symptoms. Tests for thyroid hormones, vitamin D, and vitamin B12 are some of the first tests that I can think of that might be relevant, but there are likely others that might reveal something that could be contributing to your symptoms, as well. I saw an orthomolecular psychiatrist last year, and she ordered several tests, and basically what came back was that my vitamin D level was insufficient and that I had a mild "pyrrole disorder." I became frustrated with vitamin D3 seemingly worsening some of my symptoms, so I stopped supplementing with it for a while, but I'm supplementing with the vitamin again in hopes that it will do something if I stay on it for six months or longer. And from what I've read from the scientific literature, I think it's likely that if I do benefit from vitamin D3 supplementation that it will probably take a while before I see the true benefits.
It could be the case that your vitamin D level might also be low and that supplementing with the vitamin might help to relieve some of your symptoms, or it might be the case that a thyroid disorder or something else that could be detected with a blood test might be contributing to your bipolar symptoms, but unless you get some testing done (and that's assuming that you already haven't), you won't know for sure if that might be the case.
I, of course, cannot guarantee that by following what I suggest, you'll figure out what's wrong with you and find a treatment that's truly effective, but it sounds to me like it at least wouldn't hurt to try supplementing psychiatry's trial-and-error approach with something different. And "something different" could mean taking an orthomolecular/nutritional approach, it could mean simply seeing another doctor and asking what tests he or she might want to order, it could mean participating in some psychotherapy alongside the psychopharmacological approach that you're currently using to treating your bipolar disorder, or well, it might even be something else or some combination of what I've suggested. That's not to say that I think you should necessarily abandon psychiatry, but I think that your chances or getting well would be best if you at least also look at other options.
I wish you luck in finding something that works for you, and finally, I wish you the best.
Tomatheus
Posted by Phillipa on February 15, 2014, at 17:08:47
In reply to Lamictal Higher dose causing anger and depression, posted by Quietly_Existing on February 15, 2014, at 13:55:47
Was given lamictal for a boost for mild depression. Didn't make it past 50mg. I did seem to be more angry when taking it. Threw a plastic bottle at the wall of a grocery store. As got mad. And this wasn't me. Have you also googled lamictal? I am pretty sure you have though. Good luck with your decisions. Phillipa
Posted by phidippus on February 15, 2014, at 18:43:27
In reply to Lamictal Higher dose causing anger and depression, posted by Quietly_Existing on February 15, 2014, at 13:55:47
>I kept titrating up to where I currently am - 137.5mgs.
Your just shy of 200 mg, which is considered the minimum effective dose for Lamictal.
> The problem is around 100mgs I began to feel more depressed, tired and lethargic to the point of just laying in bed most of the day.
at 100 mg, you were probably reaping more side effects than benefit from the drug-your depression may have just been sedation from the drug.
>And now anger seems to making it's way outward as well.
This is a sign that your mood is not quiet stable and that you may need a higher dose of the lamictal.
>I am confused as what to do next. I am concerned I may be in a bit of a mixed state..?
Concentrate on moving to a higher dose of the lamictal. From others accounts, 400 mg seems to be the optimum dose.
If you're having a lot of anger or irritability, consider adding an atypical antipsychotic that will help with the depression-something like Latuda.
>I am not quite certain what my next step would be.
1. Increase dose of Lamictal until you feel stable.
2. Add on an atypical antipsychotic.
>She immediately and very quickly said "Well I can give you zoloft."
Bad idea - this would destabilize your mood.
>Lamictal doesn't offer much in terms of antimanic either.
LAmictal's strengtth is its ability to treat bipolar depression
>For example Lithium made me an angry rage filled person, which immediately went away upon removal of it.
Was your blood level 1.0?
>I've tried the no medication route as well, but the depression is just too overpowering and is consuming my entire well-being.
Bipolar people need to be on meds, period.
Keep increasing that Lamictal and take a serious look at adding an AAP, they caan help with depression.Eric
Posted by Quietly_Existing on February 15, 2014, at 21:51:13
In reply to Re: Lamictal Higher dose causing anger and depression, posted by Tomatheus on February 15, 2014, at 15:13:13
Hello all,
Thank you for taking the time to respond, I appreciate it.
Thomatheus in re: to your response: I've been through a few other anticonvulsants, one being trileptal which I could see being a truly effective anti-manic for my individual chemistry. It doesn't help with the depression at all as most know. I was able to reach 600mgs (300mgs 2xaday) but it brought my mood so low it made me severely, severely depressed. Not in a good stae of mind if you will. As well as unmotivated and it greatly affected my cognition and memory to the point where I couldn't recall if I had even taken it. Upon reporting this to the "wonderful" clinic psychiatrist I see, she simply said, "just stop the 600mgs all together." A completely incompetent and dangerous order from a Dr. Listening to her nonsense could have resulted in a seizure or a severe manic episode. I used my judgement and tapered down s l o w l y and still became hypo coming off of it. I hope this gives you greater insight into just how lax and incompetent this woman is.
In regards to going to another Dr. as you suggested I am extremely limited in where I can go. No job = no insurance and no job = no money. Unfortunately most clinics are overburdened like this and switching to another may prove to be even more disastrous.
I agree with you in re: to the bloodwork. I had to ask this Dr. repeatedly to order these tests and when she didn't I took it into my own hands and had a general m.d. order bloodwork, including thyroid level. All came back normal.I also completely hear what you're saying in regards to orthomolecular/nutritional approach as I have read about it. But at this point I don't even have the energy and motivation to go that route. Even supplementation requires careful consideration as it poses a risk of pushing on into a manic state among other things.
I also have an individual therapist whom I see.
Phillipa - Hello,Thank you for your input. So sorry to hear you couldn't make it past 50mgs. You stated you "threw a plastic bottle at the wall of a grocery store" as a result of the lamictal. Glad to hear that the bottle you threw wasn't glass.
Phidippus Hello,
Thank you for your response as well.
I certainly agree with you on being just shy of the 200mgs. I plan to keep going until I reach that dose and take it from there. It may prove to be difficult. Although with each increase I get various responses with a few days which the seem to subside.
You stated "at 100 mg, you were probably reaping more side effects than benefit from the drug-your depression may have just been sedation from the drug." Sedation would be an additionally appropriate way to state how I am feeling upon titration. Sedated, lethargic, unmotivated, and now the anger emerging.
"400 mg seems to be the optimum dose"
I was under the impression 200mgs would be a beneficial dose for bipolar stabilization. There are certainly others who may reap benefits from doses over 200mgs. But numerous studies also indicate doses above 200mgs of Lamictal when being used strictly for bipolar disorder and stabilization of ones mood don't prove to be any more beneficial. Of course this can be controversial to numerous people. And I can attest as my trials and errors with psychiatric medications have proven to be that of the not so common. Of course one must also take into consideration numerous fatcors that would impact the desired results of lamictal. But that's for another day.
Your suggestion of adding a atypical antipsychotic is appropriate but has more cons than pros for me. Side note: Tried Geodon and the lower doses of acted like an antidepressant and caused psychotic symptoms I never had prior to going on the medication. Titrating up to a higher dose it proved to more like an AAP. Resulting in a 60 pound weight gain (yes weight neutral Geodon did this to me), literally passing out, wherever I was after taking it and remaining there for a good 5 hours or more. It's sedation proved to be so powerful on me that after taking it and it kicking in I passed and fell asleep in the middle of my hallway as I couldn't make it to the bedroom. I passed out/slept there for 6 hours straight.Alot to think about here. I will digest all this helpful information and try to get through each day.
Thank you again everyone for taking the time to reply.
Quietly_Existing
Posted by Tomatheus on February 15, 2014, at 23:19:45
In reply to Re: Lamictal Higher dose causing anger and depression, posted by Quietly_Existing on February 15, 2014, at 21:51:13
Hello again Quietly_Existing,
Thank you for explaining everything that you did in your post. I'm sorry to hear about your response to Trileptal and about the fact that your psychiatrist advised you to stop taking the medication abruptly. I'm certainly not an expert, but it is my understanding that stopping a medication like an anticonvulsant abruptly can potentially be disastrous, and I'm glad that you had the sense to bring yourself off of the Trileptal slowly.
I think it's good that you're both seeing a therapist and that you went to have a general practitioner order some bloodwork. It's too bad that the test results didn't come back with anything that might potentially help you with the treatment of your bipolar disorder, although, at the same time, I do think it's good that no signs of any other health problems were found (at least judging from the test results). I do have to ask you, though, if a vitamin D level test was included in the bloodwork. There seem to be some similarities between your responses to medications and my responses to medications (my responses to lithium and Lamictal were not completely unlike yours, and even though I responded well to the MAOIs and did not react adversely to Wellbutrin, I had some problems with antidepressants, as well). These similarities, of course, might just be meaningless, but I figured that I'd ask you specifically about vitamin D because that's one thing that came back abnormal for me, and I wouldn't like to see that stone go unturned for you.
I read what you wrote to Eric (Phidippus) about antipsychotics, and I do understand your desire to avoid that class of medications if you can, but I did want to put in a word about Abilify before I finished this message. Basically, of the antipsychotics that I've tried for my affective psychosis, Abilify at 5 mg has so far been the only one that I've been able to stand taking. Unlike the rest of the antipsychotics on the market -- both the "typical" ones and the other "atypicals" -- Abilify is what's called a partial agonist at the D2 receptor sites. Basically, instead of binding to the D2 receptors and exerting no effect like other antipsychotics, Abilify activates the receptors, but to a lesser extent than medications that are considered to be full agonists of the D2 receptors. So, even though Abilify is technically an atypical antipsychotic just like Geodon, Seroquel, Risperdal, Zyprexa, and others, I think that the medication in some ways belongs in a class by itself because of its unique effect on the D2 receptors. I seem to respond best to 5 mg of Abilify, but of course, some patients find that higher doses work best for them. Anyway, I just wanted to put that out there for you to think about. I know that you responded poorly to Geodon, but maybe there's an antipsychotic out there (Abilify, or something else) that you might benefit from.
Finally, thank you for writing back to me. I hope that somehow you'll find some kind of treatment that will get you from being in "quietly existing" mode to being in more of a living mode.
Tomatheus
Posted by SLS on February 16, 2014, at 8:12:34
In reply to Lamictal Higher dose causing anger and depression, posted by Quietly_Existing on February 15, 2014, at 13:55:47
For the most part, Lamictal acts more like an antidepressant than it does an anti-manic or mood stabilizer. I sometimes wonder if Lamictal can trigger mania in some people. Perhaps it is producing a sort of mixed state for you as the Lamictal unmasks a mixed state. That being said, you really cannot pass judgment on Lamictal as an antidepressant until you reach a minimum of 200 mg/day. That you experienced fleeting improvements upon dosage increases with Lamictal is quite common.
Perhaps the answer is to remain on Trileptal and add a standard antidepressant like Wellbutrin. Another option is to use an antipsychotic with antidepressant properties like Abilify or Latuda, or perhaps Geodon, even though Geodon is a rather unpredictable drug. Yet another option is to add minocycline to Abilify and Lamictal. (Minocycline is antiglutamatergic, as is Lamictal). Even minocycline and Abilify without the Lamictal can produce an improvement.
How do you respond to mirtazapine (Remeron)?
- Scott
Posted by Quietly_Existing on February 16, 2014, at 17:34:46
In reply to Re: Lamictal Higher dose causing anger and depression » Quietly_Existing, posted by Tomatheus on February 15, 2014, at 23:19:45
Thank you to All for taking the time to reply. I have replied to all of you in my last post. I apologize if my subject post didn't reveal my individual responses.
The anger from the most recent Lamictal increase has subsided for the time being. I'm optimistic the side effects from this most recent increase have passed. {It's frustrating as my mood didn't cycle this erratically prior to Lamictal- but I understand it may make things worse before they get better}
I plan to carry on and make my way to 200mgs.
I'm quite certain the Lamictal will not prove to be strong enough to tackle my deep depression.
Thinking ahead here and being my own advocate I must cautiously weigh my options as it's clear my Dr. is indeed inept. - (previous posts)
I found it quite interesting no one mentioned the use of SNRIs in the use of bipolar depression. Prior to definite DX of Bipolar I opted for Cymbalta alone. (no stabilizers in place) Interestingly enough this was the one AD that I was able to tolerate for 3 months until it made me hypo. Whereas the other AD's (SSRI's alone) made me anxious, irritable, and eventually psychotic. I felt negative effects from the very first dose of each SSRI's.
Tomatheus you had kindly suggested Abilify which has worked well for you. (Very Nice To Hear) I have thought about Abilify but am hesitant as I feel it too closely resembles the make up of geodon. Which I mentioned the low doses overactivating me and acting like an AD. The result being psychosis and higher doses resulting in extreme sedation (sleeping 6-7 hours a day) and weight gain. Not a way for me to be a functional human being. I hear what you are saying it being in a class of it's own. Perhaps some more research on my part is needed. Thank you.Scott- Hello,
Thank you for the reply. I have thought about going back to Trileptal as a safety against mania. The cognitive issues proved to be too debilitating for me though. Putting this in perspective, perhaps a low dose of Trileptal could be used as an effective anti-manic with an AD alongside. Next question I owuld ask myself would be which AD ?The following question would be if it's better to bring me down from the overactivation of an AD Or would it be better to lower my mood with the Trileptal and bring me back up with AD. Although I feel I can't afford to become any lower and dysfunctional in regards to my depressed state.
Wellbutrin has crossed my mind. Upon mentioning this to the clinic psychiatrist she said "it will make you psychotic", yet she wanted me to start zoloft. Zoloft affects serotonin and is the effect of dopamine felt at the higher levels? Whereas Wellbutrin affects dopamine and norepinepherine. I feel I should likely stay away from anything that affects the dopamine. But perhaps I'm mistaken.
Lastly you mentioned an Monoamine oxidase inhibitor- Remeron. I have never taken this. Again more research would be needed on this particular medication. Another option though.
I could continue on but I have clearly overwritten my response. I am a very analytical person and will explore every option from every angle. Which can certainly be valuable at times but also inauspicious.
Thank you very much again,
Quietly_Existing
Posted by Quietly_Existing on February 16, 2014, at 21:24:38
In reply to Re: Lamictal Higher dose causing anger and depression » Quietly_Existing, posted by SLS on February 16, 2014, at 8:12:34
Hi Scott,
I read up on your suggestion of adding Minocycline an antiglutamatergic to help with some of the bipolar depression.
The more information I was able to dig up the more promising this sounds, although there are definitely some cons as well.
In particular what struck me is the entire concept of inflammation. Inflammation undoubtedly interacts with the immune system and is connected to allergic reactions.
Brief background as I'm finding it difficult to convey my thoughts you now.
As an adult I have developed several allergies to food items which I was able to eat as a child and teenager. I now must carry epi pens with me everywhere I go. I can die as a result of my throat swelling shut If I come in contact with my allergens.
We know disorders connected with inflammation can include rheumatoid arthritis, asthma and autoimmune diseases. My allergist has been testing me for various types of autoimmune disorders for various symptoms I have. My mother has been tested repeatedly for different autoimmune diseases as well, she also suffers greatly from rheumatoid arthritis. And I have a familial background of various allergies, asthma, medication allergies, as well as mental illness within my family.
I would truly like to explore this more with you if you have the time.
Thank you again for bringing this to my attention.
I look forward to discussing this more.
Quietly_Existing
Posted by Hugh on February 17, 2014, at 15:38:13
In reply to Re: Lamictal Higher dose causing anger and depression, posted by Quietly_Existing on February 16, 2014, at 21:24:38
> My mother has been tested repeatedly for different autoimmune diseases as well, she also suffers greatly from rheumatoid arthritis.
Low dose naltrexone (LDN) can be very helpful for rheumatoid arthritis and other autoimmune disorders, as well as some forms of cancer.
A clinical trial is now underway to determine if the probiotics Lactobacillus rhamnosus GG and Bifidobacterium BB12 can help to prevent mania in bipolar disorder and schizoaffective disorder.
http://clinicaltrials.gov/show/NCT01731171
This is the probiotic blend that's being used in the trial:
http://www.usana.com/webhosting/product?page=page3
I heard about this trial from this report that aired on NPR a few months ago:
Posted by PeterMartin on February 17, 2014, at 15:40:54
In reply to Lamictal Higher dose causing anger and depression, posted by Quietly_Existing on February 15, 2014, at 13:55:47
Are you taking brand or generic Lamical? If generic which maker?
I take Lamictal and sadly there's a large difference between the brands. I'd highly recommend either the brand or Teva generic. If you search here you'll find that a lot of the generic lamictal brands are not as effective (or cause other reactions) than the brand. Personally I actually think I respond best to the Teva generic even including the brand. I was on brand for years, forced to switch to Teva generic when it came on the market, went back to brand when I was able to get my insurance to ok it, and just recently I had to switch back after changing insurance cos again. For me the Teva works the best.....can't say it's the most potent or what but I just seem to respond to it best.
Lamictal makes me tired too at ~150mg. I take an MAOI for depression as well so over the years I've found 100mg is a good enough dose for me.
This is the end of the thread.
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