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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 6 of 6. This is the beginning of the thread.
Posted by cache-monkey on March 16, 2006, at 20:15:13
Hey all,
Been a while since I've posted. I'm not doing so well right now. I'm pretty sure that I'm BPII with mixed states/dysphoria predominant and periodic depression. Possibly also ultra rapid-cycling, although that's hard to seperate out from a mixed state for me. I've recently been going off of Lithium because it irritates my urinary system and makes my kidneys hurt. Even at ~50 mg/day.
Problem is that when I do go off of it, I find myself sliding into a mixed state. On Lithium, I feel a little stabilized, provided I don't raise the dose too high, in which case I get increased anxiety. So I feel like with the Lithium I'm torn between my mental and physical health.
Oh, and I've had failed trials of the following:
1) Depakote - increased depression, fractured sleep and cognitive blunting throughout at 6 week trial
2) The atypical antipsychotics - akathisia from Zyprexa and Geodon; severe dry mouth and some agitation from Seroqual
3) Trileptal - severe cognitive dysfunction during 10 day trial
4) Lamictal - increased agitation, muscle aches, sexual dysfunction at 25 mg, panic attack at 50 mg (conservative titration, but a very stressful period of my life...) -- actually I'm going to start another thread about retrialing...My pdoc has started me on Neurontin, but I'm wary. Any thoughts on another mood stabilizer? More specifically, is there a mood-stabilizer that is considered "similar" to (low-dose) Lithium in its actions?
Also, out of the following meds, is there one that might be considered better for mixed-states and ultra-rapid cycling? {Neurontin, Tegretol, Topomax, Keppra, Zonegran, verapamil, Gabitril}
Thanks for any input you might have!
Best,
cache-monkey
Posted by bipolarspectrum on March 16, 2006, at 22:25:25
In reply to Meds for mixed state???, posted by cache-monkey on March 16, 2006, at 20:15:13
Hi,
My pdoc is well-versed in terms of clinical experience and he says tegretol is good for mixed states... tegretol's a classic, u should try it... im currently on it with lithium and seroquel and its going alright....
bps
Posted by med_empowered on March 17, 2006, at 23:10:47
In reply to Re: Meds for mixed state???, posted by bipolarspectrum on March 16, 2006, at 22:25:25
mixed states are tough, in part b/c for a long time they weren't well-recognized; "clasicc" bipolar I disorder involves discrete episodes of (euphoric) mania and (intense) depression. With the increasing attention towards bipolar II, there's also been interest in the mixed states of various sorts of bipolar.
Keppra might be good--it seems better for the mania end of things (some people report depression on it), but its pretty "clean" in terms of drug-drug interactions. Also, I think benzos can be helpful--if nothing else, they help slow things down a bit so you're less likely to do something stupid.
If you can't tolerate 1 mood-stabilizer @ full dose, perhaps you could mix? Mixing mood stabilizers happens sometimes in BP--for some people, multiple mood stabilizers are a better option than adding in antidepressants or benzos. Some combos: depakote/Lamictal (anti-depressant action from lamictal, plus anti-manic action), lithium+(tegretol, depakote)--strong anti-manic action; might also be a good call in cases of bipolar depression before trying an antidepressant; Anti-convulsant (tegretol, trileptal, keppra, depakote, possibly phenytoin) plus atypical antipsychotic (the AP can be used short-term or longer-term, as-needed)--anti-manic action, possibly some anti-anxiety/anti-depressant action, as well. The only combo I'd avoid w/o even trying is Lithium+antipsychotic, since that can make side effects from both meds more intense (back in the day, some cases of permanent brain damage were reported with haloperidol+lithium combos; no one really knows how safe these combos are long-term or what kind of subtle cognitive deficits they could produce).
Good luck!
Posted by cache-monkey on March 17, 2006, at 23:51:34
In reply to Re: Meds for mixed state???, posted by bipolarspectrum on March 16, 2006, at 22:25:25
Thanks bps,
I would like to try Tegretol, but I had a negative experience with low-dose Trileptal. (Completely numbed brain at very low dose.) Trileptal is an analogue of Tegretol, and I wonder if I'd have a similar reaction... I guess I'll look through the archives to see if anyone's been on both and can compare.
Anyway, thanks again.
~cache-monkey
> Hi,
> My pdoc is well-versed in terms of clinical experience and he says tegretol is good for mixed states... tegretol's a classic, u should try it... im currently on it with lithium and seroquel and its going alright....
> bps
Posted by cache-monkey on March 19, 2006, at 2:00:06
In reply to mixed states, posted by med_empowered on March 17, 2006, at 23:10:47
Thanks!
It seems like mixed states are pretty tough to treat. And they're no fun to experience either.
I do like the thought of Keppra. I think that or Tegretol will be my next try. The Neurontin seems to be ramping up the manic side of things. Hard to tell b/c I also tried to go off the low dose (~50 mg) of Li a couple days before. Between the two changes, I hit an incredibly debilitating mixed state. Mind just running around in circles non-stop.
I'm going to have to reinstitute the Lithium for the time being, maybe for good, and kidneys/UT be damned.
As far as the combos, it just seems to overwhelming. The really tough thing is that I'm in a kind of high-performance job and it's so hard to go through extended periods where my cognitive function is nixed. That makes me really scared to give, say, Depakote or Trileptal another go-round.
But life is so overwhelming in a mixed state that I'll have to go back through the list pair-wise (and then triplet-wise) if there's nothing that adds on/replaces low-dose lithium alone.
Ugh. I hate this.
~cache-monkey
> mixed states are tough, in part b/c for a long time they weren't well-recognized; "clasicc" bipolar I disorder involves discrete episodes of (euphoric) mania and (intense) depression. With the increasing attention towards bipolar II, there's also been interest in the mixed states of various sorts of bipolar.
>
> Keppra might be good--it seems better for the mania end of things (some people report depression on it), but its pretty "clean" in terms of drug-drug interactions. Also, I think benzos can be helpful--if nothing else, they help slow things down a bit so you're less likely to do something stupid.
>
> If you can't tolerate 1 mood-stabilizer @ full dose, perhaps you could mix? Mixing mood stabilizers happens sometimes in BP--for some people, multiple mood stabilizers are a better option than adding in antidepressants or benzos. Some combos: depakote/Lamictal (anti-depressant action from lamictal, plus anti-manic action), lithium+(tegretol, depakote)--strong anti-manic action; might also be a good call in cases of bipolar depression before trying an antidepressant; Anti-convulsant (tegretol, trileptal, keppra, depakote, possibly phenytoin) plus atypical antipsychotic (the AP can be used short-term or longer-term, as-needed)--anti-manic action, possibly some anti-anxiety/anti-depressant action, as well. The only combo I'd avoid w/o even trying is Lithium+antipsychotic, since that can make side effects from both meds more intense (back in the day, some cases of permanent brain damage were reported with haloperidol+lithium combos; no one really knows how safe these combos are long-term or what kind of subtle cognitive deficits they could produce).
>
> Good luck!
Posted by bipolarspectrum on March 19, 2006, at 22:31:34
In reply to Re: mixed states » med_empowered, posted by cache-monkey on March 19, 2006, at 2:00:06
Hey Cache,
I think reinstating the Li is a great idea... Li is just so damn useful and effective... If it means anything, I'm having a great response to Li and Tegretol (I've got some seroquel in there as well)... Mabye that will encourage u a little... I also thinkk, in my opinion, that neurontin is kinda useless, its not strong at all in terms of mood stabilizing... I totally empathize with your concerns regarding having a high performance job and cognition.. I'm a med student on sick leave and i know that my cognition as it is on my 3 drugs is nowhere near where it would need to be... I dont know of any ways around this besides aricept and finding a happy medium between effectiveness and sideeffects dosewise.... anywayz, good luck!
bps
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