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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 13 of 13. This is the beginning of the thread.
Posted by bob on September 25, 1999, at 18:14:06
My 20 year old daughter has been diagnoised with bipolar disorder, and has been given lithium and paxil. I am concerned with the rush to medication and the type. I'm new to this-any advice?
Posted by Noa on September 26, 1999, at 4:08:40
In reply to lithium, posted by bob on September 25, 1999, at 18:14:06
I have read that NOT treating affective disorders can lead to more likelihood of recurrent episodes, and a worsening course, so if your daughter really has bipolar, it is probably good to start treating it with medication. Lithium is the long held standard for BP. The paxil is to address depression. The risk of antidepresants, as you will read here (go to archives) for people with BP, is that they can stimulate manic episodes. The lithium is supposed to stabilize that. Lots of good sites on the web for BP. Start at Dr. Ivan's Depression Central, he has lots of links on BP. Good Luck. And, welcome.
Posted by maryanne on September 26, 1999, at 6:06:30
In reply to lithium, posted by bob on September 25, 1999, at 18:14:06
> My 20 year old daughter has been diagnoised with bipolar disorder, and has been given lithium and paxil. I am concerned with the rush to medication and the type. I'm new to this-any advice?
I believe your concerns are valid. Several reasons why. For one, starting two medications at the same time isn't wise. It opens a whole can of worms in terms of side effects, titration, and results. Too much confusion. Too many variables. It seems prudent to become stabilized on one and add another later if needed. It's hard enough managing one drug, not to mention two at the same time. Second, Lithium is FDA approved for acute mania. Is that where your daughter is at? It is also used to stabilize and potentiate an antidepressant, but almost always added later if needed. Third, other newer choices such as Lamictal or Neurontin have a much more favorable side effect profile. Many people can't tolerate Lithium. In the long run it is hazardous to kidneys. It can be nasty. Finally, if bipolar, it might be wise to start with Lamictal or Neurontin first, see how it goes, then depending on the results either add an antidepressant or revert back to one of the older mood stabilizers like Lithium or Depakote. I know several doctors, and have seen more in literature, who never use Lithium as a first-line treatment. Especially for someone so young with no medication experience. I would postpone your docs approach and re-evaluate the whole situation. Get a second opinion/second approach from another doc, preferably one who specializes in mental illness drugs and is well-read on cutting-edge advancements. Lots of choices. Many make a lot more sense than the one you've been given. I strongly agree with your concerns and I believe this is an appropriate situation to cause hesitation. In my opinion Lithium is a poor first-choice unless the person is experiencing acute mania. Get a second opinion. If your daughter's life is not in danger, there is no reason to rush blindly into this can of worms. It all depends on the degree or severity of the bipolar condition, but she might be fine on a simple treatment of Paxil. If it throws her into a mania that is of concern, then we would know a mood stabilizer is warranted. But again, more and more they are not using Lithium as first-line treatment.
Posted by JohnL on September 26, 1999, at 8:24:13
In reply to lithium, posted by bob on September 25, 1999, at 18:14:06
> My 20 year old daughter has been diagnoised with bipolar disorder, and has been given lithium and paxil. I am concerned with the rush to medication and the type. I'm new to this-any advice?
Hi bob. You've come to the right place to learn more. This is a great site with many experienced folks with plenty of insight. If it's alright with you, I would like to share my non-professional opinions. I've been around the block a few times with these drugs and hope that sharing my experiences might be of assistance.
I think this is a harsh overly aggressive treatment at such an early stage of treatment. We don't know from your description the severity of the bipolar situation of your daughter. But because Paxil was mentioned, I am assuming the reason for consulting a doctor was depression.
You don't have to accept the doctor's prescription. If you are uncomfortable with it, tell him/her so. Ask for alternatives. If the doctor won't budge, politely thank them for their help and ask for time to think about it. Then, see another doctor.
If I may, I would suggest two possible alternatives that to me make a lot more sense. First, assuming the manic part of her bipolar is not severe, start with the antidepressant Wellbutrin. I say this because it has one of the mildest side effect profiles and also the least risk of inducing mania. ALL drugs, including Wellbutrin, Paxil, and even including mood stabilizers, can induce mania in some susceptible people. But Wellbutrin has a very low risk of doing that in comparison to other drugs. If insomnia or nervousness are troublesome side effects, a small dose of the antidepressant Remeron would prove very helpful in addition to the Wellbutrin.
Another strategy I would personally favor would be starting your daughter on Lamotrigine (Lamictal) or Gabapentin (Neurontin), and add an antidepressant later if it appears one is needed at that time.
Many arguments could be made in favor of, and against, Lithium as a first choice. Personally I don't like it as a first choice because it is a high-maintenance treatment with troublesome side effects. But to get some insight on how respected psychiatrists in this field deal with bipolar in this day and age, please check out the following places:
First, go to www.dr-bob.org/tips/ On the right hand side of the page go down and type Lamotrigine in the search field. Perform the search. It will provide a list of topics on the left side. Check out "Lamotrigine for Bipolar Disorder" first. Also check out "New Anticonvulsants in Bipolar Disorder", and "Choice of Mood Stabilizer".
Other good locations are www.psycom.net/depression.central.lamotrigine.html, and www.psycom.net/depression.central.gabapentin.html
I think it's very important to be comfortable with the doctor's prescription, to be well educated about the choices, and to have a doctor who will cooperate with you. It is a partnership in treatment. A team. Consider printing all the info you find at the locations I mentioned and bring them to the doctor. A second or third doctor is a good idea if the first isn't receptive to your research.
In summary, I do not like your doctor's prescription. In the end, it could be the treatment that works, but I absolutely do not think it is the place to start. Simpler is better. Try Wellbutrin first. Then consider Lamictal if needed. You came to the right place for research and I truly hope this will help steer you and your daughter in the right direction.
Posted by Noa on September 26, 1999, at 11:42:51
In reply to Re: lithium, posted by JohnL on September 26, 1999, at 8:24:13
John, I guess I am surprised that you think of weelbutrin as a good choice for someone with bipolar disorder, because I have always understood it to be one of the meds that causes nervousness, agitation, possibly hypomanic irritability.
Posted by JohnL on September 27, 1999, at 6:05:08
In reply to Re: Wellbutrin--question for John, posted by Noa on September 26, 1999, at 11:42:51
> John, I guess I am surprised that you think of weelbutrin as a good choice for someone with bipolar disorder, because I have always understood it to be one of the meds that causes nervousness, agitation, possibly hypomanic irritability.
I've read about its manic safety lots of places. I know it sounds ironic. The same for psychostimulants. As for Wellbutrin side effects, not everyone gets them. They are generalizations. Wellbutrin is a miracle to some. It is no more and no less effective than anything else. The only way to know if it is right is a personal trial. For all we know at this point, the Paxil in a particular person may cause more nervousness than Wellbutrin. Wellbutrin actually makes some people sleepy. Depends on the person. An anxiety type antidepressant like Remeron is a great adjunct to counter any insomnia or anxiety. Again though, I was just hesitant about Lithium as a first choice and assumed depression was the primary problem. I was pondering a more benign first-line treatment under the assumption that the bipolar condition was predominantly depressive with low risk of true mania. If this assumption is wrong, then a mood stabilizer like Lamictal would be a preferred first choice in my non-professional opinion.
Posted by dove on September 27, 1999, at 8:50:37
In reply to Re: Wellbutrin--question for John, posted by JohnL on September 27, 1999, at 6:05:08
My psych-doc mentioned that wellbutrin is the least likely of all antidepressants (including TCA's, MAOI's and SSRI's)to cause mania in bipolar's. He also said that you could combine wellbutrin, a psycho-stimulant and a mood stabilizer for an effective treatment of severe depression with a history of mild mania (i.e. hypomania.)My daughter went total manic on SSRI's opposed to Wellbutrin and BuSpar, which relieved the anxiousness and depression with no mania. She is very stable now on only BuSpar.
The Paxil was the absolute worst for the mania. She literaly bounced off the walls, spent a lot of time looking for high places to jump from, tried to make her own parachute so she could base-jump. I would think it would be better to use an antidepressant that doesn't have such a high profile for causing mania and take out the heavy-hitter (i.e. Lithium) for the mood stabilizer using something a little more friendly. I'm not a doc though, this is just my humble opinion.
Take care.
dove
Posted by jamie on September 27, 1999, at 16:53:17
In reply to Re: Wellbutrin--question for John, posted by dove on September 27, 1999, at 8:50:37
I totally agree. Any ssri is much more likely to cause mania than wellbutrin. I would never even think about lithium for my daughter. There are newer choices much more user-friendly. Can always go back to lithium if all else fails. But what a hell of a way to get started. Yikes!
Posted by bob on September 27, 1999, at 18:10:37
In reply to Re: Wellbutrin--dove and john, posted by jamie on September 27, 1999, at 16:53:17
Please know how much I appreciate your help. This has been a great beginning. At least, by following up on your information, I feel like I'm doing something to help my daughter. Once again, Thanks.
Posted by Adam on September 27, 1999, at 20:55:21
In reply to lithium, posted by bob on September 25, 1999, at 18:14:06
I agree, mostly, with what people have been saying here, but I thought I
would share a couple of thoughts...There are a lot of new treatments out there for BD, with fewer side effects,
etc., but lithium is generally very reliable and works quickly to control mania.
It may be that bob's daughter was experiencing a particularly bad manic
episode, and thought lithium is pretty old school, it's got the best track
record, I think. Perhaps when she's stabilized she could try something else.The use of Paxil in combo. is pretty odd, unless her depression is quite severe.
Paxil seems to be one of the least desireable SSRIs as far as side effects go,
but anecdotally it seems to be the most potent serotinergic next to chlomipramine,
which has particulary noxious side effects, but is also one of the best
antidepressants out there next to the MAOIs.I've heard of some people who are bipolar doing super well on lithium+nardil or
marplan. The side effects can be truly awful, but, again, it can be very
effective. Given what are perhaps a nearly infinite number of possible drug
combinations, you can spend a whole lot of time trying to find what works, and
suffer greatly in the interim. Many of the newer drugs look great on paper,
and their relatively mild side effects and adversity make them attractive, but
what I think many good pdocs know is that the older, dirtier interventions
sometimes simply work better, more reliably, and for more people than anything
else. If time is of the essence, such choices are not irrational ones.> My 20 year old daughter has been diagnoised with bipolar disorder, and has been given lithium and paxil. I am concerned with the rush to medication and the type. I'm new to this-any advice?
Posted by Noa on September 28, 1999, at 6:55:34
In reply to Re: lithium, posted by Adam on September 27, 1999, at 20:55:21
Thanks, guys, I learned some stuff I didn't know.
Posted by Sean on September 28, 1999, at 12:26:31
In reply to lithium, posted by bob on September 25, 1999, at 18:14:06
> My 20 year old daughter has been diagnoised with bipolar disorder, and has been given lithium and paxil. I am concerned with the rush to medication and the type. I'm new to this-any advice?
I agree with the SSRI causing mania comments. I
have had that response to Zoloft and Prozac.
Oddly, the literature is full of talk about how
SSRI's cause less mania than TCA's, but I think
this not based on empirical evidence, but rather,
the "permissive" theory of serotonin. The three
big SSRI's can cause major sleep problems which
is the kiss of death for bipolar spectrum
disorders as far as I'm concerned. Later,
Sean.
Posted by Arian on October 3, 2000, at 22:04:20
In reply to lithium, posted by bob on September 25, 1999, at 18:14:06
I was diagnosed at the age of 10 or 11 with Bipolar depression. I am 20 right now. I inherited this from my mom. At that time they tried many different medications but they just couldn't seem to find the one that would work for me. Then 2 years ago they started me on Lithium that was probably the best thing for me as I look back on it today. They have placed your daughter on the best medicine there is out there for bipolar disorder. I am in the proccess right now of getting another medication to work in conjunction with the lithium. I have been doing a little research the last few days and I have found out some really good info not only about the medication for bipolar but also just about depression itself. To get some more information try going to www.hotbot.com (this is a search engine) and type in depression medication and/or bipolar depression and you can find out a lot of information that might help you cope with the diagnoses of your daughter. I hope this helps.
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