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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 4 of 4. This is the beginning of the thread.
Posted by Jota on September 13, 2003, at 17:35:16
First, a bunch of background.
I'm currently taking a heady cocktail of medicines targeting bipolar II depression: Lexapro 40mg, Straterra 80mg, Wellbutrin 300mg, Carbatrol 800 mg, Lamactil 300 mg (Carbatrol approximately halves effective dose), T3 25mg, Folate, Fish Oil, and the testosterone supplement AndroGel 10g.
I arrived at the preceding after a steep breakthrough depression this past winter. Previously I had been on Paxil 80mg plus Wellbutrin 200mg for about 18 months; and before that, Effexor 150mg rising to 300mg over the course of 5 years plus Wellbutrin 150 mg.
(All along, I have also put a lot of effort into the "psychosocial" dimension, e.g., psychotherapy, meditation, yoga, etc.)
I'm feeling way better than this winter: I'm back to work and being highly productive. Exercising several times a week; active social life. And my sleep is approximately normal: no more early-morning wakening. Sexual function is hard to judge since I'm not dating anyone at the moment. (Also making it difficult to judge is that I've been on SSRI's for most of the time since I became sexually active.)
On the other hand, I'm still having some night sweats; much less than this winter/early spring when it was 2 or 3 every night. now its more like 1 several times a week. Sometimes my sleep seems "shallow" as does my meditation. I'm still getting mild headaches several times a week (lesser versions of what I would describe as "head nausea", i.e., a feeling akin to nausea except that it originates from the head). I'm having some trouble with word retrieval. Possibly other memory and concentration deficits, though it's not obvious to me to what extent and certainly much less than this past fall, winter and spring. Also frequent mild sadness, often with a few tears. Lastly, I feel like I'm having to work harder to keep my mood up.
The testosterone supplement is the most recently added medicine. It has definitely helped restore some libido, though not as much as I would like. And the dissipation of the headaches more or less corresponded to when I started on the testosterone. The 10 g AndroGel I'm taking is the maximum recommended dose. Nevertheless, my total and free testosterone levels are just barely within the "normal" range. This is approximately 2 standard deviations below the mean associated with 10g AndroGel. For the sake of completeness, I will also mention that my sperm count is extremely low.
In addition to my regular psychiatrist, I've also been consulting with a top researcher at NIMH and with a Mass-General affiliated psychiatrist whom I saw for many years when I lived in Boston.
As I would judge that I'm still mildly depressed, I'm not satisfied with my current medicine regimen. But it's not clear what to do next.
Possibility 1: push up on the Testosterone. The Carbatrol interacts with the testosterone. As it has been explained to me, one possibility is that the blood level will read much lower than the relevant availability of testosterone. Another possibility is that the Carbatrol indeed is lowering the relevant testosterone level. So the effective supplement of testosterone I am getting is less than the nominal 10g. (Similarly, lamactil dosages need to be doubled when taking Carbatrol).
Possibility 2: taper down on the Carbatrol, possibly replacing with Trileptal. Trileptal is chemically quite similar to Carbatrol, but it doesn't induce liver enzymes and therefore has much fewer interactions with other medicines. But the NIMH researcher recommends against this saying that it's not yet clear whether Trileptal has as good antidepressant properties as Carbatrol. (I can't find anything on the web on carbamazepine's antidepressant properties; but whwn I was going through experimentation almost one year ago, my experience was that it did; also, the NIMH researcher is highly respected and follows many not-yet-published research projects).
Possibility 3: push up on the Carbatrol (my blood levels show it to be below the therapeutic range). I went up to 800 from 600 because I was getting some hypomanic mood spikes (more on the sluggish/racing thoughts dimension than on the happiness/sadness dimension). By increasing the dosage, I can see whether my mood further improves, stays the same, or goes down. If the latter, I could taper down and possibly even eliminate the Carbatrol. Analogously, during the first severe depression I had, 10 years ago, we pushed up Lithium as an augmenter and my mood plunged; we then quickly tapered off of it and my mood immediately bounced back. (Hence my resolve to avoid lithium.)
Possibility 4: add an atypical tranquilizer (probably Geodon or Abilify). My regular psychiatrist is very skeptical of doing this. But the NIMH guy is adamant (in a non pushy way) that the atypicals have excellent antidepressant properties and that I should turn to them before, for instance, trying adding or substituting in a different antidepressant (e.g., Zoloft, Remeron, or Cymbalta, if it ever is approved). And my old psychiatrist, whom I deeply respect, says that the Mass General researchers are extremely enthusiastic about using Geodon as an antidepressant, either for augmentation or even stand alone. Moreover he deeply respects the NIMH researcher, whom he feels is one of the very very best psychopharmacologists (I would also add that the NIMH guy is really nice)
I would definitely welcome people's thoughts on these another possibilities.
Jota
Posted by Terry on September 13, 2003, at 23:35:17
In reply to BP2 Polypharmacy Adjustment: Suggestions?, posted by Jota on September 13, 2003, at 17:35:16
I was on Geodon right after it came out. I went up to 120mg per day. After a while it became much to activating and I started to have severe anxiety. The Geodon done nothing for my depression so I was having severe depression with severe anxiety. I tried adding in Klonipin for the anxiety but it made the depression even worse. Then I had to come off the Geodon and had the most horrible withdrawals of any med that I've ever been on. I thought I had been through hell with depression before but nothing that I've ever been through compared to the hell that I went through then - Nothing.
My advice, if they talk you into taking Geodon then take a very minimal dose like 20mg/day. Better yet try 2.5mg of Zyprexa - in my opinion the best atypical on the market for BP2 as far as atypical AP's go. I've tried them all. Usually I get the FLAT affect without any relief of cycling. Abilify was the worst. Zy is the only one that works for me. It usually doesn't take much of an atypical for BP2. Remember one thing, Doctors think they know a lot but they don't have to go through the world of sh_t when something goes bad.
Some of the anti-epilecptics can make depression worse. Some that have affected me negitively are Tegretol, and Topamax.
Sometimes for true BP2 patients, high doses of antidepressants can make depression worse. In these cases it is better to cut way back on the AD and augment with whatever mood stablizer is best for them. For me the best mood stablizer is a low dose of Zyprexa. I'm on 2.5mg of Zyprexa and 50mg of Clomipramine, that's a small dose of a tricyclic anti-depressant. This for me is the best combination that I've found in twenty years of trying. It does have its side affect drawbacks though.
Terry
Posted by Jota on September 14, 2003, at 9:33:05
In reply to Re: BP2 Polypharmacy Adjustment: Suggestions? » Jota, posted by Terry on September 13, 2003, at 23:35:17
Terry,
Thank you for sharing your experience.
The NIMH consultant's recommended dose was 40mg Geodon, possibly augmented by Seroquel. Or else 15mg Abilify. With Zyprexa, what was your experience with weight gain?
As I was coming down from 120mg of paxil to switch to Lexapro (while taking 200mg Wellbutrin and 600mg Carbatrol), my mood seemed to get quite good at around 40mg. In retrospect, I should have stopped there. Instead, I continued down to zero. My main withdrawal symptoms were irritable bowel syndrome and a sudden dislike of many of my favorite foods (especially grains, cereal, some fruits). Rather then start lexapro, I went back up to 20mg paxil. A few weeks later, my mood/sleep/cognition plummeted.
More recently, I tried lowering the Lexapro from 40mg to 35mg and after about 10 days, my mood turned sharply down. So as much as I don't like taking such a high dosage of Lexapro, I'm even more scared of lowering it.
Jota
Posted by lesliekay on September 15, 2003, at 4:17:52
In reply to BP2 Polypharmacy Adjustment: Suggestions?, posted by Jota on September 13, 2003, at 17:35:16
If it were me...I would get off the lexapro, raise the lamictal, start the abilify (MY WONDER DRUG), start the zyprexa(RUNNER UP #2)...lamictal is the most potent mood stabilizer when it comes to depression. that is what I would do.
This is the end of the thread.
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