Expert: Ivan Goldberg, M.D. - 7/2/2008

Question
QUESTION: For the first time in 20 years my mood swings and psychotic symptoms are resolved.  I am taking 1500 mg depakote, 600 mg lithium, and 400 mg seoquel. However, I am miserable.  The side effects, including cognitive impairment, are unbearable.  I am a composer, and have been completely uncreative, dulled betond belief.  In the past, I have taken lamictal with minimum side effects.  However, my mood swings continued.  In your experience, could I lower the depakote and add lamictal as a second mood stabilizer?  Could I drop the lithium (I have no idea if it is working)?  Could I lower the seroquel (it seems to work with the psychotic symptoms, but it has sedative side effects)?  Could you suggest numbers, or any other mix?  I would very much appreciate any help you could give me.

ANSWER: Hi, Marjorie . . .

I can answer in the most general terms but cannot suggest doses or specific strategies to you.

People with  schizo-affective disorder often require a "cocktail" of medications generally including an antipsychotic medication and one or more mood stabilizers. The doses of all mediations should be the minimum necessary to keep the symptoms under reasonable good control. Too many psychopharmacologists forget he old saying, "The perfect is the enemy of the good."

While I occasionally prescribe it, Seroquel is not one of my favorite antipsychotic medications because it is so damn sedating. Geodon and Abilify often do an excellent job of controlling the psychotic aspects of the illness without inducing crippling sedation. The combination of lithium and Lamictal is often very useful in controlling the mood aspects of the illness.

Best regards . . .

Ivan
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---------- FOLLOW-UP ----------

QUESTION: Thank you for your reply.  However, it was a little too general to be useful.  

First, seroquel was prescribed by my neurologist, since I had developed TD as a result of high doses of zyprexa.  Seroquel and clozeril are apparently are the best in that case, although seroquel is, unfortunately, sedating.  

I had specifically asked you about the efficacy of combining lamictal and depakote, or even the possibility. Could you please comment.  Also, in your experience, are the depakote side effects ever dose related?

Sincerelky,
Marjorie

Answer
Hi Marjorie . . .

I am sorry my answer was so nonspecific as to be uninformative. But I am prohibited form giving specific medical advise.

The combination Depakote and Lamictal is a useful one although many psychiatrists are unwilling to prescribe it because Depakote can double the blood level of Lamictal. I have frequently used the combination to treat people with hard-to-treat bipolar states including schizo-affective disorder and mixed bipolar states. For many people the most effective blood level of Depakote is about 110 mcg/ml a level that is above the most often utilized level.

As you suspect the side-effects of Depakote are dose-related.

Best regards . . .

Ivan
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