Expert: Ivan Goldberg, M.D. - 12/8/2010

Question
Hi Dr. Goldberg:

I recognize that it must be very difficult to give advice with so little information. However, I do appreciate your patience and willingness to help those of us who feel like we've fallen through the cracks of the DSM IV.

I am a 31 yr old male, with a long history of depression, mixed with symptoms along the lines of GAD/OCD/ADD. I was diagnosed rapid cycling, bipolar spectrum, after four separate antidepressants destabilized my mood and make me suicidal. And yes, there is a history of mood disorders in my family.

After years of activey seeking treatment, and many consults with specialists, I have still not responded to medications. Lamotrigine (200) has slowed down the cycling somewhat but has not helped with the agitation, difficulty concentrating and irritability. I find the antipsychotics far too sedating. I tried Lithium up to 750 mg before I began experiencing tremors and stopped (never had a blood test). Divalproex made me gain weight - even at extremely low doses (125 mg). I am now trying Trileptal. It has only been a week or so but I have not experienced any relief at 1200 mg.

I am exhausted. My pdoc is at a loss. Your thoughts on the following would be most appreciated:

1. I know you have suggested long term trials of mood stabilizer cocktails. How long would you suggest I try Lamotrigine (200)-Trileptal (1200) before adjusting the dose or adding/dropping a medication?

2. Is there any value in trying Tegretol if I have already tried Trileptal?

2. I recognize that I may not have given Lithium a fair trial. But would it be wise to try again given that Li is not generally indicated for rapid cycling/mixed states and that I'm not sucidal?

4. If the traditional mood stabilizers are not effective, would you try to target the cycling using Keppra or Thyroid Medication or the anxiety using Neurontin, Lyrica or one of the Benzos?  

Answer
1. I know you have suggested long term trials of mood stabilizer cocktails. How long would you suggest I try Lamotrigine (200)-Trileptal (1200) before adjusting the dose or adding/dropping a medication?

WHEN SEEING A PATIENT WITH A HISTORY SUCH AS THE ONE ABOVE THE FIRST THING i DO IS GET 12-HOUR BLOOD LEVELS OF LAMOTRIGINE AND TRILEPTAL AND ADJUST THE DOSES TO BEING THE BLOOD LEVEL WITHIN THE THERAPEUTIC RANGE. AN 8-12 WEEK TRIAL IS THEN INDICATED. PATIENTS AND THEIR DOCTORS OFTEN EXPECT RESULTS TOO SOON.

2. Is there any value in trying Tegretol if I have already tried Trileptal?

i HAVE SEEN A FEW PEOPLE WHO HAVE DONE WELL ON TEGRETOL AFTER FAILING AN ADEQUATE TRIAL OF tRILEPTAL.

2. I recognize that I may not have given Lithium a fair trial. But would it be wise to try again given that Li is not generally indicated for rapid cycling/mixed states and that I'm not suicidal?

THE COMBINATION OF LITHIUM AND LAMOTRIGINE IS ONE OF THE BEST TREATMENTS WE HAVE FOR PEOPLE WITH RAPIDLY CYCLING BIPOLAR DISORDER. aDDING LITHIUM TO YOUR CURRENT MIXTURE IF MEDS SHOULD BE CONSIDERED. THE DOSE SHOULD BE SLOWLY INCREASED TOT 600 MG/DAY, A 12-HOUR BLOOD LEVEL OBTAINED, AND IF POSSIBLE THE DOSE INCREASED SLOWLY TO ACHIEVE A BLOOD LEVEL OF AT LEAST 0.6 mEQ/L.


4. If the traditional mood stabilizers are not effective, would you try to target the cycling using Keppra or Thyroid Medication or the anxiety using Neurontin, Lyrica or one of the Benzos?  

KEPPRA OR HYPERMETABOLIC DOSES OF THYROID ARE THINGS THAT CAN BE UTILIZED TO SLOW DOWN OR STOP MOOD CYCLING. BENZODIAZEPINES OR LOW DOSE ANTIPSYCHOTICS REDUCE ANXIETY IN SOME PEOPLE WITH BIPOLAR DISORDER. i HAVE USED CLOZAPINE TO STOP BIPOLAR RAPID CYCLING WHEN NOTHING ELSE HAS WORKED.

Best regards . . .

Ivan
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%