Expert: Ivan Goldberg, M.D. - 6/5/2010

Question
QUESTION: Greetings. It was back in 2002 that I acted on your cryptic advice to increase Lamictal to upto 600 mg before deciding it didn't work for me. It worked at 400 mg. Against all orthodox advice. Two psychs had told me they had run out of ideas. I was then also taking Effexor 75 and Lithium about 500.

Today I am taking Lamictal 500 (my psych increased it during a difficult period), Effexor 75 and Lithium just 100. My kidneys were stressed with Lithium so I had to reduce in a hurry. It didn't have any adverse effects.

Since exactly a year ago, despite all the med I developed depression again, as well as attendant physical symptoms such as generalized pain, buzzing in legs, etc. Also, I started to have pain AS A RESULT OF sex, swimming, exercising, other supposedly good activities. So the situation is getting quite confusing.

Several months back, you said I need (1) intensive psychotherapy, and (2) removal of anti-depressants and managing mood with Lamictal, Lithium, other stabilizers. I went through pretty intensive therapy sessions, but could identify no psychological reasons for such reaction to good activities. I think my problem is physical.

Sorry this is getting long. I think my options are:

1. Increase Lamictal from 500 to 600. But this is getting a bit high, no? However, I feel this has the greatest chance of success, if other remedies fail, and if this dosage level is still manageable.

2. Increase Effexor to 112.5 or 150.

(I flirted with Cymbalta for about 8 months then switched back to Effexor as it had made my hair fall).

3. I can't increase Lithium as my kidneys start protesting vigorously.

There is vey little advice available here beyond what the text book says.

Best regards,
Ahmad Gilani

ANSWER: Hi Ahmad . . .

I can no longer give anything that approaches medical advice.

T think that both you and your psychiatrist should read Robert Post's book on the treatment of individuals with bipolar disorder. You can learn more about the book at:

http://www.amazon.com/Treatment-Bipolar-Illness-Casebook-Clinicians/dp/039370537

Best regards . . .

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

QUESTION: I fully appreciate your comment and position. May I then ask a specific question? Are there patients taking 600 mg or higher, for long periods of time? Any issues which resulted from this? Please realize psychiatrists don't have this kind of experience of treating hard-to-treat cases.

Much thanks,
Ahmad

Answer
Hi, Ahmad . . .

I have many patients who are taking 600 mg of Lamictal a day, some who are taking 800 mg a day, and a few who are taking 1,000. I regulate Lamictal based on blood tests done 12-hours after the last dose and aim for blood levels of between 6 and 18 ng/ml.

Best regards . . .

Ivan
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