Expert: Ivan Goldberg, M.D. - 8/10/2011

Question
I certainly fall into the category of treatment-resistant. I have been on pretty much every medication out there and some provide temporary relief but never for an extended period of time. Right now I'm on 400mg Lamictal (have been for about 6 years), 60mg Prozac, Klonopin (0.25 am, 0.5 pm). Sometimes I use an additional 0.25 of Klonopin if I need it.  My mood fluctuates at the drop of a hat. My Dr. diagnosed me as bipolar and said he would say 2 except that I was hospitalized once. Eventually he put me into the NOS category. The past week or so I feel like I'm losing my mind. When I'm at home all I do is sleep or eat. When I'm at work (like now) I am so irritable that I want to tell everyone where to go. I'm slamming doors, the phone, and I am extremely close to just walking out the door.  At the same time I am very preoccupied with death and suicide. I don't have a plan and I am not actively suicidal; it's just an "escape hatch" that sits in the back of my mind. The past 2 days I have not been overly talkative; in fact, I've isolated as much as possible so I don't lash out at anyone.  I am typing this furiously but in 30 min I'm going to go home for lunch and take a nap. I started wondering if this was some type of hypomanic episode but it doesn't seem to fit the criteria. I seem to fall into a depressive state more than a manic state, but I've never had this kind of irritability with depression. My Dr. has pretty much told me that we are keeping me on medication not so much to improve symptoms but to decrease the risk of relapse (ha!) if I stop taking them. He thinks I may not be doing as well as I'd like, but I might do far worse with no meds. Where do I go from here? I know you can only give me advice and I'm not looking for a clear-cut plan of action. But I feel like I'm going to lose my job and my mind...and actually I don't particularly care. I would rather lose my job so everyone would leave me alone. I'm not going to proofread this because I don't have the patience so I apologize for any errors. I've had a hard time concentrating on things and I have made 3 mistakes at work in 3 days, which is more than I've made in probably 6 years. If you'd like to know I am a 34 year old female. Thank you so much for your time.

Answer
Hi Jennifer . . .

Many people with bipolar disorder continue to have mood swings despite treatment. This is often because the treatment is not intense enough to control the illness, or because part of the treatment is interfering with the success of the total regimen.

People with incompletely controlled bipolar disorder often need complex combinations of mood stabilizers. Lithium + Lamictal + (Tegretol and/or valproate) is one such combination.

Also, some people with bipolar disorder have more irritability and cycling od they take ANY antidepressant. So while it may seem counterintuitive,stopping all antidepressants is a strategy that should be tried at some point.

You may want to read Robert Post's book on this topic. See:
http://www.amazon.com/Treatment-Bipolar-Illness-Casebook-Clinicians/dp/039370537

Best regards . . .

Ivan
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