Expert: Ivan Goldberg, M.D. - 2/13/2006

Question
For a very long time I've been cycling on basically a monthly basis on average.  For the last year I've been on so many different medications, it's hard for me to remember them all.  My new psychiatrist has prescribed 300 mg. of trileptal twice daily, various dosages of serequel at night depending on the amount of sleep I'm getting and 1200 mg of Neurontin daily.  He seems confident that I will stablize with this.  I am not so confident as I've had two minor episodes in the last two months.  How long would you continue with this treatment before deciding it isn't working?  Is there ordinarily a period of time after the correct treatment is found that one would continue to have symptoms?

Thanks,

Dallas

Answer
Hi  . . .

I'd try it for about 2 months before bringing the following abstracts to your doctor';s attention:

1: Eur Psychiatry. 2005 Mar;20(2):92-5.

New data on the use of lithium, divalproate, and lamotrigine in rapid cycling
bipolar disorder.

Calabrese JR, Rapport DJ, Youngstrom EA, Jackson K, Bilali S, Findling RL.

Case Western Reserve University School of Medicine, University Hospitals of
Cleveland, 11400 Euclid Avenue, Suite 200, Cleveland, OH 44106, USA.
Joseph.Calabrese@uhhs.com

The rapid cycling variant of bipolar disorder is defined as the occurrence of
four periods of either manic or depressive illness within 12 months. Patients
suffering from this variant of bipolar disorder have an unmet need for effective
treatment. This review examines two major studies in an attempt to update
understanding of the current therapies available to treat rapid cycling
patients. The first trial compares lamotrigine versus placebo in 182 patients
studied for 6 months. The second is a recently completed, 20-month trial
comparing divalproate and lithium in 60 patients. Both trials had a
double-blind, randomized parallel-group design. The data from the latter study
indicate that there are no large differences in efficacy between lithium and
divalproate in the long-term treatment of rapid cycling bipolar disorder. In
addition, lamotrigine has the potential to complement the spectrum of lithium
and divalproate through its greater efficacy for depressive symptoms.

Publication Types:
   Review

PMID: 15797691 [PubMed - indexed for MEDLINE]

2: Bipolar Disord. 2004 Dec;6(6):523-9.

Rapid cycling bipolar disorder: historical overview and focus on emerging
treatments.

Mackin P, Young AH.

School of Neurology, Neurobiology and Psychiatry, Department of Psychiatry,
University of Newcastle upon Tyne, Royal Victoria Infirmary, Newcastle upon
Tyne, UK. paul.mackin@ncl.ac.uk

OBJECTIVE: Rapid cycling bipolar disorder presents a significant challenge with
respect to treatment. The cyclical nature of bipolar disorder has been well
recognised for over a century, and following Dunner and Fieve's landmark paper
in 1974, investigators have increasingly turned their attention to issues such
as the definition of rapid cycling, demographic characterisation, treatment
response and pharmacologic intervention. METHODS: A literature search using
Medline was performed, and selected articles which consider important
developments in the definition, demographics and course of rapid cycling are
reviewed. In addition, a systematic review of the literature published during
the past 5 years (1999-2004) relating to treatment was conducted. RESULTS:
Relevant articles are reviewed. CONCLUSIONS: This review highlights the
important developments in our understanding of rapid cycling bipolar disorder,
and focuses particularly on the recent literature regarding treatment. Blackwell
Munksgaard, 2004

Publication Types:
   Review

PMID: 15541068 [PubMed - indexed for MEDLINE]

3: Bipolar Disord. 2004 Oct;6(5):435-9.

Lamotrigine therapy in treatment-resistant menstrually-related rapid cycling
bipolar disorder: a case report.

Becker OV, Rasgon NL, Marsh WK, Glenn T, Ketter TA.

Department of Psychiatry and Behavioral Sciences, Stanford University School of
Medicine, Stanford, CA 94305-5723, USA.

AIMS/OBJECTIVES: To evaluate lamotrigine in a woman with a 30-year history of
treatment-resistant menstrually-entrained rapid cycling bipolar II disorder with
follicular phase depressive and luteal phase mood elevation symptoms. METHODS:
Lamotrigine was started at 5 mg/day and gradually increased up to 300 mg/day,
while venlafaxine was tapered gradually and discontinued, and divalproex sodium
500 mg/day and levothyroxine 175 mcgm/day were continued. Daily self-reported
mood ratings were obtained from the patient, using ChronoRecord software.
RESULTS: As lamotrigine was increased gradually, mood cycle amplitude
attenuated. There was notable decrease in the severity and duration of
depressive symptoms specifically during the follicular phase of the menstrual
cycle. At the time of submission of this paper, the subject had remained
euthymic for a total of 12 months. CONCLUSION: This case suggests the potential
utility of lamotrigine in treatment-resistant menstrually-related rapid cycling
bipolar disorder, and raises the possibility that lamotrigine might be able to
treat pathological entrainment of mood with the menstrual cycle. Both of these
issues merit systematic assessment.

Publication Types:
   Case Reports

PMID: 15383138 [PubMed - indexed for MEDLINE]

Best regards . . .

Ivan
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