Q:  Medications Aren't Stopping My Rapid Cycling

 I am a rapid cycler and my medicine (Depakote 750mg, Neurontin 300mg, Serzone 3 tabs, Klonopin 1 1/2 mg) are not keeping me from cycling. When I have an 'episode' I end up violent and usually have to be restrained from hurting myself. I had one a few weeks ago, and still have bruises as well as my boyfriend. I talked to my psych. Dr. and he said that I will continue to have them for the rest of my life and I just needed to cope. I called him yesterday to tell him about anxiety attacks I am having at bedtime and he told me to wait until my next appointment, 2 weeks from now. What do you suggest? Do I need Lithium? I have recently gone back to work I have 12 hour days, from the time I leave the house until I get home. My job is relaxing and so is the commute, but I am still falling apart regularly and thinking of suicide often, which my Dr. just sort of let slip by. I am just in need of some suggestions. Thank you for your time.

Dear Ms. B' -- 
Hear are some ideas to talk about with your doctor.  You could just say:  I want to get on more mood stabilizer, I think it would help me.  Lithium would be a reasonable choice of something to add.  If you increase your Depakote, you could get an appetite increase that signals weight gain (if you don't get that, you can try that too).  Serzone may not help as much as a mood stabilizer overall; you could ask about trading that in for a mood stabilizer.  

Neurontin has not been shown to be a mood stabilizer in randomized trials, and can act too much like an antidepressant and thus make things more unstable.  You could ask about trading that one in too (I don't use it in bipolar disorder except as an antidepressant with antianxiety properties). 

Basically you're on a less-than-usual-low-dose dose of Depakote, although that could be smart as even low-dose can cause weight gain, and no other known mood stabilizer (Klonopin is probably helping but isn't really regarded as a "mood stabilizer" by most).  That means you have lots of alternatives and things to try.  Trileptal, for example, is making trials of carbamazepine less scary nowadays.  

Finally, some of my patients have responded to naltrexone (aka Revia, used to decrease alcohol craving), which block opiate receptors and for some reason seems to decrease self-harm behaviors in some folks (although usually just getting symptoms well controlled is enough, so I usually just keep adding mood stabilizers until either there are no remaining target symptoms, or some other approach looks more sensible -- e.g. an antipsychotic if there are symptoms that look on the edge of reality, like paranoia).  So that's one more thing to consider as you go. 

Dr. Phelps

Published April, 2001