Q:  Cycling & Internal Voice Monologue

I have (obvious now) had BP disorder my whole life but only diagnosed within the last year.  I currently take 200 mg Topamax, 150 mg Effexor, 40 mg Geodeon and sometimes an "extra" 37.5 mg of Effexor at lunch.  I am a mother to a 4 year old and to 2 year old triplets and am married, happily.  I experience mixed states and rapid cycling.  Lately I have been completely off-the wall thoughts that I am processing as totally rational then getting into "fights" with myself for a good hour or two trying to decide which "side" is going to "win".  Like, if the information is right or wrong.  I know the the thought is totally screwy (an example, my husnad is into telescopes big time, I wanted him to stop using them so the "people" of Saturn wouldn't be so encouraged to contact us).  This is pure lunacy.  I am highly educated and highly medicated.  This has NEVER happened before.  I've always had the "internal voice monologue" but never one that was totally and utteraly crackers.

Please advise.
 

Dear Jenn -- 
You can ask your doc's about whether there might be a different medication regimen that would be better, more able to control the cycling and the thoughts.  I think most mood experts agree that the key to bipolar control is to rely on mood stabilizers and watch out for antidepressants, at least if when on them a person is cycling and having mixed states.  In that case it looks to me as though most mood experts think it's a good idea to address the mixed states and rapid cycling by gradually tapering off the antidepressants -- but don't do this on your own, it needs to be an agreed-upon plan with your doctor; and there might be a good reason in your symptoms or your history for keeping the Effexor where it is, for all I know based on your paragraph. 

Geodon may be a pretty good antimanic, that's not fully clear yet.  It's less clear whether this medication can prevent cycling, i.e. keep a person well.  And Topomax has not been shown to be a mood stabilizer at all, though it can be pretty amazing for weight gain control.  So you can ask your doctors for the logic that leads to this current medication regimen; for the plan on where to go from here if you're not doing well (e.g. see if that includes consideration of tapering off the Effexor); and if you don't get a pretty clear straight answer on why the doc' is not using your current approach (e.g. compared to the APA Consensus guidelines), then you might just get a second opinion about treatment options and see how that sounds.  There are a lot of mood stabilizer options; here's a current list including a table of them listed by the evidence supporting their use. 

Dr. Phelps

Published September, 2004