Do the Dangers Outweigh the Benefits in this Treatment Plan?
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Q:  Do the Dangers Outweigh the Benefits in this Treatment Plan?

Dr. Phelps,

 Hopefully you will have a chance to give me an opinion based on a nutshell  history over the past 5 years. I have been struggling with severe depression  and generalized anxiety disorder (mood cycling) and was recently diagnosed  (after many psychiatrists, therapies and meds) as Bipolar II (fits  symptoms  listed in your site to the "T"). Have tried Paxil  (terrible withdrawal), Celexa, Serzone, Xanax, Effexor, amyltriptoline,  imiprimine, Wellbutrin, Depakote (had liver and diarrhea problems),  Serequel, Topamax, Lexapro (last 4 simultaneously), Lithium (extended  release but had kidney and TSH problems), Neurontin, Klonopin, from what I can remember off hand (several of these at high doses) and nothing worked beyond ~2 mths (temporary improvement may have been mood cycling, not  the  medications). I am currently ramping up on Lamactil VERY slowly (currently  at 75 mg), Valium (helps anxiety), I have hyperlipedimia (Triglycerides in 1000-2000 range), high cholesterol, (all eliminating Zyprexa) and have experienced significant weight gain. Liver enzymes are also high (not on statin, ect). I have started an exercise regimen (does help  temporarily), diet, nutritional supplements for the last month but nothing has helped  the depression (severe) and anxiety(severe) cycling.

 My doctor is recommending we try dextroamphetamine (5-10mg/day, we are  just  starting on a minimum dose to determine value, dosage & effectiveness),  valium to counteract the anxiety and continuing Lamactil, but I have  fear of  amphetamine, Valium and dependence issues. Have you ever heard or had  success with this angle of treatment and do the dangers outweigh the  benefits? I seem to be running out of options!!!!!!   

Dear Michael -- 
I'll just add some medications to consider among these options, as to comment directly on your doctor's plans without knowing you and your history better would be inappropriate.  I will in the process refer you to a very lengthy but
superb interview with Dr. Husseini Manji, one the world's bipolar experts, and the expert on what causes bipolar disorder, in which he comments on amphetamine approaches in bipolar patients.  He is so well informed, I hope you'll enjoy the whole thing as well as those remarks on stimulants. 

As for other medications to consider:  there is Trileptal (oxcarbazepine), sort of a carbamazepine lite, but less likely to bother your liver than carbamazepine itself; and certainly fish oil is worth looking at although it doesn't have enough "oomph" in my experience, but might be useful as an add-on; and I have finally been able to get a few patients going on Zonegran (zonisamide), as an alernative to Depakote that actually seems associated with weight loss, rather like Topomax, but perhaps with less cognitive impairment, although there is a rash risk here as well and you'd have to wait until lamotrigine was either clearly in place and tolerable, probably several months, before adding Zonegran. But from the sound of things that might be worth looking into, as a Depakote-like effect to replace the Valium-group, should you end up havig to use those in the short run (although I'm not sure I'd even start, given that Klonopin only worked for a while, and that's about the best in this role, in my experience, for not developing tolerance and becoming merely something useless one has to try to taper off). Good luck with all that. You'll find some more info' on all those choices in the table on the Mood Stabilizers page on my website. 

Dr. Phelps

Published April 2005


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