Q:  Are There Any Treatment Options Left?

I've been diagnosed bipolar 1 with psychotic features.  I also rapid cycle and get mixed states.  Fun huh?  Complicating things, I have concurrent psych diagnoses of PTSD and Dissociative Disorder NOS and I also have physical issues with a movement disorder, PCOS and type 2 diabetes.  I know, this doesn't exactly make me easy to treat.

 At this point, we've tried (as far as I know) all the atypical antipsychotics except for clozaril.  When I've managed to take the medication two weeks at about 2 weeks all sorts of movement disorders (in addition to the one I normally have) show up and I have akathisia pretty bad.  This has happened every time.  Zyprexa, Abilify, Risperdal.  Additionally, Abilify was bad because it kept me manic or mixed and mildly psychotic and Risperdal did some  pretty nasty metabolic things.  I'm allergic to Geodon and Seroquel actually makes me more psychotic (these are the two that didn't make it to  two weeks).

I haven't fared much better with anticonvulsants.  Depakote (regular formula) sedates me horribly and causes very rapid weight gain.  Extended release Depakote makes me wired and very nauseaus.  I'm allergic to Tegretol.  I get the rash on Lamictal (which was too bad because it actually did seem to be working).  Trileptal makes my mood really unsettled and irritable.  Topamax didn't exactly do anything for moods, but it did leave me stupid.

There's got to be something worth trying.  I'm being threatened with clozaril by an ARNP who insists it's the "only option".  That med sounds horrid and with weight issues, diabetes and PCOS isn't it a bad idea?

What would you suggest?



Dear Dee -- 
Since it helped, we'll start with lamotrigine.  Some prescribers have re-tried lamotrigine in patients who got a rash the first time, in most cases using ultra-ultra slow dose increases. Those data are summarized on this page about lamotrigine rash details (see the update near the bottom of the page).  I am not advocating that you try that, and certainly not telling you it's safe to do so, but it's something to think about with your provider.  

Didn't see lithium on your list, but surely that's been tried too.  Sometimes low-dose lithium is workable when full-dose is not, when it's used as an add-on to other treatment (in many folks, I think that's the main role for lithium, and I use it a lot). Since you have rapid cycling and are female, you should also have a look at the UCLA approach, led by Dr. Whybrow, using very high-dose thyroid hormone. You'll find that approach described and linked on my Thyroid and Bipolar page (see High Dose Thyroid at the bottom of the page).  

As you may have seen, there are some data supporting verapamil as a mood stabilizer. That has an uncommon interaction with lithium you have to watch out for, if you were to try combining those two. Low-dose Depakote, maybe half of what you were taking, could be used in a mix-strategy. 

The PCOS might, just might, be part of the problem.  This is really a far-out idea, one I virtually never see in others's writings, but there is a tiny smidgin of data to suggest that treating that might be good for mood, summarized in this essay about Metabolic Syndrome and Mood (as you probably know, PCOS is a Metabolic Syndrome variation; the relationship between the two summarized in that link).  

There are quite few other possible "mood stabilizers" that have been discussed in one way or another in the mood literature. One more prominent one is Zonegran (zonisamide). I have one patient who gained a bunch of weight on Depakote who's been losing weight, after switching to Zonegran, while still on 15 mg of Zyprexa, which is an amazing declaration.  But you can't even consider that one if you have had allergic reactions to sulfa medications like Bactrim or Septra, and it has a rash risk for the same kind of problem as lamotrigine, so if you try it, you'd have to go ultra-slow on that one too.  

How about high-dose fish oil? There is some reason to think that might be a helpful part of a solution. In any case, a regular exercise program; and use of the concept behind "dark therapy"; as well as possibly other light modalities; and a good psychotherapy component using the bipolar-specific psychotherapies out there; -- all that would be an important part of the solution as well. 

After all that, before clozaril, you'd want to make sure you'd really done the exercise part, as having that up and running (so to speak) would be an important part of maximizing protection against getting diabetes from that one (i.e. on top of the heritage of previous medications).   But, if that's what it takes to get symptom control, it deserves to be on the list as well. 

And any medication that you can actually tolerate, that didn't work, if there were any; but which was tried with an antidepressant on board at the same time (was that the fate of lithium, perhaps? common story), should be a candidate for trying again without the antidepressant around. That might expand the list just a bit further.  

Good luck with all that. 

Dr. Phelps

Published November, 2005