If Lithium Doesn't Work as a Monotherapy?If Sleepy on Current Regime, then Overmedicated?Should I Try Provigil?
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Q:  3 Q's: If Lithium Doesn't Work as a Monotherapy?
                If Sleepy on Current Regimen, then Overmedicated?
                Should I Try Provigil?

I am a resident physician with bipolar disorder. I have definitely had my share of mixed and depressive episodes, but only very brief euphoric episodes that are linked to my taking antidepressants (even once when I was on a mood stabilizer) or are linked now to my stopping medications. I am officially carrying the Bipolar Disorder Type I label.

Like everyone, I have been on many different medicines, and I am currently doing well on Lithium and Depakote.  If I stop Lithium, I start to act manic. If I stop Depakote, I get depressed. So I take them both and that is fine with me, except that I am SO TIRED on Depakote.  For me, an intern with a 80-hr work week, in a job that is mentally demanding, I cannot be falling asleep every day at 3pm, even after 10 hours of solid sleep. Even if it keeps me happy, if it costs me my career, it is the same as it not working.

I have three questions:
1. Someone (not my doctor) told me if lithium doesn't work for all my symptoms as monotherapy, then lithium isn't for me. This doesn't sound right.
2. I was also told that if I am sleepy on my current regimen, then I am over medicated by definition. However, I have tried a lower dose of Depakote and I get the blues...within days.
3. What about Provigil? I just got a prescription and I am eager to try it. Is this a solution, if it works (albeit an expensive one!!)? I found one Canadian letter to the editor about Provigil for depakote-induced sedation. They seemed to think it an okay solution.

Should I try the Provigil...or is it back to the drawing board for me?

Thanks in advance.

Dear Dr. F' --
Some thoughts to take along to discussions with your prescribing doc': 
1. If lithium doesn't work as monotherapy, it's not good at all. After suppressing some spluttering and near-expletives, may I simply respond: "wrong", in the opinion of nearly every mood expert I've ever read (can't really think of a single exception at this point), nor in mine either. Indeed, our whole strategy is generally based on the opposite principle: if you get some clear benefit from one agent, keep it, add another; if the latter works great, later try tapering the first one to see if the second can carry the ball all by itself.  This is utterly routine, and reflects your experience so far as well. 

2. If sleepy on current regimen, this is "overmedication". Oversimplified and not adding information to add the label "overmedication"; simpler to say "sleepy", which is a problem enough in itself, for anyone, let alone you in your situation. Definitely needs to be addressed. As you've surely checked out, one wonders if when the Depakote it turned down, and the depression is worsening -- is the sleepiness reduced? If it was, in the face of increasing depression which often is accompanied by low energy, that would strongly implicate Depakote as the "cause" of the sleepiness all right; on the other hand, there are lots of causes of daytime sleepiness including sleep apnea -- and being a resident!  So we'd also want to make sure those other causes were thoroughly investigated (particularly thyroid status, for example). 

3. What about Provigil? 
Indirect solution at best; consider if more direct and long-term solutions not available, not practical to try right now, or not working. Given that list of priorities, I'd think Provigil would come along pretty late amongst the things to try. It would be different if we didn't have reason to think that Provigil could be "destabilizing". Although there is much more concern right now about antidepressants' risk of destabilizing things, and even that is quite controversial, there are plenty of experts who worry similarly about stimulants, as you know. 

Meanwhile, though you'll probably have tried the Provigil by the time you read this, it might be daunting to know that amongst the handful of folks in whom I've tried this strategy, not a single one is still going on it.  Worked great at first. Didn't stick. But, except for the risk angle, which is pretty difficult to quantify given the lack of data and the wide variety of expert opinion, a logical option. 

Good luck working out the work/life/bipolar balance. Tricky enough without that last one.  

Dr. Phelps

Published Sept., 2006


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