Q: BP2 and GAD, Concerned about Treatment Plan
I was diagnosed in spring 2008 with BP (cyclothymia bordering on BP2).
Previously, in 1994, I was diagnosed with GAD. On your site, you describe an
overlap between BP2 and GAD. My symptoms fit that description exactly. (What a
I'm on 600mg/day quetiapine and 150mg/day venlafaxine. The latter
dates back to my diagnosis with GAD, before my diagnosis with BP. I don't think
the venlafaxine is helping with the anxiety any more; i get a lot of
breakthrough waves of anxiety. I also find it makes me a bit too high. And I'm
worried about the long-term risk of this.
I'd like to stay on the quetiapine but replace the venlafaxine with
something else that will tackle my anxiety more effectively and with less risk.
What do you recommend I should discuss with my psychiatrist, please? I've read
positive reports in this respect about benzodiazapines (but am wary of these
because I've self-medicated with alcohol in the past), carbamazapine,
oxcarbamazapine and gabapentin.
Dear S --
I would not presume to make a recommendation for a medication to add, because --
as you point out -- there are numerous options to consider. Instead, I will
present one more choice for you and your physician to discuss.
You may already have had this discussion, although your description does not
strongly suggest so. But it is fairly simple logic, with one twist. First, the
logic: since venlafaxine was there before quetiapine; and since things may be
better with the quetiapine -- judging from your explanation; at some point,
almost under any circumstances, you'd want to determine whether quetiapine alone
might be sufficient. In other words, you'd be trying to figure out whether
venlafaxine was contributing anything at this point. The only really sure way to
know is to try tapering it off.
But here's the twist: it's possible that venlafaxine is actually contributing to
whatever symptoms you still have. So one of the things you should discuss with
your psychiatrist is whether she/he thinks this might be so in your case.
Obviously, if so you have the option, instead of adding another medication, of
getting rid of one. It is always nice to solve a problem by taking medications
out rather than putting them in.
When you get around to tapering the venlafaxine, you might also want to discuss
with your psychiatrist my
perspective on taper rates.
Beyond that, and all of the medications you have named are either widely used or
considered in bipolar disorder, with the possible exception of gabapentin, which
has been studied for use in bipolar disorder and found not to add value greater
than a placebo (and in one study, it was worse than a placebo (those studies are
reviewed on my
Good luck with the process --
Published January, 2009