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Need medication advice: Bipolar I, mixed episode...


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Hi everyone,

This is my first post on here, I recently discovered this community and have found all of your posts helpful in not feeling so alone while I'm going through these rough times. I apologize for this being a long post, but I really have no where else to go, and I haven't asked for help before online. And also I am in Canada. I am looking at at least a 2 week wait, probably longer. Prior to my hospitalization in December of 2019, I was treated for what was thought to be MDD, GAD, and ADHD.

previous meds (from 2016-late 2019):

-sertraline, citalopram, escitalopram, concerta, dexedrine, ritalin

So, I don't know what to do right now. For the past 2 weeks I have been in a mixed episode after being put on escitalopram 20mg again for depression, by my psychiatrist. I was previously taking 600mg of lithium and 50mg of Seroquel at night while I was started on escitalopram. I stopped taking the ssri when I finally realized what was going on: Snapping on my family, insanely racing thoughts, speaking fast and changing topics that people around me were starting to notice, sleep being extremely disrupted, and pretty much running around with the pedal to the metal.

Around 2 weeks into the titration of escitalopram, I reported to my case manager about increasing anxiety and agitation. She told me to give the medication time to work. A week later, things got worse, and I didn't even realize it because I was being controlled by the symptoms. I contacted my GP and told him what was going on, since it was a Saturday (last Saturday) and I couldn't get in touch with my case manager and my psychiatrist. Told him that I was going to increase my lithium to 1200mg (which I was previously on during my last hospital stay in December 2019, until about May of this year), and that I have been taking extra doses on Seroquel 25mg during the day to calm down these symptoms (which would only last for 1.5 hours). He just approved all of these changes without much input at all. A few days later, symptoms were only getting better by about 20%. I then started increasing my dose to 100mg at night, then to 150mg. I was also previously on 200mg of Seroquel from December 2019 to around April or May, before decreasing it due to daytime sedation. I started treatment for in December 2019 after I checked myself into Emerg with full blown mixed episode and suicidal ideation that was so distressing.

Once I got In touch with my case manager, which is a nurse, she just took down notes of the changes and told me to wait until I see my psychiatrist on the next coming Monday, but I had to cancel because I am also starting a new job on Monday, and I couldn't get approval for a break at the appointment time, which was going to be over the phone. I contacted her again, and pleaded for some input from my psychiatrist on any sort of change to calm down these symptoms, but she said she couldn't do anything unless I speak to him directly, through an appointment, because he needs to know the exact symptoms I am going through, even though I described every single one to her and told her how distressing it has been. She told me to go to emergency and check myself in if it was that bad... or get back in touch with my GP for a medication change. From no fault of his own, my GP knows absolutely nothing about treating manic/bipolar symptoms, and believes that 75mg of Seroquel will be enough, while indications for manic symptoms range from between 300-700mg (please correct me if this is wrong!). He also didn't really see the point of increasing lithium from 600 to 1200 because "it will take a month to work, like an antidepressant would".

So, where I am left at now, is to bring the exact recommendation to my GP for him to prescribe, as had been the case as he has been trying to treat me since July of 2019. I am just looking for some suggestions from anyone. I don't want to keep increasing Seroquel without any direction. Any suggestions about starting another AP (olanzapine, something with stronger D2 antagonism???), to replace or augment the Seroquel, or to ask to be started on valproate again? Again, sorry for the long post and for being all over the place.

Edited by AbuTony
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You are right, mood stabilization with seroquel is typically higher. Also, Lithium may not take a month. That said - 600 to 1200 is a big jump and it is risky to be doing such things without expert care. I know you are struggling, but dosing yourself without a competent doc has the potential to go really wrong and you need to be very careful here. Have you ever tried other APs ever? Thinking about augmenting with a second AP without trying adequate doses of several alone might be jumping the gun by a lot (back to my point about dosing without an expert.) I think right now you need to get your dosages optimized before any other big changes- ideally by your pdoc but at least by someone who can manage the situation knowledgeably. I am not trying to criticize you and I know you are in a very difficult situation, I am just warning you- lots of us here have gone down the path of setting our own med treatment and it can go really wrong   

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I really appreciate your input. You're 100% right, I shouldn't have changed dosages by myself. It didn't even cross my mind that my lithium levels could become toxic with a big jump like that. It's something I've had a habit of doing and it rarely ends well, i'm glad i'm not the only one though. I have tried latuda (for depression) at the lowest dose for a really short time, while I was taking seroquel, but I went off of it because at the time, I was really paranoid about the amount of medications that were being thrown at me in the first 3 months following my hospital stay/bipolar diagnosis, and I didn't click well with my assigned psychiatrist at the time. I've changed psychiatrists since then, and feel really comfortable with this my current one as he takes the time to educate me about side effects and why he is prescribing, taking away or changing doses of medications. I won't question his recomendations once I see him in the next appointment. But anyway, I really don't remember how the latuda effected me.. So you think it would be best to titrate the seroquel up with the instruction of my GP hey? I will definitely run it by him. And how much of the IR vs XR would be ideal in these higher dosage situations?

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The PI for seroquel suggests 400 as the low end for mania, but some get benefits lower. For IR vs XR that’s really an individual thing of what you tolerate better... some people get less daytime sedation with XR, others find it doesn’t help them sleep as well. For what it’s worth - it might make sense to ask pdoc his thoughts on the lithium too. That might be another way to manage things 

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  • 2 weeks later...

 

On 11/6/2020 at 6:51 PM, AbuTony said:

Hi everyone,

This is my first post on here, I recently discovered this community and have found all of your posts helpful in not feeling so alone while I'm going through these rough times. I apologize for this being a long post, but I really have no where else to go, and I haven't asked for help before online. And also I am in Canada. I am looking at at least a 2 week wait, probably longer. Prior to my hospitalization in December of 2019, I was treated for what was thought to be MDD, GAD, and ADHD.

previous meds (from 2016-late 2019):

-sertraline, citalopram, escitalopram, concerta, dexedrine, ritalin

So, I don't know what to do right now. For the past 2 weeks I have been in a mixed episode after being put on escitalopram 20mg again for depression, by my psychiatrist. I was previously taking 600mg of lithium and 50mg of Seroquel at night while I was started on escitalopram. I stopped taking the ssri when I finally realized what was going on: Snapping on my family, insanely racing thoughts, speaking fast and changing topics that people around me were starting to notice, sleep being extremely disrupted, and pretty much running around with the pedal to the metal.

Around 2 weeks into the titration of escitalopram, I reported to my case manager about increasing anxiety and agitation. She told me to give the medication time to work. A week later, things got worse, and I didn't even realize it because I was being controlled by the symptoms. I contacted my GP and told him what was going on, since it was a Saturday (last Saturday) and I couldn't get in touch with my case manager and my psychiatrist. Told him that I was going to increase my lithium to 1200mg (which I was previously on during my last hospital stay in December 2019, until about May of this year), and that I have been taking extra doses on Seroquel 25mg during the day to calm down these symptoms (which would only last for 1.5 hours). He just approved all of these changes without much input at all. A few days later, symptoms were only getting better by about 20%. I then started increasing my dose to 100mg at night, then to 150mg. I was also previously on 200mg of Seroquel from December 2019 to around April or May, before decreasing it due to daytime sedation. I started treatment for in December 2019 after I checked myself into Emerg with full blown mixed episode and suicidal ideation that was so distressing.

Once I got In touch with my case manager, which is a nurse, she just took down notes of the changes and told me to wait until I see my psychiatrist on the next coming Monday, but I had to cancel because I am also starting a new job on Monday, and I couldn't get approval for a break at the appointment time, which was going to be over the phone. I contacted her again, and pleaded for some input from my psychiatrist on any sort of change to calm down these symptoms, but she said she couldn't do anything unless I speak to him directly, through an appointment, because he needs to know the exact symptoms I am going through, even though I described every single one to her and told her how distressing it has been. She told me to go to emergency and check myself in if it was that bad... or get back in touch with my GP for a medication change. From no fault of his own, my GP knows absolutely nothing about treating manic/bipolar symptoms, and believes that 75mg of Seroquel will be enough, while indications for manic symptoms range from between 300-700mg (please correct me if this is wrong!). He also didn't really see the point of increasing lithium from 600 to 1200 because "it will take a month to work, like an antidepressant would".

So, where I am left at now, is to bring the exact recommendation to my GP for him to prescribe, as had been the case as he has been trying to treat me since July of 2019. I am just looking for some suggestions from anyone. I don't want to keep increasing Seroquel without any direction. Any suggestions about starting another AP (olanzapine, something with stronger D2 antagonism???), to replace or augment the Seroquel, or to ask to be started on valproate again? Again, sorry for the long post and for being all over the place.

Wow, sounds like you've been getting really jerked around by your care team. A real shame, but such is the nature of healthcare nowadays.

I'm surprised and simultaneously not surprised that your pdoc said to either go to the hospital if it was bad enough or go to your gdoc if it was bad but not bad ENOUGH (i.e. not a danger to others or yourself). None of us here are doctors, so we can't give you a direct medication recommendation, but we can provide our experiences and information about these medications that is public knowledge.

First and foremost as already indicated, your gdoc through no fault of his own just isn't as well versed in psychiatric care. He's in general practice, and psychiatry just isn't his bread and butter. I'd say it's pretty normal for a general practice doctor to see that low doses of Seroquel (e.g. 75mg) are quite sedating to patients and they believe that translates into manic/mixed control, when that may not necessarily be the case. At doses that low, it largely achieves sedation via 5HT2A antagonism and H1 antagonism, but that isn't mania control. Sufficient occupancy of dopamine receptors to blunt manic episodes isn't achieved generally until like 200mg+. If your gdoc isn't willing to go that far, then you should discuss other options with him.

It's also important to not change doses without the supervision of a doctor, even a doctor that may not be as well-versed in psychiatry. As @Iceberg mentioned, if it were lithium, it would be good to do it with your gdoc's supervision so that he could write for the necessary blood work to make sure your levels aren't in the toxic range after a few days of the new dose, as well as assess basic things like kidney function. Those are all things that a general doctor can do. And yes, there may be a delay with lithium until full effect is realized, but it's probably more like 2 weeks and not a month. Lithium isn't an antidepressant. Perhaps full effect on mood may take 2-4 weeks, but effects on mania are usually apparent in 1-2 weeks.

I wouldn't recommend having your gdoc change your medications to something else. Optimize doses, yes. Swap them out, no. Your gdoc isn't going to have the tribal knowledge to accurately decide which way to go next. You also don't want to lose the progress you've made with your pdoc. Your pdoc is more likely to be receptive to hearing that a gdoc increased doses of the current medications to achieve better symptom control rather than swap them out because he thinks he has a better idea than the pdoc does. Catty I know, but this is the prideful side of medicine.

If it were me, and I were to talk to my gdoc about increasing the doses of medications that my pdoc prescribes, for the fastest effect, I would ask for an increase to Seroquel because between lithium or atypical antipsychotics (AAPs), the latter have far more evidence in favor of RAPID effect. However, Seroquel stands to cause more weight gain than lithium and probably more sedation. Zyprexa (olanzapine) likely will cause more weight gain than Seroquel and even more metabolic dysfunction. So if you can stand to wait a bit, it may behoove you to optimize the lithium dose because there is more positive evidence in its favor in the long term. You're only on 600mg and many go to 900mg or higher. You should be able to get either 300mg or 450mg tablets which should allow you to do 2x450PM, 450AM/450PM, 300AM/2x300PM, etc.

Now, when you have your next pdoc appointment, if you find that you aren't tolerating the increase to either lithium or Seroquel (or both), maybe you should talk to your pdoc about valproate again. For those who don't tolerate lithium well, valproate is often a good alternative although there may be less evidence in valproate's favor from a maintenance perspective. However, valproate's strong point is fighting mixed mania, a prize that AAPs take home most of the time. Valproate seems to be better than lithium in this regard but maybe not as good as AAPs. It also doesn't seem to be effective at all for most bipolar depression, except when the core of that bipolar depression is mixed or anxious distress, similar to what you are describing. Therefore, valproate may be worth considering if you've taken it before and tolerate it. Personally, I LOVE valproate. HATED lithium. LOVE VALPROATE. It's literally the backbone of my cocktail. We cycled through several antipsychotics trying to find one that I could tolerate at the doses I needed to control my symptoms. But we couldn't find one. Every single one caused akathisia before I could achieve appropriate mood control. But with valproate, my baseline is so much lower that I don't need mood stabilizing doses of AAPs, the lower antidepressant doses of AAPs are sufficient, hence I now take 1250mg divalproex with 2mg Rexulti and 15mg Trintellix.

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