Is it a speed bump or a spiral

[Iceberg]

So had pdoc like a week ago and talked about some insomnia/mild depression. His opinion was it’s probably situational from school stress and lack of sleep.

However, fast forward to last few days and I’ve been experiencing some intrusive thoughts including passive flashes of self injury and SI. My pdoc is in no way dismissive, but I feel like I have to let things play out a little more since he just suggested it will be transient a week ago.

unfortunately if it doesn’t go away I’m in a bit of a tough spot. Of my three mood meds lamictal is maxed, clozaril can’t really be touched in the middle of a semester due to sedation issues which leaves lithium (currently at a low dose.) if something does need change a small lith increase would probably be the safest move. But lithium has never helped me with acute depression before and the reason it’s so low is I get some very nasty side effects.

so I guess that leaves an add on- and if you exclude antidepressants which don’t play nice with my bipolar I’ve tried or eliminated most of the adjunct options I can think of. 
 

so- I know I’m not there yet, but given how impossible it’s been to treat my acute depression I want to have a plan ready for asap use if necessary. My sig is up to date - anybody have thoughts ? Both on lithium vs add and which to add 

[CrazyRedhead]

1 hour ago, Iceberg said:

so- I know I’m not there yet, but given how impossible it’s been to treat my acute depression I want to have a plan ready for asap use if necessary. My sig is up to date - anybody have thoughts ? Both on lithium vs add and which to add 

This is just a shot in the dark, since I'm not too familiar with bipolar meds, but I don't see tegretol (carbamazepine) on your "Past-meds" list.

Edited February 9, 2022 by CrazyRedhead

[jarn]

I don't much about thorazine, but would increasing the PRN help?

[Iceberg]

3 hours ago, CrazyRedhead said:

This is just a shot in the dark, since I'm not too familiar with bipolar meds, but I don't see tegretol (carbamazepine) on your "Past-meds" list.

This is true, I haven’t tried that … good point.  I’m not sure that many pdocs would want me on 3 mood stabilizers at the same time… especially because tegretol can mess with lamictal levels. It has come up in the past, but each of my last three pdocs have considered it not worth a trial (probably because anti epileptics haven’t ever helped on their own) so I’m inclined to go with the masses there

1 hour ago, jarn said:

I don't much about thorazine, but would increasing the PRN help?

Hey thanks for the reply. I only use Thorazine when I’m flipping the hell out, because it basically makes me into a voluntary zombie… so using it with depression would have to be more in the context of a bad mixed episode 

[jarn]

10 hours ago, Iceberg said:

Hey thanks for the reply. I only use Thorazine when I’m flipping the hell out, because it basically makes me into a voluntary zombie… so using it with depression would have to be more in the context of a bad mixed episode 

Oooh, yeah, and zombie + school = not good.  So that's not a good solution.  

I am no med genius, so I will just say I hope you can sort this out.  Depression is a miserable bitch.

[Wonderful.Cheese]

@Iceberg

Shoot. I’m sorry I can’t see your signature. But I had some ideas. Also, please know I’m sending good thoughts your way and I hope this goes away soon for you.

Provigil or nuvigil for a boost? It would kick in fast. Or a slight adderall (I think you take that one?) increase? My first pdoc gave me provigil off label for BP depression.

Could you try a sleep drug with the above to help the insomnia too? Is there anything that’s helped in the past? I know sleep is a tough one for you.

And try the lithium increase too? (While waiting for the lithium to kick in you’d have the above meds fast acting to give you some relief and then one of your main mood stabilizers has time to kick in and do its thing)

[Iceberg]

2 hours ago, Wonderful.Cheese said:

Could you try a sleep drug with the above to help the insomnia

Thanks cheese- Update So the plan we decided on … going to try benzo for a short term sleep reset. If I start sleeping well and the depression doesn’t resolve we will reevaluate the lithium vs add on depending on what non-insomnia generated symptoms are looking like.

2 hours ago, Wonderful.Cheese said:

Provigil or nuvigil for a boost? It would kick in fast. Or a slight adderall

In the past we have considered short term adderall bumps…. Unfortunately the fact that I’m on about 5 hours of sleep total the last three nights might make pdoc nervous about adding anything stimulating until we get the sleep (at least semi) controlled 

[kelbelle3201]

 I am bipolar ? because I have symptoms from both 1 & 2, plus I'm ADD

My questions is what do you mean by being maxed at Lamictal? Does the blood test say you are in a therapeutic range?

I see you took Seroquel - That I have for sleep, and it works for me but it's hard to get the dose right after time changes. Either oversleeping or under sleeping. Which benzo are they putting you on? We've tried to reduce my benzo's in the past but I've been on them so long that I become unstable if they are lowered. I found the following from the Mayo clinic. https://www.mayoclinic.org/diseases-conditions/insomnia/in-depth/sleeping-pills/art-20043959

 

 Lamictal, Adderall, Fludrocortisone, Seroquel, Abilify, Alprazolam, Clonazepam

 

 

 

[Iceberg]

1 hour ago, kelbelle3201 said:

My questions is what do you mean by being maxed at Lamictal? Does

Thanks for the reply- Typically doses over 400 (or even 200 depending on some factors/pdoc preference) aren’t considered to be much more beneficial 

 

1 hour ago, kelbelle3201 said:

Which benzo are they putting you on

Currently alprazolam ODT, I have weird absorption timing with the regular Xanax where it takes two hours and then hits sedation all at once. I have been on all of the common ones and I know what works for specific situations. I had some really nasty panic disorder stuff go on a few years ago and I cycled through klon, valium, ativan, Xanax XR and ir within like a year, with the goal of not having to drop out of school. So I was on round the clock of one benzo plus 1800 gabapentin- I’m just trying to say that trying to get off benzos is so tough and I sympathize. In addition I have failed temazepam and triazolam for sleep. It’s almost it’s own diagnostic test. If symptoms are mild or likely to not linger too long, a benzo can help. If it’s BP related, the benzos aren’t going to cover it.

so update- as i just posted on the board, I got dealt a nasty schedule so any possible changes are on (at least temporary) hold. I’m too tired to feel depressed most days haha 

Edited April 6, 2022 by Iceberg

[kelbelle3201]

These are probably stupid questions but have they run the Lamictal blood test to see if you are in a therapeutic range?  The first time I went on Lamictal I got up to the 200mg and it didn't work so they took me off of it. Fast forward 17 years to my current psychiatrist and now there is a blood test. Because of this my doctor and I have realized I metabolize medication quickly. It took forever to get into range. I had to get blood tests three times a week until I got there and now once a month to monitor my levels. So, I now take 450mg in the morning and 450mg at night.  Yes, your doctor may need to get special permission like mine did, but it was worth it. I've been pretty stable for the last five years.

I see you've take Seroquel, but I'm not sure what else you were taking at the time. My night time cocktail for sleep is 4mg Xanax to get me to sleep, and 4mg clonazepam to keep me asleep until the 900 mg's of Seroquel kicks in and knocks me out for 8 or 9 hours. Maybe you metabolize some medication faster like I do? Maybe ask your doc for a Lamictal test? Just information and suggestions here. I'm not a doctor, this is just my experience.

[Iceberg]

13 hours ago, kelbelle3201 said:

These are probably stupid questions but have they run the Lamictal blood test to see if you are in a therapeutic range?  The first time I went on Lamictal I got up to the 200mg and it didn't work so they took me off of it. Fast forward 17 years to my current psychiatrist and now there is a blood test. Because of this my doctor and I have realized I metabolize medication quickly. It took forever to get into range. I had to get blood tests three times a week until I got there and now once a month to monitor my levels. So, I now take 450mg in the morning and 450mg at night.  Yes, your doctor may need to get special permission like mine did, but it was worth it. I've been pretty stable for the last five years.

I see you've take Seroquel, but I'm not sure what else you were taking at the time. My night time cocktail for sleep is 4mg Xanax to get me to sleep, and 4mg clonazepam to keep me asleep until the 900 mg's of Seroquel kicks in and knocks me out for 8 or 9 hours. Maybe you metabolize some medication faster like I do? Maybe ask your doc for a Lamictal test? Just information and suggestions here. I'm not a doctor, this is just my experience.

Yep, I get all of my med levels every 6 months. The seroquel was adequately tried at 800 with several different meds and multiple times so I don’t think there’s much point. Sleep aside, it was consistently not helpful for mood 

[ChunkOfCheesecake]

Just my opinion:

It's sounds like school is creating some wonkiness-- with insomnia manifesting, and also being a catalyst for your observed symptoms.

This looks like a situation where you can just pull back, and not look at diving into med cocktail adjustments (at least not yet) and figure out how to get the sleep issue resolved-- which should alleviate said symptoms.

Its easy to overlook simple solutions when you feel like crap. Things to try to resolve insomnia:

- Try melatonin

- Change your routine-- like stop studying at say 6pm, don't consume any more food or drink, and don't do anything stimulating. Seriously. This is to prep your brain for sleep.. then try to drift off to sleep at 9pm or 10pm

- Don't consume *any* caffeine

Lastly, I have to say, the very act of studying, thinking through problems, reading texts for hours on end can aggravate BP and produce the symptoms you listed. Always keep this in mind. Remind yourself of this too, when intrusive thoughts start creeping in.

If things really go sideways, yes a llithium addition/increase might be good to block out the SI nastiness and keep things straight.

Edited April 16, 2022 by ChunkOfCheesecake