My Blueprint

[NMethylTransferase]

Okay, I'm Bipolar II, and here was my medication plan. I broke it down into three phases.

Phase I: Mood Stabalization & Sleep Enhancement

Lamictal--'Cause it's one of the best mood stabilizers, with low incidence of side-effects, doesn't have cognitive side effects, doesn't disrupt sleep, and lifts mood without triggering mania.

[Silver]

Okay, I'm Bipolar II, and here was my medication plan. I broke it down into three phases.

Deplin, Methylcoabalamin, and Acetylcysteine--Okay, you can get Deplin in 7.5 mg tablets by RX. I can also get an RX to have methylcobalamin injections compounded. The two agents together support methylation, the same mechanism of action that SAMe works by. Well, SAMe is expensive and insurance doesn't cover it. The insurance may bitch and moan, but I can get them to pay for Deplin and MC. I'll also add 6 grams daily of Trimethylglycine. Insurance won't pay for it, but it's cheap. The acetylcysteine keeps glutamate in check. Excess glutamate is a putated cause of depression, and there is at least one (small) trial (double blind, placebo controlled) to support its use in bipolar depression.

Or you could just take Cerefolin NAC, which has all three of those and will probably be covered by your insurance if the Deplin is.

Lots in there to respond to, and I have to go do chores now - "make hay while the sun shines" isn't just a saying, as it turns out - but please note that low-dose lithium can certainly cause thyroid dysfunction too... which is why you monitor it. It's not an absolute rule-out.

As to your psychiatrist 'flipping out' over lithium and giving you sedative-dose quetiapine as a sleeper... sigh. I can't say anything nice, so I'm just going to get back to helping fix my balking baler.

[Reborn]

Reality Check: When I brought up lithium, my p-doc flipped out. She gave me the speech about thyroid, tremors, and memory problems. Apparently, she didn't hear the low dose part. She recommended Lamictal (without me bringing it up), and basically told me to shut up, just try it, and be patient. The less medication we have to use, the better. When I complained about poor sleep quality, she wrote a script for Seroquel (25 mg, 3 HS) and gave me another speech about how wonderful it was. I'll try bringing up Lyrica at the next appointment.

Can I trade you docs? It sounds like you've got a winner there. Mine tries to throw everything under the sun at me. Key word tries.

Excess glutamate is a putated cause of depression, and there is at least one (small) trial (double blind, placebo controlled) to support its use in bipolar depression.

I supplement glutamate, and it doesn't affect my depression at all. If anything, it might improve it. (Secondary to the physiological changes it creates anyway. It doesn't have any noticeable/studied mood altering properties that I know of.)

endorphins and enkaphilins, which everyone knows makes you happy!

Yeah, there's just one problem; you can develop a tolerance to natural endorphins as well as synthetic opioids if they're triggered in the same manner repeatedly.

folks, there you have it. My grand master plan to improve my life through drugs. If there are any holes in my plan that I'm not seeing, please feel free to point them out to me. Be merciless!

When you think of drugs, think of them as poison. The human body has spent thousands of years evolving, and so far, it has done a pretty damn good job of keeping everything in check. Yes, drugs can improve the quality of your life if they are used to counteract a condition which would otherwise cause a significant, negative impact. If, on the other hand, you are throwing every drug under the sun at yourself to become some super human, you're probably just killing yourself.

So, it's pretty well known that chemotherapy drugs kill cancer. Does that mean they should be used proactively to prevent cancer? Hell no. Chemo drugs make rat poison look healthy. Doctors prescribe chemotherapy in hopes that the drugs kill more bad cells than good. It's not some magic cure that simply reverses cancer. Drugs aren't simply a way to reverse a condition.

Drugs require a sort of reverence. They can do a lot of good in the right hands, but if used improperly, well, they'll flat out f*** you up.

P.S. Oh, and before you point this out to me: yes, I do plan to continue psychotherapy, start to exercise (both lifting and running), meditate daily, and take my vitamins, minerals and omega-3's. Thank you.

Sounds like a good plan to me.

[NMethylTransferase]

Okay, I'm Bipolar II, and here was my medication plan. I broke it down into three phases.

Deplin, Methylcoabalamin, and Acetylcysteine--Okay, you can get Deplin in 7.5 mg tablets by RX. I can also get an RX to have methylcobalamin injections compounded. The two agents together support methylation, the same mechanism of action that SAMe works by. Well, SAMe is expensive and insurance doesn't cover it. The insurance may bitch and moan, but I can get them to pay for Deplin and MC. I'll also add 6 grams daily of Trimethylglycine. Insurance won't pay for it, but it's cheap. The acetylcysteine keeps glutamate in check. Excess glutamate is a putated cause of depression, and there is at least one (small) trial (double blind, placebo controlled) to support its use in bipolar depression.

Or you could just take Cerefolin NAC, which has all three of those and will probably be covered by your insurance if the Deplin is.

Well, Cerefolin costs twice as much as Deplin. Separately, I can get NAC very cheap. And finally, taking B12 orally can correct deficiency, yes. But it won't help someone in my case. Why not? Because if you take 1000 mcg of B12 by mouth, you can absorb a few micrograms. Hooray if you have a deficiency, since the human body only requires a few micrograms daily. But no dice if you're trying to increase methylation. By the way, you

[Silver]

Um... copay for CerefolinNAC was exactly the same as Deplin for my policy when I was insured, is the same price for the Blue Cross and Aetna policies in my area that cover them, and the cash price with the discount card is within $3 at my pharmacy. For the record.

My apologies. The thought was reduction of the pill load. One of the many things that's been found to increase treatment adherence. Best of luck.

[JackBQuick]

I'm BPII as well. Yay, we're genetic siblings.

In your P.S. you had some great alternative/complimentary notions. I'd also recommend reading Dr. Jim Phelps' book "Why am I still depressed?" and reading his [link=http://www.psycheducation.org" target="_blank]website[/link] thoroughly, especially the part about talking to docs, light/dark therapies, evidence based treatment, and of course the evolutionary stuff. We aren't "sick" we just got too damned much of the good genetic stuff. (Okay some would call that mentally ill, but whatever--IMHO the medical problem model is as much a problem as getting too much of the good stuff).

Since you're eager to experiment with the cocktails, Phelps' experience with evidence based treatment would likely help steer you clear from letting those meds fuck you up (too much). I can corroborate Reborn's advice on that--in my own experience, a decade of drug fuckups and another half decade dealing with them, evidence based discipline helped me find the correct balanced approach with minimal pharma-chemical intervention to manage my genetic excesses (I know that's CB heresy to not obsess over drugs but, fuck it, that's my lived-truth).

I use the dark therapy Phelps recommends as well. It's the only way I can sleep and actually benefit from it.

[SashaSue]

Okay, I'm Bipolar II, and here was my medication plan. I broke it down into three phases.

Deplin, Methylcoabalamin, and Acetylcysteine--Okay, you can get Deplin in 7.5 mg tablets by RX. I can also get an RX to have methylcobalamin injections compounded. The two agents together support methylation, the same mechanism of action that SAMe works by. Well, SAMe is expensive and insurance doesn't cover it. The insurance may bitch and moan, but I can get them to pay for Deplin and MC. I'll also add 6 grams daily of Trimethylglycine. Insurance won't pay for it, but it's cheap. The acetylcysteine keeps glutamate in check. Excess glutamate is a putated cause of depression, and there is at least one (small) trial (double blind, placebo controlled) to support its use in bipolar depression.

Or you could just take Cerefolin NAC, which has all three of those and will probably be covered by your insurance if the Deplin is.

Lots in there to respond to, and I have to go do chores now - "make hay while the sun shines" isn't just a saying, as it turns out - but please note that low-dose lithium can certainly cause thyroid dysfunction too... which is why you monitor it. It's not an absolute rule-out.

As to your psychiatrist 'flipping out' over lithium and giving you sedative-dose quetiapine as a sleeper... sigh. I can't say anything nice, so I'm just going to get back to helping fix my balking baler.

What is it about seroquel for sleep that you don't like?

[Silver]

I love it for sleep. It's just that it's not doing much more than antihistamine and maybe some alpha-blocker work at low-low doses, and it's a rather pricey sleeper.

And it seems more and more common to just throw the 'St. Joseph's Baby Seroquel' tablets as a sleeper at the problem, rather than trying to address the underlying process by giving, say, 200 mg of Seroquel. I'm not saying that this is what NMT's psychiatrist was doing, by the way - I'm just used to university/academic groups, which would be thrilled to have someone come in and ask for a well-validated mood stabilizer, as NMT had done, to try and actually address the central disruption... because, as s/he writes, the fewer meds, the better. Chasing down individual symptoms is a quick road to crazy.

That was all.

[SashaSue]

I hate to burst your well constructed bubble here, but lamictal can absolutely have cognitive side effects. Word finding problems, and assorted memory issues are the most common. Also, it has actually been known to flip people into hypo/mania. As far as Lyrica making you more alert during the day, I'm wondering where you got that notion, other than your theoretical model? Neurontin helped me sleep for about the 1st month I took it, but didn't make me more alert, and it certainly didn't make me any smarter, to put it mildly.

I don't know what your pdoc's issue is about lithium, but she's so right that it's best to use as few meds as possible. Why on earth would you want to start off with so many?

Also wondering why you want to start w/the emsam, and why you'd augment it rather than increasing it?

Finally, I noticed that you're concerned with the potential for liver toxicity w/Tasmar, yet you don't seem concerned in the slightest about the damage being on so many meds could do to your liver. I mean, left to your own devices, you'd be on, what? 12 meds? That's quite the daily workout for your liver. Just saying...

[Velvet Elvis]

Lyrica--At bedtime. Enhances slow-wave sleep, so may enhance daytime alertness.

[SunshineOutside]

I know that you are a student...

How did you come up with this plan?

Has anyone else (other than us) seen it?

Sunshine Outside

[NMethylTransferase]

Alrighty…

Some o’ y’all are wondering why I might want to take this crazy cocktail.

The simple answer is that I’m not interested in being normal. In fact, I don’t care about being human. I want to be superhuman.

My father works 60 hours a week, every week. He doesn’t take a day off. He only takes his vacation because his company basically forces him to, or unless he has an emergency come up. He never takes a sick day. Ever.

You see, depression, or even mental illness, in general doesn’t run on either side of my family. Then again, it might be because I’m an immigrant from a third-world country, where health is on the bottom of most people’s list of priorities, let alone mental health.

I’m smart, and I know it. But all this smartness is totally useless, because I haven’t achieved anything. It’s been four years since I graduated high school, and I’m still a college freshman.

The first year, I didn’t go to college because I hadn’t taken the SAT’s. The second year, I took a few math and English classes, along with “baby chem.” That got me enough credits to get into college as a matriculated student. The third year, I took general chemistry, in which I had lack-luster performance, and calculus, which I totally bombed. The fourth year, my parents cut off my funding and since I had failed to make enough money through the summer, I was forced to work though the fall semester. In the spring, I took a few fluff courses, just to warm up. I had figured that I would be able to do well. I was wrong. I had one Incomplete, another withdrawal, one B, and one B-. Yeah, in case you’re wondering, that totally steamrolled my spirit.

Throughout this time, I was seeing my school’s psychiatrist. He thought I had dysthymia. Actually, he called it “Neurotic Depression.” But anyway, I tried Wellbutrin and Lexapro, neither of which did diddly squat for me. Then in the spring semester of the third year (since high school graduation), I developed a strange syndrome. I had excessive daytime sleepiness (despite eight, and sometimes ten or more hours of sleep), and really bad problems with concentration and memory.

Thus he prescribed Adderall XR 20 mg QD. It “worked” inasmuch as it improved my concentration and memory. However, within a week of taking it, I developed another strange constellation of symptoms. Basically, I felt like I had a viral infection, except that I had no fever. BAD muscle and joint pain, runny nose, watery eyes, and excessive daytime sleepiness. Yes, much worse than the original complaint. It was so bad that I was afraid to drive, for the fear of passing out behind the wheel. I also started to get overwhelming anxiety. Just the thought of my finals was so overwhelming that I didn’t bother to show up for any of my finals.

I never again took Adderall in a daily basis. However, it did let me get through my bad days. On the other hand, I didn’t think popping amphetamines was a good way to deal with my problems. Adderall had given me a glimpse of the promised land, but the place where it had actually taken me was NOT where I wanted to be.

I compiled this list by first identifying my core problem, which was, of course, bipolar disorder. My concern was mental performance, but in my case, it was caused by recurrent episodes of depression. However, trying to elevate my mood would ultimately only lead to failure, because the nature of my illness is recurring. Therefore, any strategy that I came up with had to proceed in a stepwise fashion.

[NMethylTransferase]

Oh, Lyrica improving alertness.

Okay, this is my theory. Xyrem/oxybate/GHB increases slow-wave sleep. Taken at night time, it helps to increase daytime alertness. Albeit, majority of narcoleptics continue to require

[Reborn]

When I think about your plan, one thing comes to mind: Rube Goldberg.

Do you all know who Rube Goldberg is? He was the cartoonist who created ridiculously complex solutions to simple tasks. They would work in theory, yet while they were well thought out, they were so foolish that they were laughable.

Your plan reminds me of a Rube Goldberg machine. Each little step in it makes perfect sense. It seems well thought out and meticulously planned. yet when you step back and look at the big picture, it's ludicrous. Drugs aren't like a physics equation or chemical reaction. They're not very predictable. With that mess you're proposing, you'll never be able to tease out the source of the negative side effects.

I don't mean to insult you, but I just think you should step back, so to speak, and consider what you're really proposing. I'm pro drugs. Really, I am. I just think this seems a bit irresponsible.

You sound smart enough to do whatever it is you want to do. Just trust yourself and go for it. If you don't succeed the first time, hit it from another angle.

P.S. I don

[LikeMinded]

Here's something...

We're here to give you advice on what to discuss with your pdoc. Please don't self-medicate, even if it is via a pdoc.

That's how I got on Zyprexa, a med that turned out to be inappropriate for me, and ruined my career (for now, at least). At least I've been off the stuff for 3 years.

I have a weird gut feeling your pdoc must have seen this drug company-sponsored presentation on Lamictal in bipolar disorder and then felt it was a magical cure for you (the predominantly depressed bipolar). My pdoc 3 years ago was adamant about putting me on lithium until 3 weeks after she'd first suggested it, after viewing a drug rep presentation about how wonderful Lamictal was (and this was before it gained approval for maintenance therapy of bipolar!!). I'm not trying to accuse your pdoc of being an idiot here, as I have no idea what the real story behind everything is, but it's something you should mind when he says something or other.

If you don't agree with what one pdoc says, then get a second opinion. Often the two pdocs are willing to converse with each other. The downside is that insurance may only cover one of them (meaning your second opinion will either be a single visit... or end up being your new pdoc). I got a double opinion on my med cocktail and managed to change a few meds from regular dosage to (rare at that) PRN schedule. No major change in symptoms, but my liver's probably happier for it. Nine meds is enough to make almost anybody's liver scream (though strangely, my liver enzymes have been slightly abnormal, but in the opposite direction from the levels that indicate drug toxicity, don't ask me why).

As far as your idea of taking Zofran, have you considered Remeron (mirtazapine) in lieu? It also acts as a 5HT-3 antagonist (although it also blocks receptors 5-HT2A/C and H1, which can cause weight gain if you don't watch your diet). By way of blocking 2A/C, it also will have antidepressant effects theoretically greater than those of Zofran's.

And the Lamictal. Hits the cognition. Almost all anticonvulsants do. If you're that hell-bent on staying in tip-top smart shape, well, as you suggested, you might have to settle for being rather abnormal elsewhere in your mind.

I know what I said sounds (pun intended) a bit antagonistic, but I definitely have both my empathies and sympathies for you. I'm not an immigrant from a third-world country, but my parents are, and they had me soon after. When I was in high school and college, they upheld their traditional Eastern values of... intensely controlling their child. (I was an "only".) They finally dropped the pressure my senior year of college after finding out I nearly offed myself at the end of my junior year, when I was 19, before going and seeking psychiatric treatment without them knowing (on my own buck, that is).

(Slightly OT - Now I'm very ill physically and incapable of working or going to school, so they've lowered their standards to the level of me getting out of their house, getting a job, and eventually finding a girl to marry. I'm almost 25 as it is, so the clock's ticking.)

I also know how it is to be the persistent and aggressive "Type A" style of individual. With a debilitating physical illness (confined to bed at least half the day, anything more kills my immune system and results in really weird things happening), it has been extremely frustrating, and I can easily see how it can disturb someone such as yourself with an equally disabling mental illness. Honestly, after I got over my Zyprexa episode and got a job a few months later, I used to work 40-50 hours a week and work out for at least an hour a day. On the weekends, I'd go road cycling for about 50 miles (and Maryland/Virginia is hilly!). But yeah, it feels like running smack into an invisible chainlink fence and clawing at it to get the hell out, so all I can do is empathize and sympathize.

(n.B. - If it makes you feel any better, well, I didn't get into med school either, the best I could muster was one waitlist that I gave up on for a job. I know you don't want cyberhugs, but I'm just delivering empathy here. I'm perversely glad for it, though, since now I realized I want to go more into the engineering and logistics side of pharmaceuticals and healthcare, or potentially pharmacy.)

I could talk to you about the specific meds you've mentioned, but that'd take me too long and with my verbal issues (probably due a little to the Lamictal, but I started having them with the onset of my first fevers prior to that) I could be difficult to understand. PM/IM/whatever me and we can talk further about these fun chemicals.

--fous