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disappointed with new pdoc


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I've been seeing my tdoc for a year and a half, but only started seeing my pdoc in October when it became clear that something else was going on besides PTSD. (symptoms, family history, and bad response to depression all point to bipolar II). My first appointment with my pdoc was in the beginning of October, she was awesome, discussed med options very thoroughly with me, and got me into a PAP so I could start Lamictal right away, as we agreed it was the best solution. I started feeling better within a few weeks, but I only got up to 50 mg (25mg/2x per day). Because of scheduling, it took me until Tuesday to get in for a second appointment. I'd been having what I know are the precursors to an episode - disrupted sleep, depression, and inability to quiet down at night - but I wasn't worried, as I expected her to raise my lamictal dosage. But she kind of pooh-poohed my concerns and said she thought it might be SAD, as it get dark out very early and I spend most of the day inside. However, she told me to email her if I wanted to go up to 75 mg.

Well, I started feeling irritable yesterday, and then today I got hypomanic and wrote 5 pages of my research paper on Louisa May Alcott, except that's not the topic of my research paper and she was supposed to be a one paragraph reference. :| I came home and had started to get into a mixed state, but I took my evening lamictal dose early, it passed very quickly and I managed to calm down. I emailed my pdoc and told her we need to go up to 75 mg.

I don't know, I just think that it's weird that she wants to keep my dose so low. That's not even the therapeutic dose for mood stabilization. Should I push to titrate up to 100 mg (which is the threshold for mood stabilization, according to what I've read)? I'm also concerned that she might not be taking me seriously because I don't have a history of hospitalization or self-injury, in large part because my tdoc picked up on it before my mood swings really escalated.

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Some pdocs are very conservative with meds. It also sounds like this one doesn't know you very well yet, which probably makes her a little bit wary of shoving around your medication. Since she did give you a way out if things got bad (i.e. emailing) she probably did take you at least somewhat seriously. You should probably tell her that you didn't feel like she was taking your concerns seriously, but all in all, it sounds like she's just being cautious.

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Objectively write down your symptoms with enough description for her to understand but not so much she'll be reading a book. Then, email as she advised. I'd wait for the response before asking her why she is choosing the course of treatment that she is. First things first, so don't muddy those waters via written forum.

Btw, 200mg of Lamictal is the max recommended bipolar therapeutic dose. There are some on higher doses because that works for them. Others are on lower doses for the same reason. All said, 50mg is not apt to be much more than an antidepressant dose.

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belated reply:

I did ask her why she was keeping my dose so low, and she said, "Oh, if it's working, I don't want to change it." ?! Well, it was working for a while, but not long term...

About my lamictal dosage: I am not using the starter pack, because she was out of those when I started lamictal. I started out taking 25 mg/day for two weeks, then went up to 50 mg/day. I came in for an appointment to affirm that I hadn't died of the death rash ;) and to affirm it was working, assuming she'd continue raising my dose, but she seemed content keeping me where I was at.

Susan, the course of this cycle, from depression -> irritability -> hypomania, was about 5 days. I have never had one that short before. In the past they've usually been over weeks. I don't know if the lamictal was affecting it, or what. It did seem much more mild than past cycles.

I agree with you guys, I need to go back and talk to her. Thanks for all your help. :)

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I'm on 400 mg of lamictal right now.

The pdoc says we can go up to 600.

Honestly, this is the first time in a few years I've felt normal. It almost worries me because I'm used to my mood being all over the place.

The point: Lamictal kicked the door in and yelled at my neroutransmitters saying, "Quit acting like jackasses!"

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