Am I running Out of Options...?

[CaptainYaaar]

I am bipolar, although Im not sure which kind. I am currently on Trileptal 300mg 2x a day, Risperdone 4mg, Prozac 20mg, and a trial run for Nuvigil 150mg for mood and Risperdone 8mg, and Zolipdem 20mg for sleep. I can't tell if its the Prozac or the Zolipdem, but I am struggling with depression and the kind of apathy that surprises me. The Nuvigil is helping a little bit but for the most part I feel just apathetic, dumb, mute, and down. I am getting ready to start school for fall semester and Im pretty sure that I don't give a rats ass, which is really unlike me. What makes this problem more complicated is the fact that my file is pretty thick and my med options are running out. My pdoc is starting to suggest things like Lithium and MAO Inhibitors to me, and Im really hesitant. The Trileptal and Risperdone work well for me and I have no desire to lose them. Im thinking the Prozac is contributing to the apathy and the Zolpidem is contributing to the depression, but its the only thing that gets me to sleep. I would like to try a med that targets depression like Lamictal does but I tried it before and I was one of the patients who got swollen and rashy from it. Things are progressing to the point where I just fake a smile through social situations and that's not like me at all. Its to the point where people notice that I am depressed and ask me about it.

My questions are:

Is Lithium really that bad?

Is it possible to just stay on the Trileptal and Risperdone and not take an AD?

Does anybody have any insights into my situation that I just may not be seeing?

Any input that anyone has to offer on this will be really appreciated and thanks in advance!

[SashaSue]

Lithium's really not that bad at all. It works really well for a lot of people, and is definitely worth considering. You could absolutely be on mood stabilizing meds without an antidepressant. SSRI's elicit a kind of awful apathy in me, unlike any other mood state. Have you tried trazadone or seroquel for sleep?

[gizmo]

I've been on lithium for more than 3 years, and I think it's a cornerstone in my treatment. No, it's not bad - but I understand where you are coming from. I was quite hesitant when my pdoc brought up lithium as well... I mean, that's for the "really sick" bipolar people, right? Nope, it is simply the gold standard of treatment for bipolar mania and has been for eons.

The main thing you will probably notice is that you will be thirsty... so be prepared to drink more water and other fluids, and if need be, carry fluids with you on your commute, at a rest place at work, etc.

I don't take an AD, and I have bipolar. My pdoc believes that the AD I was taking was increasing my cycling, and felt that the medication I was taking was sufficient to cover any depressive episodes. I've been off the AD since November, so it's still too early to tell if she's right or not. If I still have no depressive episodes after 2 years, I'll think about believing her (I have more mania than depression).

I take remeron (similar to trazadone) to assist in falling asleep. It works fair. Just enough of a push to get me to fall over the edge, but no hangover the next day. I take it prn.

[CaptainYaaar]

I am also considering going back on Seroquel as I did really well on it. I only stopped it because I developed Jaw pain due to TMJ and mistakenly thought it was from the Seroquel. I am concerned because I have heard Lithium is quite toxic for the body and since I have already put my body through quite a lot, I dont wanna do anything further. My main problem is the fact that I get anxiety and depression together, and I panic about a variety of things, at times irrationally. My depression is to the extent that people notice and they wonder (and ask) what is wrong with me. Is that a normal thing or am I just overreacting? I dont laugh out loud anymore, I fake a smile most of the time, my personality and sense of humor are missing, I dont even talk anymore and if I do it's just one word responses and it really bothers me that people notice.....at what point does one akcnowledge a problem?

Even though it runs in my family bipolar is still very new to me and I am saddened to know that in the past when I have felt my best I was really at my worst........and I can see why people go off their medications.

[gizmo]

I am concerned because I have heard Lithium is quite toxic for the body and since I have already put my body through quite a lot, I dont wanna do anything further.

Listen, I am not here to "convert" you to lithium. You will either take it or you won't. It's your choice.

But to dispell your theory - lithium is a salt. If taken in the proper dosage, it is not more toxic to you than the pepper shaker that you have at the table. To ensure proper dosage, you will have a couple of fasting blood tests when you first start the med. However, there is such a thing as lithium toxicity. Which may be what you are referring to. This is a *temporary* condition in which the blood serum level of lithium in your blood gets too high. I've experiences lithium toxicity first hand when I rapidly lost 33 lbs and stayed on the same lithium dose. It did not agree with me. Trust me, you know when you go into lithium toxicity. Main indicators: thirst like there is no tomorrow, whole limb tremors, sometimes vomiting, dizziness. I knew something was wrong when I demolished an entire case of bottled water in less than 24 hours. Treatment? Stop the lithium for a bit, get your blood retested, and start a lower dose. That's pretty much it. It's very low tech.

However, there is decades of research on lithium, and not one doctor or researcher has shown that taking theraputic lithium is detremental to the patient.

[CaptainYaaar]

What are the affects of Lithium cognitively? Will it slow me down? Will it slur my speech? I have heard many things about this drug and I do not wish to be misinformed.

I am concerned because I have heard Lithium is quite toxic for the body and since I have already put my body through quite a lot, I dont wanna do anything further.

Listen, I am not here to "convert" you to lithium. You will either take it or you won't. It's your choice.

But to dispell your theory - lithium is a salt. If taken in the proper dosage, it is not more toxic to you than the pepper shaker that you have at the table. To ensure proper dosage, you will have a couple of fasting blood tests when you first start the med. However, there is such a thing as lithium toxicity. Which may be what you are referring to. This is a *temporary* condition in which the blood serum level of lithium in your blood gets too high. I've experiences lithium toxicity first hand when I rapidly lost 33 lbs and stayed on the same lithium dose. It did not agree with me. Trust me, you know when you go into lithium toxicity. Main indicators: thirst like there is no tomorrow, whole limb tremors, sometimes vomiting, dizziness. I knew something was wrong when I demolished an entire case of bottled water in less than 24 hours. Treatment? Stop the lithium for a bit, get your blood retested, and start a lower dose. That's pretty much it. It's very low tech.

However, there is decades of research on lithium, and not one doctor or researcher has shown that taking theraputic lithium is detremental to the patient.

[AnneMarie]

Hi CY,

Just based on my own experience...

Seroquel - The first thing I'd do is go back on it since it wasn't the source of the jaw pain. In addition to help sleeping, it may have been helping w/depression a bit, too. That's probably dose and person dependent. Over 100mg, it does help me a little there.

Lamictal - People do rechallenge Lamictal and sometimes it works out fine. Personally, I'd probably hold off 10 years or so. Your own natural body chemistry will change in that time, which might increase the odds. I'm pulling this out of my ass, so if it's something you consider, definitely research to see if there's any relevancy.

Lithium - I love my Lithium. It works as an antimanic, but more important for me lately, it works as an antidepressant. That is priceless for me since I can't take SSRIs/SNRIs/TCI/MAOI/Geodon/Abilify. As for toxicity, get blood tests, stay hydrated, keep the level in the safe range. It's actually not that hard to do. About half the people who try Lithium benefit w/o significant s/es. About 25% benefit but have serious s/es. The other 25% don't benefit. Or, stats something like that. Other meds have caused me more problems than this one.

As for treating depressive symptoms, aside from Seroquel and Lithium, there still are more options than MAOIs. Have you tried Wellbutrin? Probably yes, I'd guess. If it helped in any way, Mirapex is a Parkinson's med that acts as an AD for some. It also works on dopamine, but differently than Wellbutrin. Another is supplementing your thyroid T3 hormone. When's the last time you had your thyroid checked - TSH, T3, and T4? If you are leaning hypothyroid, that could be part of your problem. If not, supplementing a little still helps some. Mostly, though, my suggestion is to try Lithium for it's antidepressant powers. You could end up not only not depressed, but able to ditch the AD and Trileptal or Risperdone. ?

[CaptainYaaar]

I do think I would like to give Seroquel another run because it worked so well for me.

My doctor reccomends Lithium more than any other drug. My big concerns with Lithium are cognitive slowing and feelingsleepy/stoned all the time. Im doing school and work full time thisyear and I just can't afford to be in bed the whole time.

I think I am going to hold off on Lamictal although it has been 11 yrs since that happened. Im glad to know that chemistry can change.

Wellbutrin and I did not get along at all, major panic attacks. I think I have heard of Mirapex, but not all that much.

I think it's been something like a year or so since my thyroid was checked.

I think Im more than likely going to end up on Seroquel or Lithium, however Im trying to make the most subtle adjustments here so whatever it ends up being I need it to be slow.

Hi CY,

Just based on my own experience...

Seroquel - The first thing I'd do is go back on it since it wasn't the source of the jaw pain. In addition to help sleeping, it may have been helping w/depression a bit, too. That's probably dose and person dependent. Over 100mg, it does help me a little there.

Lamictal - People do rechallenge Lamictal and sometimes it works out fine. Personally, I'd probably hold off 10 years or so. Your own natural body chemistry will change in that time, which might increase the odds. I'm pulling this out of my ass, so if it's something you consider, definitely research to see if there's any relevancy.

Lithium - I love my Lithium. It works as an antimanic, but more important for me lately, it works as an antidepressant. That is priceless for me since I can't take SSRIs/SNRIs/TCI/MAOI/Geodon/Abilify. As for toxicity, get blood tests, stay hydrated, keep the level in the safe range. It's actually not that hard to do. About half the people who try Lithium benefit w/o significant s/es. About 25% benefit but have serious s/es. The other 25% don't benefit. Or, stats something like that. Other meds have caused me more problems than this one.

As for treating depressive symptoms, aside from Seroquel and Lithium, there still are more options than MAOIs. Have you tried Wellbutrin? Probably yes, I'd guess. If it helped in any way, Mirapex is a Parkinson's med that acts as an AD for some. It also works on dopamine, but differently than Wellbutrin. Another is supplementing your thyroid T3 hormone. When's the last time you had your thyroid checked - TSH, T3, and T4? If you are leaning hypothyroid, that could be part of your problem. If not, supplementing a little still helps some. Mostly, though, my suggestion is to try Lithium for it's antidepressant powers. You could end up not only not depressed, but able to ditch the AD and Trileptal or Risperdone. ?

[AnneMarie]

What are the affects of Lithium cognitively?

Not at all for some. Others it may cause some dulling that fades over some weeks. Still others, it can cause dulling that sticks around. If it's much, then it's a deal breaker, IMO. Truth is, this isn't different than many other meds, especially the ACs. Tegretol and Lamictal cause me more dulling than Li.

Will it slow me down?

That's a relative question. You won't be hypo/manic if it's working. That's distinctly different than slowed, but can be confused if you've lived undiagnosed for long. Slowed as in impaired s/e slowed, it shouldn't if the dosing is right.

Will it slur my speech?

Nope.

That's reason to get off any med asap, and I think other meds would have a higher probability.

I have heard many things about this drug and I do not wish to be misinformed.

All info is to the best of my knowledge.

The input Gizmo provided is accurate. It is the same as my info.

Not mentioned... Lithium is the only bipolar med statistically proven to reduce suicides. No AD or AP can say the same.

To reiterate... more is known about Lithium, short-term and long-term use, than any other psych med. Period.

And one of the most compelling reasons to take it IMO... it is the most neurotrophic and neuorprotective med. That means it does more to protect your brain from further damage and it stimulates new neuronal growth, which means it is helping to grow more brain (heh, non-scientific descriptions!).

Better explanation:

[link=http://www.mcmanweb....ide_neuron.html]Inside the Neuron - Neurotransmitters are about outside the cell. Let's open up the hood.[/link]

.... Meanwhile, a study led by Dr Manji found that lithium "significantly increases total gray matter volume in the human brain of people with manic-depressive illness."

Using a gene chip micro-array (a process that allows researchers to record the interactions among thousands of genes simultaneously), Dr Manji and his colleagues started experimenting with lithium and Depakote on brain cell tissue, and found to their surprise these two completely different medications indirectly affected some of the same cell pathways associated with cell survival and death. One protective protein that utilizes these pathways is Bcl-2, which in one experiment was doubled by lithium and Depakote administration. Subsequent experiments on rats found lithium mitigated the effects of lab-induced stroke and led to the growth of new neurons in the hippocampus. When Dr Manji asked Dr Drevets to revisit his study, it was found that those patients on lithium or Depakote did not show brain atrophy. More recently, a study on human patients with bipolar found lithium increased overall brain grey matter.

But producing new brain cells is only part of the picture, and probably not the main part of the picture. What may be even more important is the ability to protect and rescue damaged brain cells and helping them to re-establish connections, according to Dr Manji. To appreciate lithium’s possibilities we need to realize that both depression and bipolar disorder are more than mere mood disorders. The impairments to function and cognition may last far beyond the course of an actual episode, and although not "classic" neurodegenerative diseases such as Parkinson’s and Alzheimer’s, they are clearly illnesses associated with brain cell loss and shrinkage.

Tellingly, Bcl-2 protects against free radicals that can damage brain cells, as well as Parkinson’s and possibly the ravages of mood disorders, Dr Manji informed a session at the National Alliance for the Mentally Ill annual conference held in Cincinnati in July 2002. Dr Manji also drew attention to the related work of Ron Duman PhD and his team at Yale, who found antidepressants turned on the expression of BDNF. Significantly, Dr Duman and his team have recently found that an infusion of BDNF may produce an antidepressant effect in lab rats.

A good source of info is [link=http://www.ncbi.nlm.nih.gov/sites/entrez]PubMed[/link]. If you query "lithium neurotrophic" current abstracts come up. Query anything. It's a good source of info, MI or medical.

I'm not trying to sell you! Lithium is steeped in superstition and misinformation thanks to those good old movies, books, and sensationalism about crazy. You should make an informed decision.

Lithium also is like all other meds in that YMMV. How it effects you as an individual will depend on how your biology/chemistry/etc responds. As said earlier, 25% who try bail because of bad s/es, whereas 50% have a much better experience. Odds favor a good response, enough for me to try it at any rate... once I learned some factual info about the med.

ETA cross post.

If you decide to try Li and it's not an emergency, I'd go slower than the typical titration especially with work and school. The typical titration that I've heard is increasing 300mg every few days to a week. I had problems with that. When I retried going much slow, it was pretty seamless.

[SashaSue]

Since you've taken it successfully before, it seems like it'd make sense to restart seroquel first, maybe play with the dosage a bit, and see where that leaves you. Just yesterday I came across a study in which lithium and seroquel worked together really well in treating bipolar depression, so that's worth keeping in mind as well.

[CaptainYaaar]

This is great information! Again, Im not as informed on Li so this is wonderful information. I mean slowed as in impaired...which really doesnt make much of a difference because I feel slowed on Prozac anyways.

What are the affects of Lithium cognitively?

Not at all for some. Others it may cause some dulling that fades over some weeks. Still others, it can cause dulling that sticks around. If it's much, then it's a deal breaker, IMO. Truth is, this isn't different than many other meds, especially the ACs. Tegretol and Lamictal cause me more dulling than Li.

Will it slow me down?

That's a relative question. You won't be hypo/manic if it's working. That's distinctly different than slowed, but can be confused if you've lived undiagnosed for long. Slowed as in impaired s/e slowed, it shouldn't if the dosing is right.

Will it slur my speech?

Nope.

That's reason to get off any med asap, and I think other meds would have a higher probability.

I have heard many things about this drug and I do not wish to be misinformed.

All info is to the best of my knowledge.

The input Gizmo provided is accurate. It is the same as my info.

Not mentioned... Lithium is the only bipolar med statistically proven to reduce suicides. No AD or AP can say the same.

To reiterate... more is known about Lithium, short-term and long-term use, than any other psych med. Period.

And one of the most compelling reasons to take it IMO... it is the most neurotrophic and neuorprotective med. That means it does more to protect your brain from further damage and it stimulates new neuronal growth, which means it is helping to grow more brain (heh, non-scientific descriptions!).

Better explanation:

[link=http://www.mcmanweb....ide_neuron.html]Inside the Neuron - Neurotransmitters are about outside the cell. Let's open up the hood.[/link]

.... Meanwhile, a study led by Dr Manji found that lithium "significantly increases total gray matter volume in the human brain of people with manic-depressive illness."

Using a gene chip micro-array (a process that allows researchers to record the interactions among thousands of genes simultaneously), Dr Manji and his colleagues started experimenting with lithium and Depakote on brain cell tissue, and found to their surprise these two completely different medications indirectly affected some of the same cell pathways associated with cell survival and death. One protective protein that utilizes these pathways is Bcl-2, which in one experiment was doubled by lithium and Depakote administration. Subsequent experiments on rats found lithium mitigated the effects of lab-induced stroke and led to the growth of new neurons in the hippocampus. When Dr Manji asked Dr Drevets to revisit his study, it was found that those patients on lithium or Depakote did not show brain atrophy. More recently, a study on human patients with bipolar found lithium increased overall brain grey matter.

But producing new brain cells is only part of the picture, and probably not the main part of the picture. What may be even more important is the ability to protect and rescue damaged brain cells and helping them to re-establish connections, according to Dr Manji. To appreciate lithium’s possibilities we need to realize that both depression and bipolar disorder are more than mere mood disorders. The impairments to function and cognition may last far beyond the course of an actual episode, and although not "classic" neurodegenerative diseases such as Parkinson’s and Alzheimer’s, they are clearly illnesses associated with brain cell loss and shrinkage.

Tellingly, Bcl-2 protects against free radicals that can damage brain cells, as well as Parkinson’s and possibly the ravages of mood disorders, Dr Manji informed a session at the National Alliance for the Mentally Ill annual conference held in Cincinnati in July 2002. Dr Manji also drew attention to the related work of Ron Duman PhD and his team at Yale, who found antidepressants turned on the expression of BDNF. Significantly, Dr Duman and his team have recently found that an infusion of BDNF may produce an antidepressant effect in lab rats.

A good source of info is [link=http://www.ncbi.nlm.nih.gov/sites/entrez]PubMed[/link]. If you query "lithium neurotrophic" current abstracts come up. Query anything. It's a good source of info, MI or medical.

I'm not trying to sell you! Lithium is steeped in superstition and misinformation thanks to those good old movies, books, and sensationalism about crazy. You should make an informed decision.

Lithium also is like all other meds in that YMMV. How it effects you as an individual will depend on how your biology/chemistry/etc responds. As said earlier, 25% who try bail because of bad s/es, whereas 50% have a much better experience. Odds favor a good response, enough for me to try it at any rate... once I learned some factual info about the med.

ETA cross post.

If you decide to try Li and it's not an emergency, I'd go slower than the typical titration especially with work and school. The typical titration that I've heard is increasing 300mg every few days to a week. I had problems with that. When I retried going much slow, it was pretty seamless.

[AnneMarie]

In the interest of full disclosure...

Gizmo addressed the biggest issue w/Lithium, toxicity. There are few other reasons why Lithium absolutely has to be monitored.

Monitored, it is safe. Unmonitored, it is not.

Staying hydrated is very important on Lithium. That doesn't mean drinking gallons, just making sure you drink what's generally considered a healthy amount for everyone. The easiest way to have problems with Lithium is to get dehydrated. That, btw, usually does not mean go toxic. It means get an idea what toxic could be like. In other words, you'll get sick. In nearly four years, I've had that happen once because I ignored my body when it said drink something.

Standard blood work includes a Lithium level check every three months to verify your level hasn't changed. It changes for some seasonally. It changes for other reasons, too. Generally, levels don't move huge amounts, but it can be enough to effect your mood.

Standard blood work also includes thyroid and kidney function every six months to a year. The two long-term potential effects of Lithium are damage to thyroid and kidneys. Long-term as in 15-20 years, I think, but I might be off a little, and YMMV. Blood work will give you flags before there's permanent damage. A fair number of people who end up w/thyroid problems opt to continue Li and supplement their thyroid hormones. If you start to have renal problems, then you stop taking Lithium. If you have regular blood tests, you'll be able to do that before there is a problem.

One of the more common side effects is tremor. Some stop the med. Others take something for the tremor.

That pretty much covers the potential down side as I know it. Keep in mind that most psych meds haven't been around long enough to know what their long-term impacts are. So, at least here, they are known.