cognitive impairment on lithium - adding a stimulant?

[larkspur]

Hi folks. Important background info: My drug cocktail last week was Seroquel XR (titrating up to 300 by 50mg per night. So on the first night I took 50mg, then 100mg, then 150mg, and so forth until I took 300mg of Seroquel XR with dinner) and Depakote 500mg at dinner. Xanax PRN for anxiety (about all the drug changes). I also take 2000mg fish oil (2 caplets).

This week, I have remained at 300mg Seroquel XR q.pm, decreased to 250mg Depakote at dinner, added lithium 300mg b.i.d. and a sample pack of Nuvigil 150mg q.am. Still taking the fish oil and my multivitamin (prenatal because my hair is falling out!)

Next week, Depakote is gone and we're adding Lamictal.

Ever since starting Seroquel last week I have had profound cognitive impairment. I'm all over the map. I don't remember when I'm told things, I get lost coming home, I'm constantly leaving my cell phone in odd places (like in the freezer or on shelves in the pantry). Adding lithium this week compounded this issue, to the point where yesterday, without thinking, I took my "PM" drugs at 8am! I use a pill organizer so I can devote time once a week to making sure I have it right, but I consciously looked at the compartment that was labeled "F - PM", right underneath "F- AM" and decided that at eight in the morning, the F-PM box was the correct choice! So then I had taken Seroquel XR 300mg just 12 hours apart, an insignificant (we're weaning down) amount of additional Depakote, and then I'm forced to guzzle coffee all day just to be conscious!

Now, my thought process is "Well, that's what Nuvigil is for!" except it isn't. Yesterday, it wasn't until 7pm that I realized I'd made the switch, so I didn't take it (duh). My experience with Nuvigil so far is that I'm still a vegetable, still non-functional and dumbed down to the point of disability, but I'm a vegetable who doesn't particularly need a nap. Nuvigil means I'm not crazy tired, but it does NOT give me any focus.

I do have ADHD normally, of the inattentive type, so I'm no stranger to "zoning out"... but this is a whole new level. I was previously stable on a combination of antidepressants and stimulants, but had what was apparently a hypomanic response to the addition of Remeron, doctor said I'd been kindling it for years by taking AD's, and now I'm worse than ever. I'm only about 2 months into this whole bipolar thing, though every shrink I've ever seen has mentioned it because I talk so fast (former competitive debater...if you know what that means). I have never felt this dumbed and numbed by a drug ever, in my life, and to be completely honest it is scaring me! I'm on disability leave from work because the drug changes give me terrible anxiety about everything, and the side effects make me useless to my clients right now.

So, in conclusion,

a) Has anyone else ever had this type of cognitive impairment when starting Seroquel, or when adding lithium to your cocktail?

b) Will Lamictal make it worse?

c) Does it go away? Do I magically wake up one morning, take my AM lithium, and feel competent to act in a fiduciary capability for my clients?

d) I took Adderall IR before, twice daily, and felt great. I've read about the "kindling" theory of AD's in bipolar, and I don't feel that it applies to stimulants, my doctor is cautious that it might, though. I keep telling him I can't read a book, can't watch a TV show, probably shouldn't be driving, etc. because of my low level of cognitive function, and he and I are going to evaluate adding a stimulant back in (probably Adderall or Dexedrine, based on my past med. responses). Does anyone have any experience with taking stimulants in combination with lithium, Lamictal and/or Seroquel XR? How did that go for you?

[koali777]

Not with Seroquel, but yes with Risperdal and Geodon, and with Lithium. People are right when they say sometimes it could be depressive symptoms. However, yes these meds can make you flatter and less motivated and dull cognition. I am hoping that it is just from being overmedicated, and I am probably getting back on an antipsychotic or mood stabilizer. For me, it didn't go away, but I mean I was on 240 mg Geodon which is a LOT. I was taken off of them because of this. But it's possible it goes away or you get used tp it. And yes I understand the terrible situation with not even being able to read. I am a smart person, and on these meds I am dumb. I know some people say the stimulants work fine, but online it says that antipsychotics make stimulants less effective. Hopefully people can provide some better anecdotal evidence than I can.

[Guest]

The dulling I got on seroquel was mainly after a dose, and it lessened after a few weeks, However I wasn't taking XR, I was just taking one big dose of IR at night.

I got different dulling from lithium where I couldn't remember words, but it didn't stop me thinking.

I was having severe problems staying awake after taking geodon, and for that modafinil worked pretty well (The drug that came before nuvigil). I wouldn't say it helped my focus noticabat small doses, but at higher doses it has some effect. I take 2-400mg. Just being able to stay awake is nice sometimes.

[larkspur]

Thanks for the helpful replies - what others have experienced on Seroquel gives me hope that some of this will wear off. Lithium is definitely affecting my word recall, so that makes sense as well.

I'll do some research into the combination of antipsychotics and stimulants.

[larkspur]

So, I was able to figure out that stimulants working on noradrenaline should be able to work well with Seroquel, because norquetiapine works as a noradrenaline reuptake inhibitor, as do stimulants. So they're friends on that front.

But then there's dopamine...

I've found several pubmed articles indicating that while it hasn't had any major harmful effects in studies, nobody is quite sure how they compete with one another as far as dopamine goes. I'm thinking maybe something along the lines of Seroquel being more selective for D1, so the amphetamine can still stimulate at D2.... or something about glutamate...

help?

[crtclms]

You really can't make decisions based on neurotransmitters and such. No one really knows or understands what is going on in your particular neurotransmitter soup. Hence the difficulty in finding which particular cocktail works for you.

[smurf2050]

Lithium messed with my ability to process language.

[wemble]

not so much with lithium that i can remember (though to be honest, i can't remember much around then, i was a mess) but after getting to my regular dose, my pdoc combined the amount into one pm dose. you could ask about that so you sleep through any side effects.

seroquel didn't necessarily numb my cognitive effect, but i was sleepy as all hell. i mean, it was awful. that did start to fade after a while, but i wasn't on it long enough to see if it went away completely. once again, i took it at night so i could sleep through side effects.

depakote DID dull my processing, but only when my dose was increased from 500-750mg. that eventually faded after a week or two.

honestly, it sounds like you're coming off and going on a whole bunch of things at once, so you're gonna feel weird. i'd let that stabilize a bit and then reassess.

[Guest]

Why are you coming off meds and starting others at the same time? It will intensify side effects and obscure your ability to see what is having an effect.

While I don't doubt you are having problems, you can write eloquent posts and research neurotransmitters, you may not have as much dulling going on as you first think. Maybe take a few weeks for this to settle before you add to your cocktail.

[larkspur]

February was a month of grasping at straws trying to get a bad mixed episode under control, so lots of med changes in a short time. Definitely not the way my doc usually does things.

My lithium dose is now 300mg am, 600mg pm. Will ask about nightly dosing.

My doc gave me dextroamphetamine when I went back to work, and I only took it on work days. It helped a little, not a lot. I'm back to the drawing board now after experiencing psychosis and adverse reactions to lamotrigine, so these cognitive problems are the least of my concerns right now.

Titania- I appreciate that you feel my posts are eloquent. It takes half an hour to compose and edit one, so I'm glad my efforts help mask my many "duh" moments.

[Guest]

I couldn't tolerate the seroquel sedation, I have had cognitive issues on Li but that has gone away. My smarts tie into a stable mood, some cognitive blips are tolerable to me cos I am dumb as a box of rocks when manic or depressed.

[matthewmurphyj]

A stimulant you may want to try is Nuvigil. It is a novel analeptic drug that provides a comfortable level of alertness and helps me overcome the sedation induced by the myriad of drugs I take. So my combo with Nuvigil works very well.

[leopard]

I couldn't tolerate the seroquel sedation, I have had cognitive issues on Li but that has gone away. My smarts tie into a stable mood, some cognitive blips are tolerable to me cos I am dumb as a box of rocks when manic or depressed.

Titania, may I ask what your seroquel dose was, and how long you waited before you decided the sedation was too much to tolerate?

Thank you

[LeftyLucy]

I take Saphris and Topamax among others but those two in particular are doing in me in at work so the doc gave me Nuvigil yesterday to help me stay awake and concentrate. Hopefully it will be the missing puzzle piece.