Best Mood Stabilizer & A/D combo?

[cloudmonger]

Starting from scratch again with meds. My question is around mood stabilizer/Antidepressant combos -

If you could be on only 2 Medications (to stabilize mood and treat chronic, severe depression) what would they be and WHY? I am more concerned with finding a combo that treats Depression (not mania) with least side effects. (i.e. some mood stabilizers are better for lifting depression versus mania and don't cause sedation.)

Also concerned about long-term side effects (mostly: impaired Liver/Kidney/Thyroid function, vitamin/hormone deficiencies, memory/concentration loss, blurred vision, hair loss, heart rhythm defects, permanent sexual dysfunction, emotional blunting, apathy, detached de-personalization, weight gain, severe discontinuation syndrome) Unfortunately, from past experience, I feel like all meds cause some of the above issues with long term use. Please help me weigh the pros/cons and what you've experienced...

 

Edited October 25, 2016 by cloudmonger

[jt07]

Tegretol and citalopram and Abilify help me the most. I take other meds, but these three are the backbone of my cocktail. Since we are all different, I'm not saying those meds work for everyone. But they do work for me. Not really terrible concerned about possible side effects that probably won't happen. All these meds are pretty safe or else they wouldn't be on the market.

I literally would be dead without Tegretol, and Abilify helps me to be somewhat functional. Citalopram helps with anxiety and pairs well with Abilify.

[morpheus]

For me valproate + venlafaxine + quetiapine as a backbone. If 2 meds only then it would be valproate + quetiapine.

From your description i see you could do best on lamotrigine + some ssri or snri. Or even only lamotrigine.

[OliverB]

If I had to take mood stabilizer+ad, I would take lamotrigine and bupropion prolonged release, so lamictal and wellbutrin SR or XL.

SR is taken twice a day, while XL lasts longer and is taken once, as far as I know the SR version is more prone to cause anxiety since it is released quicker than the XL version.

I have had many issues with SSRI and SNRI, mostly weight gain, feeling emotionless or death inside. I chose lamortigine over others mood stabilizers because it's one of the best ones for depression and it doesn't have weight gain as a side effect, also, it tends to be activating rather than sedating.

If I had to add a third med, I would add an antipsychotic like aripiprazole -abilify- or amisulpride -solian-.  Because, again, they don't tend to cause as much weight gain as other meds, they both work different from others antipsychotics, they are more activating thand sedating. The only problem it's abilify is really prone to cause akathisia while amisulpride easily cause hyperprolactemia and it's not available in the US, but in other countries it's aproved for both psychosis at 400-1200mg and dysthimia at 50mg-100mg. There are other new meds similar to abilify with less side effects as far as I have read, but since they are not available in my country yet, I don't know too much about them.

Edited October 26, 2016 by Bixo

[cloudmonger]

Very interesting...it's true I guess, meds can really effect people completely differently...also varies depending on the age you take them, circumstances in your life and the mental state you are struggling with.

I have not had much luck with any SSRI's (tried them all - they made me feel emotionless) Citalopram was ok, but made me a more listless/tired with sexual side effects & hormone problems. SNRI's I tried Cymbalta, which made me agitated/restless, tapering off I had a hellish, long withdrawal. Due to the short half-life & withdrawal, I vowed never to try a similar drug like that or Effexor ever again.

I'm surprised Bixo that you didn't have any weight gain/hunger OR sedation problems with antipsychotics. I tried 5 different A/Ps (including Seroquel and Abilify) and found this class of meds the worst offenders as far as terrible physical, metabolic & cognitive side effects (although I was usually on the therapeutic dose or higher, maybe it was TOO high for me) Wellbutrin did nothing but make me sweat alot (even at 400 mg)...I haven't heard much about Tegretol (it's an anticonvulsant like Lamictal I'm assuming?)

I have not tried MAOIs because of all the food restrictions (and haven't heard too many great reviews either). I've tried a Tricyclic (Nortriptyline) which did nothing, and not really motivated to try others because they are all older drugs with (usually) more side effects than the newer drugs.

All I can do is wait with Lamictal...but from past experience, I predict I'll be feeling like "is this as good as it gets?" !

[OliverB]

47 minutes ago, cloudmonger said:

I'm surprised Bixo that you didn't have any weight gain/hunger OR sedation problems with antipsychotics. I tried 5 different A/Ps (including Seroquel and Abilify) and found this class of meds the worst offenders as far as terrible physical, metabolic & cognitive side effects (although I was usually on the therapeutic dose or higher, maybe it was TOO high for me) Wellbutrin did nothing but make me sweat alot (even at 400 mg)...I haven't heard much about Tegretol (it's an anticonvulsant like Lamictal I'm assuming?)

I have tried all atypical antipsychotic except clozaril, and the only ones that didn't cause me sedation, cognitive or metabolic side effects were abilify and amisulpride, all the others did, like seroquel, geodon, zyprexa, risperidona, ... abilify caused me severe akathisia even at only 5mg, but didn't make me hunger, so even if it doesn't work for me because of akathisia it's one of those antipsychotic I would take if I want to avoid sedation and weight gain.

amisulpride causes me akathisia if I take 150mg or more, but nothing at 50-100mg, so basically amisulpride it's the only antipsychotic I can tolerate. I guess the only reason why these two have different kind of side effects it's because they work different from  the rest of antipsychotics. abilify is a partial agonist, while amisulpride it's just a D2 and D3 antagonist, it doesn't touch any other receptor and at lower doses it blocks autoreceptors so dopamine transmision is enhanced, this is why it can be used to treat dysthimia while higher doses are need to treat psychosis. I guess low amisulpride dose+wellbutrin is a good combo, actually I am going to try it. Wellbutrin help me with motivation and concentration more than with depression, taking it alone is not really good.

I always take normal or low doses beyond therapeutic one, specially with antipsychotics. I should be taken 400mg of amisulpride at least, but I function better with only 100mg.

Tegretol is an anticonvulsant too.

Edited October 26, 2016 by Bixo

[JustNuts]

Lamotrigine + any AD. Lamotrigine is considered the best AED for depression, and most ADs are similar in terms of efficacy. Since you've failed SSRIs/SNRIs and bupropion, I'd recommend another atypical such as mirtazapine, vortioxetine, or vilazodone.

Edited October 27, 2016 by JustNuts

[thunder]

I don't really think anyone is going to be able to tell you what will work best, since people respond so differently to meds and your response can shift over time and depending on what it is combined with. It sounds like your best bet would be to get to a therapeutic dose on Lamictal (probably somewhere between 100mg and 200mg), and then assuming this has provided some benefit but isn't enough, work with your pdoc to determine what symptoms are not adequately being controlled, and see what they think would best address those. Unfortunately, it may take some trial and error. While SSRI's and SNRI's alone have been of little help, it's possible that you might respond differently when they are combined with Lamitcal.

Regarding the question of "is this as good as it gets," it's important to remember that medication can only take you so far. Therapy, self care, behavioral activation and such are often needed to really get back to "normal" and may require considerable effort at first (I can't remember if you've mentioned if you are in therapy or have been in therapy in the past). Sometimes, the role of meds is really to take this effort level from impossible to possible, rather than impossible to easy.  

[cloudmonger]

Thanks everyone for the input. I will stick it out with the long Lamictal titration and assess, then discuss trying a newer atypical (vortioxetine/Brintillex, or vilazodone/Vibryd).

I've been to many therapists (currently go as well) but find it very difficult to find someone really good with expertise treating someone with a somewhat complicated long history, hospitalizations, etc. It becomes very expensive also, which is why I end up having to drop out. Often I leave sessions with little "new" insight or positive/hopeful feelings, I easily get discouraged, then it's hard to motivate to continue going for a long period. You probably all know how it is! Maybe I just haven't found the right therapist.

[browri]

@cloudmonger it may be worth your while to look into Latuda. As far as I know, Seroquel, Latuda, and Zyprexa are the only 3 antipsychotics that have an INDICATION for bipolar DEPRESSION. Zyprexa is probably my favorite antipsychotic when it comes to specifically overall antidepressant effect. It helped quiet my inner chatter (not voices, per se. Just something gets on your mind and you LITERALLY can't stop thinking about it), thus less anxiety, and less depression. I couldn't keep taking it because of the weight gain and the increase in lipids/cholesterol. However, if it weren't for the side effects I would still be on it.

Seroquel also carries the same weight gain potential and also low risk of movement side effects like Zyprexa.

Then there is Latuda, which I happen to be taking now at 40mg. I'm not sure how I feel about it yet. But it's for bipolar depression (it's only other indication is schizophrenia, no bipolar mania). It doesn't make you foggy or sleepy during the day, but it isn't really good at quieting the mind either. However, it has MUCH less potential for weight gain. In fact it's pretty much weight neutral. I've even read stories of some people losing weight on it.

My doctor has been pushing me to start taking loxapine instead of Latuda, which is an older antipsychotic that is known for having a strong antidepressant effect. Additionally, the body breaks it down into several metabolites, one of which is known as amoxapine. They later declared this metabolite a crossover tetracyclic/tricyclic antidepressant that fell under a class closer to Remeron (mirtazapine). Loxapine is a typical antipsychotic but it seems to be lumped in a pseudo-category with clozapine and olanzapine which are atypicals. Loxapine was one of the first typical antipsychotics to cross over into the atypical category because of some unique characteristics like having a high 5HT2A : D2 antagonism ratio.

This is all good information, but the reason I'm saying this is because Lamictal will help prevent a cycle from occurring but its effects in my experience are that it shortens episodes or prevents them from spilling over. Basically Lamictal has helped me to "get over it" faster. What would normally be a 3-5 days catatonic episode becomes a 1-2 day episode. It smooths the waves. But the waves still happen. If you add an SSRI or an SNRI, it can make things worse if you aren't careful. Some antipsychotics have a positive antidepressant effect for some people. Which ones have you taken and why did you stop taking them?

Alternatively, if antipsychotics have been ruled out for other reasons, I would say Lexapro, hands down. Cymbalta, Effexor, Pristiq were actually MORE likely then others to trigger mania. Prozac can do this as well, but it is actually indicated to treat bipolar depression when used with Zyprexa. Zoloft seems to be used a lot as well because it's particularly good at melancholic depression. All this being said, Wellbutrin was shown in a few studies to be the LEAST likely to cause cycling.

 

Edited October 30, 2016 by browri

[y1gFwo]

in Stephen Stahl's book on Mood stabilizers he says:

"The best evidence-based combinations [for bipolar disorder] are those that combine an AAP, especially ones that have been on the market longest such as olanzapine, risperidone, quetiapine, or aripiprazole, with the addition of lithium or valproate. These four atypicals are FDA-approved as combination therapy with lithium or valporate for manic and mixed episodes. Newer atypicals such as ziprasidone, paliperidone and asenapine may also be useful in combination with lithium or valproate but are not as well studied."

https://books.google.com/books?id=ZbD_yBjRRiMC&pg=PA126&dq=mood+stabilizer+combo+stahl&hl=en&sa=X&ved=0ahUKEwjplcvTzILQAhUSySYKHVtaBOYQ6AEIMTAB#v=onepage&q=mood stabilizer combo stahl&f=false

Edited October 31, 2016 by y1gFwo

[cloudmonger]

On 10/30/2016 at 2:11 PM, y1gFwo said:

in Stephen Stahl's book on Mood stabilizers he says:

"The best evidence-based combinations [for bipolar disorder] are those that combine an AAP, especially ones that have been on the market longest such as olanzapine, risperidone, quetiapine, or aripiprazole, with the addition of lithium or valproate.

Thanks for the feedback. I've tried many A/P's: Seroquel, Risperdol, Abilify, Zyprexa, Remeron and Lithium. I think they are helpful for acute mania or psychosis but I'm not suffering from these issues.

Most of these (for me) caused Blurred Vision, Weight gain (or feeling hungry all through the night) Involuntary movements/tremor, or severe drowsiness, mental dulling. Lithium worsened hypothyroid (which I take meds for now) Unfortunately, none really helped my depression....