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Managing Bipolar I without an AP is it possible?


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First time poster here. I have bipolar 1, diagnosed last year after some horrible psychotic/manic episodes. I was put on lexapro which made me go insane and then put on zyprexa 10 mg which I abruptly stopped (I didnt get that you cant do that) which then again made me go crazy. Right now I am on Rexulti 1.5 mg and Seroquel 37.5 mg (I am tapering the Seroquel slowly to come off of it). I know these are low doses but I tend to be very sensitive to meds. The highest does of seroquel I was on was 300. I am not having any weird psychotic symptoms or manic feelings but am struggling with some depression. I am really unhappy with the weight gain from the antipsychotics. I have gained 10 lbs and from what I read all the APS will put weight on you. I also do not like how tired I feel. When I first started taking them I think the Rexulti was more activating, I actually felt jittery and seemed to be getting more stuff done, but now I just feel lazy and unmotivated. I was curious about trying Lamictal, and I was wondering if it would be possible to take that instead of the Rexulti. The only thing I worry about is I hear it impacts your cognition and I am starting school soon. Has anyone managed Bipolar 1 without a AP? Is it possible to just be on lamictal? I won't try antidepressents again after what happend with the lexapro. 

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you probably know this, but in case not--bipolar I w/ psychosis in theory doesn't have psychosis outside of a mood episode (if it did, it would be schizoaffective).  So, in theory, if you have your mood controlled and don't end up in a mood episode, you won't have the psychosis either.  because of that, in theory you could get by without a AAP. 

I say in theory with all that because the diagnoses and symptoms don't always fit into the nice little boxes that the DSM suggests.  So i'd agree with Iceberg that it takes some luck to have it work out completely. 

I agree with the two above that lamictal alone does not sound safe.  You've got decent antidepressant features, but only mild mood stabilizing ones (it's really not an anti-manic drug).  I'd want to pair it with something or take something else. 

To answer your other question, Lamictal doesn't give me brain fog.  I know it does for some people, so I couldn't guarantee that you wouldn't have it.  But I've managed to get by without that side effect.

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49 minutes ago, dancesintherain said:

you probably know this, but in case not--bipolar I w/ psychosis in theory doesn't have psychosis outside of a mood episode (if it did, it would be schizoaffective).  So, in theory, if you have your mood controlled and don't end up in a mood episode, you won't have the psychosis either.  because of that, in theory you could get by without a AAP. 

I say in theory with all that because the diagnoses and symptoms don't always fit into the nice little boxes that the DSM suggests.  So i'd agree with Iceberg that it takes some luck to have it work out completely. 

I agree with the two above that lamictal alone does not sound safe.  You've got decent antidepressant features, but only mild mood stabilizing ones (it's really not an anti-manic drug).  I'd want to pair it with something or take something else. 

To answer your other question, Lamictal doesn't give me brain fog.  I know it does for some people, so I couldn't guarantee that you wouldn't have it.  But I've managed to get by without that side effect.

Although I know of one person who is stabilized on lamictal alone...but I feel like that's not "some" luck...that's a ton of luck 

Especially with the psychosis component you might need more anti manic punch 

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35 minutes ago, Mistylumos said:

Which drugs prevent mania? 

Depakote and lithium are two big ones, tegretol (carbamazepine) is used as well, and some people also swear by trileptal, although that isn't actually approved. Lamictal is supposed to sustain normal mood but after another drug stops the mania 

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Well I am not currently having any mania and Im not on a mood stabilizer just Rexulti which my pdoc is hoping will be enough. Lithium makes you gain weight though, are there any meds that don't that is part of the reason I have gotten depressed. I feel like the meds have taken passion from my life. I just feel flat, apathetic and not myself. I have been depressed before but never in a way where life just felt dull. I cry alot randomly. Seroquel withdrawl is also no joke. Its hard to tell what is the illness and what is the meds, but I just know some of it is from the meds as I have never been on them before this year and I have never felt like this before. 

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3 minutes ago, Mistylumos said:

Well I am not currently having any mania and Im not on a mood stabilizer just Rexulti which my pdoc is hoping will be enough. Lithium makes you gain weight though, are there any meds that don't that is part of the reason I have gotten depressed. I feel like the meds have taken passion from my life. I just feel flat, apathetic and not myself. I have been depressed before but never in a way where life just felt dull. I cry alot randomly. Seroquel withdrawl is also no joke. Its hard to tell what is the illness and what is the meds, but I just know some of it is from the meds as I have never been on them before this year and I have never felt like this before. 

Unfortunately it is often a necessary evil. Basically all psych meds run the risk of some weight gain.... Unfortunately BP 1 requires some sort of mania protection 

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  • 3 months later...

I'm late to the thread....I'm BP1 with psychosis. I do not (cannot) take antipsychotics. I manage with lithium. I'm also older and tired of the ups and downs, so I am more careful about daily schedules, sleep, exercise, etc. It's not perfect, but better than the hell of the med-go-round that you can see in my signature.

I don't gain weight on lithium. AAPs made me fat. Depakote was evil - 15 pounds in a month. I'm actually at a normal weight now.

I tend to run fast, so lithium keeps my mania down. I had a crisis that pushed me into a depression (first in three years), so ketamine is helping with that.

 

 

 

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On 1/6/2019 at 8:29 PM, elby said:

I'm late to the thread....I'm BP1 with psychosis. I do not (cannot) take antipsychotics. I manage with lithium. I'm also older and tired of the ups and downs, so I am more careful about daily schedules, sleep, exercise, etc. It's not perfect, but better than the hell of the med-go-round that you can see in my signature.

I don't gain weight on lithium. AAPs made me fat. Depakote was evil - 15 pounds in a month. I'm actually at a normal weight now.

I tend to run fast, so lithium keeps my mania down. I had a crisis that pushed me into a depression (first in three years), so ketamine is helping with that.

 

 

 

The ketamine didn’t cause mania?

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5 hours ago, Riggs1 said:

The ketamine didn’t cause mania?

 

No. It's a most interesting med. It has a good anti-depressant effect, but it wears off. SSRIs did make me manic, often euphoric, which isn't good because I didn't care about anything in my life except my awesome euphoric crazy thoughts. Ketamine gives me some peace, but I still am aware of general life problems, if that makes sense. I would say it's what I think normal would be.

Ketamine is amazing with anti-suicidal thoughts. That's the main reason I was put on it. I had my first depressive episode in over three years (I run hypomanic generally, even on lithium). I was given three options: inpatient, ECT, ketamine.  I chose ketamine. I use intranasal because I can't afford IV. 

EDIT: I take ketamine every other day (intranasal, each nostril every 10 minutes 5 times). It's been four months. No mania.

Edited by elby
dosage
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16 hours ago, elby said:

 

No. It's a most interesting med. It has a good anti-depressant effect, but it wears off. SSRIs did make me manic, often euphoric, which isn't good because I didn't care about anything in my life except my awesome euphoric crazy thoughts. Ketamine gives me some peace, but I still am aware of general life problems, if that makes sense. I would say it's what I think normal would be.

Ketamine is amazing with anti-suicidal thoughts. That's the main reason I was put on it. I had my first depressive episode in over three years (I run hypomanic generally, even on lithium). I was given three options: inpatient, ECT, ketamine.  I chose ketamine. I use intranasal because I can't afford IV. 

EDIT: I take ketamine every other day (intranasal, each nostril every 10 minutes 5 times). It's been four months. No mania.

That’s very interesting that ssri s cause mania but not intranasal ketamine. Something I will have to discuss with pdoc at some point.

 

thank you for sharing

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15 hours ago, Riggs1 said:

That’s very interesting that ssri s cause mania but not intranasal ketamine. Something I will have to discuss with pdoc at some point.

Ketamine's mode of action is assumed to be glutamate receptor modulation, the assumption is it helps regrow connections between cells in the brain. There is nothing like it in the antidepressant arsenal we have today and most all other antidepressants seem to work through affecting monoamines. So given its novel nature as a treatment and a mode of action it is not going to have all the characteristics that present day antidepressants have as it is nothing chemically like them. It is also a dissociative at high enough doses which is unique.

The mania reaction to some antidepressants seems to center around serotonin and Ketamine is not a SRI.

https://www.scientificamerican.com/article/getting-the-inside-dope-on-ketamine-rsquo-s-mysterious-ability-to-rapidly-relieve-depression/

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I would say I would agree with most in this thread so far that you likely won't get far with lamotrigine monotherapy if you've experienced psychosis. However, some people get by fine using anticonvulsants (ACs) as their main medications and only using antipsychotics (APs) during mood episodes. Theoretically, lamotrigine should "delay the time to a mood episode" meaning mood cycling should occur with less frequency. However, as was indicated earlier, lamotrigine is more for the depressive side of things and CAN slow down cycles, but nothing will truly slow down an acute manic episode like lithium, valproate, or an AP and when psychosis is an issue, this may not always resolve with lithium or valproate.

I've found over the course of my own treatment that an AP is a necessity. More than likely this is because I take a stimulant which ramps up dopamine and this needs to be balanced out with an AP. However, I've always found that my akathisia/restlessness threshold with APs is generally lower than most. Once we finally figured that out after several trials of different APs, we decided that ACs needed to be the primary mood stabilizers with the AP acting as a booster. This allows me to take lower doses of APs that are more tolerable.

I currently take Rexulti and actually just dropped down to 1mg. Because Rexulti has such a long half-life, it takes about 2-3 weeks to reach steady state once you've been at a consistent dose. So basically, whenever you make a change to the Rexulti dose, you can't ask yourself how you're feeling from the change for at least 2 weeks. Generally the impact on racing thoughts or rumination is pretty rapid and can happen in 2-3 days, but the effects on depression and anxiety can take much longer.

Rexulti also hasn't demonstrated as much anti-manic activity as its predecessor, Abilify. So for that reason, I need to take Depakote to maintain mood control with Rexulti acting as a booster to both the Depakote and the Trintellix that I'm taking. Rexulti CAN have mood stabilizing effects but typically not on its own unless you go to higher doses like >2mg where it may not have as much antidepressant effect due to the blunting of dopamine signaling.

If your mood switches easily or you rapidly cycle between depressive and manic, then valproate would be your best option if you didn't want to do an AP. It works wonders for my cycling and I've tolerated it really well where lithium just made me downright sick. Everyone is different. Many on here have expressed that Depakote makes them horribly depressed. It hasn't done that for me as long as I'm not dosed too high. 1500mg was about where I started experiencing depressive symptoms, but it's so vastly different from one person to the next because weight greatly affects blood concentrations of valproic acid.

As for the ketamine, yeah not as likely to cause mania. In fact there's a good possibility that mania/hypomania may precipitate due to a dysfunction in the glutamate system and ketamine may correct that. Using ketamine based compounds is so new and really only for treatment-resistant depression with prominent suicidal ideation at this point, but I'm very curious to see in the coming years what role it may play in bipolar disorder given its lower propensity for manic switch relative to SSRIs and TCAs.

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5 hours ago, browri said:

I would say I would agree with most in this thread so far that you likely won't get far with lamotrigine monotherapy if you've experienced psychosis. However, some people get by fine using anticonvulsants (ACs) as their main medications and only using antipsychotics (APs) during mood episodes. Theoretically, lamotrigine should "delay the time to a mood episode" meaning mood cycling should occur with less frequency. However, as was indicated earlier, lamotrigine is more for the depressive side of things and CAN slow down cycles, but nothing will truly slow down an acute manic episode like lithium, valproate, or an AP and when psychosis is an issue, this may not always resolve with lithium or valproate.

I've found over the course of my own treatment that an AP is a necessity. More than likely this is because I take a stimulant which ramps up dopamine and this needs to be balanced out with an AP. However, I've always found that my akathisia/restlessness threshold with APs is generally lower than most. Once we finally figured that out after several trials of different APs, we decided that ACs needed to be the primary mood stabilizers with the AP acting as a booster. This allows me to take lower doses of APs that are more tolerable.

I currently take Rexulti and actually just dropped down to 1mg. Because Rexulti has such a long half-life, it takes about 2-3 weeks to reach steady state once you've been at a consistent dose. So basically, whenever you make a change to the Rexulti dose, you can't ask yourself how you're feeling from the change for at least 2 weeks. Generally the impact on racing thoughts or rumination is pretty rapid and can happen in 2-3 days, but the effects on depression and anxiety can take much longer.

Rexulti also hasn't demonstrated as much anti-manic activity as its predecessor, Abilify. So for that reason, I need to take Depakote to maintain mood control with Rexulti acting as a booster to both the Depakote and the Trintellix that I'm taking. Rexulti CAN have mood stabilizing effects but typically not on its own unless you go to higher doses like >2mg where it may not have as much antidepressant effect due to the blunting of dopamine signaling.

If your mood switches easily or you rapidly cycle between depressive and manic, then valproate would be your best option if you didn't want to do an AP. It works wonders for my cycling and I've tolerated it really well where lithium just made me downright sick. Everyone is different. Many on here have expressed that Depakote makes them horribly depressed. It hasn't done that for me as long as I'm not dosed too high. 1500mg was about where I started experiencing depressive symptoms, but it's so vastly different from one person to the next because weight greatly affects blood concentrations of valproic acid.

As for the ketamine, yeah not as likely to cause mania. In fact there's a good possibility that mania/hypomania may precipitate due to a dysfunction in the glutamate system and ketamine may correct that. Using ketamine based compounds is so new and really only for treatment-resistant depression with prominent suicidal ideation at this point, but I'm very curious to see in the coming years what role it may play in bipolar disorder given its lower propensity for manic switch relative to SSRIs and TCAs.

To me it came down to round(s) of ketamine or round(s) of ECT and it was just too much to try ECT again without using up my other options

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9 hours ago, Iceberg said:

To me it came down to round(s) of ketamine or round(s) of ECT and it was just too much to try ECT again without using up my other options

I'm interested. ECT has been on the table for me, but I'm avoiding it. Ketamine is working for me, so I will keep on it. How do you compare ketamine to ECT?

 

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Hi, sorry to jump in but it was mentioned that Rexulti can help with rumination--is this referring to the ruminating that goes along with depression? Or is there a different type of rumination that accompanies bipolar? (Sorry, it's a newbie question.)

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