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Valproat/Ergenyl and dopamine?


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After many years on different SSRI meditations I haven’t found any medication that has worked real good for my depressions, except lamitrigine, but I had to stop it after a skin reaction.

My doctor have seen signs of these two paths: light bipolar, ADHD, either any of the alone or in combination.

I got prescribed Valproate 600mg at night. But I read that it blocks dopamine D2 receptor. If it would turned out I have ADHD signs instead of bipolar, wouldn’t it be wrong medication? Is it possible to reverse the block with voxra or other meds?

Does the block means total block or is it dose dependent?

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Where are you reading that it blocks dopamine?

i see one study that shows it helps regulate circadian rhythm via dopamine regulation.

An open letter about dealing with excessive dopamine from dopamine replacement therapy.

that isn’t the same thing as a block (antagonism or partial agonism) that you would get from antipsychotics.

lamotrigine helping may indeed suggest some light bipolar spectrum issue. However there is evidence that it may help adhd when there is comorbid bipolar or trd

valproate is theorized to work on the gaba and glutamate system via effects on the sodium gated channels.

have you tried bupropion? It’s an ndri antidepressant that is also potentially helpful for adhd, as it increases dopamine levels via reuptake inhibition of dopamine.

 

 

 

Edited by argh
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It might have been this one I read

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3190603/

 

No I never tried Wellbutrin. It’s a shame that it has been so many years with wrong medications, but I guess it is what it is. My problems have been rather complexed with nerve/muscle tensions specially from nerve briachialis through the neck. This has been easy triggered from many medications. So my current doctor think that SSRI put to much nerve activity and trigger the nerves, IF I’m light bipolar.

But if the valproate don’t mess with the D2 receptor it sounds good. I’ll talk to my doctor in November about this. 

Edited by Bobo77
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Good luck with your appointment.

wellbutrin is also indicated as the ad which is the least likely to have manic or hypomanic switching for folks with bp if that is a concern.

If the valproate helps but only partially that could be an option to augment with Wellbutrin.

curious, did your SSRIs just not work or did they make things worse mood wise? Or is that neck tension what occurs, but no mood changes?

How many have you tried?

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@Bobo77 I can actually answer this for you based on the article that you read.

Valproate isn't a D2 receptor blocker like antipsychotics. This article simply suggests that there is a reduction in signaling along the D2 pathways. However, this is more likely due to the upstream effects that valproate has on catecholamines like dopamine and norepinephrine. Valproate actually inhibits catecholamine synthesis, the brain's ability to make more norepinephrine and dopamine. It's been noted in studies that these neurotransmitters and their metabolites are elevated in those with bipolar disorder.

One thing to keep in mind is that bipolar disorder and ADHD do cross over (comorbid) more often than you would think. I take mood stabilizers and Vyvanse (amphetamine stimulant) and Depakote is the only thing that allows me to tolerate the necessary dose of Vyvanse I need to function properly. Without Depakote I can get a bit stressed after 2-3 weeks of 40mg so I have to decrease to 30mg. I don't have to do that when I'm taking Depakote. A dopamine modulator (partial agonist) like Rexulti (which I take) further controls the Vyvanse but doesn't outright block it like some of the older atypical antipsychotics.

If SSRIs make you agitated and you may be bipolar then bupropion is a good way to go if you're still depressed because it's less likely to cause a manic switch. It should also help any ADHD symptoms a bit.

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Argh:

I feel that a few SSRI I’ve tried did lift the mood but also triggered the tensions (which activate an enormous stress reaction) After a while they didn’t seem to work, and raised the dose etc. Some of them didn’t work at all. I Don’t remember all of them but I’ve tried, Zoloft, Effexor, cymbalta, fluoxetine, cipralex... also tried zyprexa, ability, seroquel, tegretol, lamotrigin, lyrica, noozinan, 

The tensions have practically crippled me in most ways, haven’t been able to exercise at all including walking. Before I was very active with all kinds of sports, was good on many of them and loved to compete and focus. So a big part of me is currently loss. Social relations have also been very hard because of tensions, to never been able to calm down and focus and feel any kind of peace. I could that before this, but almost every time after I did something, exercise, worked etc..

34 minutes ago, browri said:

@Bobo77 I can actually answer this for you based on the article that you read.

Valproate isn't a D2 receptor blocker like antipsychotics. This article simply suggests that there is a reduction in signaling along the D2 pathways. However, this is more likely due to the upstream effects that valproate has on catecholamines like dopamine and norepinephrine. Valproate actually inhibits catecholamine synthesis, the brain's ability to make more norepinephrine and dopamine. It's been noted in studies that these neurotransmitters and their metabolites are elevated in those with bipolar disorder.

One thing to keep in mind is that bipolar disorder and ADHD do cross over (comorbid) more often than you would think. I take mood stabilizers and Vyvanse (amphetamine stimulant) and Depakote is the only thing that allows me to tolerate the necessary dose of Vyvanse I need to function properly. Without Depakote I can get a bit stressed after 2-3 weeks of 40mg so I have to decrease to 30mg. I don't have to do that when I'm taking Depakote. A dopamine modulator (partial agonist) like Rexulti (which I take) further controls the Vyvanse but doesn't outright block it like some of the older atypical antipsychotics.

If SSRIs make you agitated and you may be bipolar then bupropion is a good way to go if you're still depressed because it's less likely to cause a manic switch. It should also help any ADHD symptoms a bit.

 

It does sounds really good to know it isn’t blocking the D2 receptor. And I will ask my doctor about adding Wellbutrin to valproate later on if needed. But if I’m not bipolar but have ADHD symptoms, how do you know that?

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2 hours ago, Bobo77 said:

Argh:

I feel that a few SSRI I’ve tried did lift the mood but also triggered the tensions (which activate an enormous stress reaction) After a while they didn’t seem to work, and raised the dose etc. Some of them didn’t work at all. I Don’t remember all of them but I’ve tried, Zoloft, Effexor, cymbalta, fluoxetine, cipralex... also tried zyprexa, ability, seroquel, tegretol, lamotrigin, lyrica, noozinan, 

The tensions have practically crippled me in most ways, haven’t been able to exercise at all including walking. Before I was very active with all kinds of sports, was good on many of them and loved to compete and focus. So a big part of me is currently loss. Social relations have also been very hard because of tensions, to never been able to calm down and focus and feel any kind of peace. I could that before this, but almost every time after I did something, exercise, worked etc..

 

It does sounds really good to know it isn’t blocking the D2 receptor. And I will ask my doctor about adding Wellbutrin to valproate later on if needed. But if I’m not bipolar but have ADHD symptoms, how do you know that?

It would probably come down to seeing if a first line stimulant like adderal or ritalin works for you, assuming your pdoc is willing to prescribe.

Wellbutrin could possibly provide a hint, thought I believe it's 3rd or 4th line in treating ADD.

A lack of focus can also be attributed to depressive symptoms or subthreshold/hypo/manic symptoms

It's been proven that exercise can be equivalent to an anti-depressant, so it does make sense that when you were able to exercise and be active, you could focus.

https://www.ncbi.nlm.nih.gov/pubmed/10547175?dopt=Abstract

In fact, MDD with comorbid ADHD in adults are more likely to convert from unipolar to bipolar disorder. There are also some drug/treatment recommendations to deal with ADHD in the link below.

http://www.psychiatrictimes.com/special-reports/comorbid-adhd-and-depression-assessment-and-treatment-strategies

 

Anecdote time..

I've personally always had issues with focus and concentration. Doesn't mean that i can't at all for certain things..I do get hyperfocused in things that interest me...almost word for word as the article below

https://www.additudemag.com/understanding-adhd-hyperfocus/

Never officially diagnosed as a kid. Parents never thought of it as my issue vs just being lazy, stupid and useless...so be extra hard on me vs my brother. That was fun

Former pdoc thinks maybe ADHD..but I'm reasonably successful so I've learned to work around it and don't need to be explicitly put on ADHD meds per her conclusion. We had agreed to a conservative approach to treatment (was for MDD), so I didn't push for ADD meds or an official dx.

For me personally, wellbutrin helped somewhat, which would sort of make sense based on research and evidence. When I did focus for a topic of task that I didn't hyperfocus on, I was able to maintain it longer. Adding gabapentin (no evidence whatsoever that it should do anything in this realm..this is not a recommendation i can back up by research), worked to quiet my mind and helped somewhat to prevent it from jumping around to different topics or going so fast it started stumbling on the topic at hand...which in turn also helped focus and concentration.

Edited by argh
Why was there so much white space at the end?
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When I look back Ive always had the ability to hyperfocus. And often changing Jobs because I got understimulated very fast. And liked when I had many things to do at the same time with some  pressure it got me very focused and was easy to flow. Jobs with very monotone tasks didn’t really Worked out.

Then since I was little I was really sucked into different interests for a short time, then after I few weeks or days I just dropped it. It could be getting a parrot, I lend all the books on the local library and knew all facts of all different species and so on.. Is this typical for ADHD or could it be under bipolar disorder as well? 

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8 minutes ago, Bobo77 said:

When I look back Ive always had the ability to hyperfocus. And often changing Jobs because I got understimulated very fast. And liked when I had many things to do at the same time with some  pressure it got me very focused and was easy to flow. Jobs with very monotone tasks didn’t really Worked out.

Then since I was little I was really sucked into different interests for a short time, then after I few weeks or days I just dropped it. It could be getting a parrot, I lend all the books on the local library and knew all facts of all different species and so on.. Is this typical for ADHD or could it be under bipolar disorder as well? 

Hmm. Same here for that first bit about work.

and same here for that second piece too regarding interests. I have about 3k worth of equipment, not going to get into what, strewn across my room right now acquired over  3 months last year from two different passing interests/hobbies. No desire to use either for a good long while. Haven’t touched either since last year.

related to that second piece, starting projects and never finishing them too unfortunately are symptoms of both adhd and bp. Do you ever get that too?

if you do get to the bottom of your issue, stick around and update this thread, yeah? Like you, former pdoc also had a soft bipolar/bipolar spectrum suspicion too.

 

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20 hours ago, Bobo77 said:

It does sounds really good to know it isn’t blocking the D2 receptor. And I will ask my doctor about adding Wellbutrin to valproate later on if needed. But if I’m not bipolar but have ADHD symptoms, how do you know that?

 

16 hours ago, Bobo77 said:

When I look back Ive always had the ability to hyperfocus. And often changing Jobs because I got understimulated very fast. And liked when I had many things to do at the same time with some  pressure it got me very focused and was easy to flow. Jobs with very monotone tasks didn’t really Worked out.

Then since I was little I was really sucked into different interests for a short time, then after I few weeks or days I just dropped it. It could be getting a parrot, I lend all the books on the local library and knew all facts of all different species and so on.. Is this typical for ADHD or could it be under bipolar disorder as well? 

What you are describing is much more typical of bipolar disorder. People with ADHD have a much harder time accomplishing the things that you are describing without stimulants. Inability to maintain focus on one thing for long could be a symptom of ADHD.

My pdoc has said to my partner and I before (he sees both of us and we both have BP2 and ADHD), "Bipolar disorder is a moving target. ADHD is not." For example, I have experienced three kinds of inattentiveness related to my diagnosed conditions.

On the one hand, I lose focus and concentration because I lose interest in things I find enjoyable or I'm just apathetic. Depressive inattentiveness.

On the second hand, I may be inattentive or hyperactive because I'm hypomanic and my thoughts are racing. They may be fluid and seem collected. I may also be quite productive, but my follow-through is bad and my attention to detail is poor. Manic inattentiveness.

On the third and final hand, though, there is an area of my mood where I'm neither hypomanic nor depressed, but euthymic. Sometimes in that happy medium my attention/focus is still off, and this is where we're actually fighting ADHD.

Once we're sure my mood is completely stable from modifying mood stabilizer dose, then we look at adjusting the stimulant, but we know my doses at this point based on some time to feel it out. On Adderall XR, 20-25 mg is usually enough for me. On Vyvanse, I float between 30mg and 40mg depending on whether or not I'm taking an antidepressant.

What you are describing may be a form of grandiosity, becoming wildly fascinated with random things and pouring yourself into projects, jumping from job to job. My therapist has told me a few times before about how I like doing what I do because my job in and of itself is "manic". I work in IT. It's a 24/7 job, and it can be very, VERY fast-paced. I can get really stressed at work, and my job definitely tests my limits on a regular basis. But my therapist impressed upon me that no matter how frustrated or stressed my job makes me, I'm still drawn to that kind of work because of my nature. My partner is in sales, and he has said the same thing about his own job and spoke with our pdoc about it, who said he's heard that from a lot of his bipolar patients when they describe their jobs.

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3 hours ago, browri said:

 

What you are describing is much more typical of bipolar disorder. People with ADHD have a much harder time accomplishing the things that you are describing without stimulants. Inability to maintain focus on one thing for long could be a symptom of ADHD.

My pdoc has said to my partner and I before (he sees both of us and we both have BP2 and ADHD), "Bipolar disorder is a moving target. ADHD is not." For example, I have experienced three kinds of inattentiveness related to my diagnosed conditions.

On the one hand, I lose focus and concentration because I lose interest in things I find enjoyable or I'm just apathetic. Depressive inattentiveness.

On the second hand, I may be inattentive or hyperactive because I'm hypomanic and my thoughts are racing. They may be fluid and seem collected. I may also be quite productive, but my follow-through is bad and my attention to detail is poor. Manic inattentiveness.

On the third and final hand, though, there is an area of my mood where I'm neither hypomanic nor depressed, but euthymic. Sometimes in that happy medium my attention/focus is still off, and this is where we're actually fighting ADHD.

Once we're sure my mood is completely stable from modifying mood stabilizer dose, then we look at adjusting the stimulant, but we know my doses at this point based on some time to feel it out. On Adderall XR, 20-25 mg is usually enough for me. On Vyvanse, I float between 30mg and 40mg depending on whether or not I'm taking an antidepressant.

What you are describing may be a form of grandiosity, becoming wildly fascinated with random things and pouring yourself into projects, jumping from job to job. My therapist has told me a few times before about how I like doing what I do because my job in and of itself is "manic". I work in IT. It's a 24/7 job, and it can be very, VERY fast-paced. I can get really stressed at work, and my job definitely tests my limits on a regular basis. But my therapist impressed upon me that no matter how frustrated or stressed my job makes me, I'm still drawn to that kind of work because of my nature. My partner is in sales, and he has said the same thing about his own job and spoke with our pdoc about it, who said he's heard that from a lot of his bipolar patients when they describe their jobs.

I can really relate to the first two things you wrote, I’m not sure I understand the third one.

 

I can add that I’m a very artistic person. Have been playing music and painted among all through my life. When I’ve painted especially time and space disappeared, music as well. Nowadays I cant paint so much because of the nerve/muscle tensions that become worse in static positions and also the ON switch turns on from things that gets me going.

 

browri, can I ask do you use any medication for the BP2 condition?

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3 hours ago, Bobo77 said:

I can really relate to the first two things you wrote, I’m not sure I understand the third one.

You aren't depressed and you aren't "up". You're in between, right where you should be.

3 hours ago, Bobo77 said:

I can add that I’m a very artistic person. Have been playing music and painted among all through my life. When I’ve painted especially time and space disappeared, music as well. Nowadays I cant paint so much because of the nerve/muscle tensions that become worse in static positions and also the ON switch turns on from things that gets me going.

Being interested to the point of excitement and pouring large amounts of energy into your interests COULD be a sign of bipolar disorder but on its own isn't necessarily. It's when your latest obsessions start to eclipse all else that it starts to border on bipolar. People with bipolar 1 often have issues holding down jobs because their mood swings are too extreme. People with bipolar 2 on the other hand could be very high functioning individuals, sometimes quite intelligent. However, their condition doesn't regularly impede normal functioning in the world like getting out of bed and going to work or meeting your other non-work obligations that way that it can in bipolar 1 disorder. Interestingly enough, people with bipolar 2 disorder in particular seem to have prominent impulsivity issues which translates into a high rate of suicide attempts. Additionally, bipolar 2 disorder can go undiagnosed for a while. I knew in 2004 I had mood issues but wasn't appropriately diagnosed as bipolar 2 until 2013. Everything changed when I started taking the appropriate medications.

3 hours ago, Bobo77 said:

browri, can I ask do you use any medication for the BP2 condition?

I take a combination of Depakote and Rexulti as a mood-stabilizing backbone but the core of it is really the Depakote. I have a tendency to rapidly cycle and become mixed, and it does suit me better per the evidence in its favor for these kinds of conditions. Rexulti has positive effects on my depression and anxiety and also calms intrusive or racing thoughts when I get a little "wobbly".

I'm also currently taking Lamictal as a preventative measure against depression and added mood stabilization. However, I'm likely going to be going back to Trintellix at my next appt, which is what I was on previously, and it worked quite well. Lamictal hasn't been cutting it for my depression going into Fall/Winter.

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I was just reading about Rexulti, I didn’t know it was an improved ability, sounds also interesting to target my depression.

I’m now on 300mg Depakote together with 25mg Zoloft and 15mg cymbalta. I will do a shift soon so I remove sertralin/cymbalta and go up to 600mg Depakote. I don’t know if that dose is normal, low? I understand Depakote is better targeting the maniac fases than depressive ones. My bigger problem is the depression.

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16 minutes ago, Bobo77 said:

I was just reading about Rexulti, I didn’t know it was an improved ability, sounds also interesting to target my depression.

I’m now on 300mg Depakote together with 25mg Zoloft and 15mg cymbalta. I will do a shift soon so I remove sertralin/cymbalta and go up to 600mg Depakote. I don’t know if that dose is normal, low? I understand Depakote is better targeting the maniac fases than depressive ones. My bigger problem is the depression.

600mg of Depakote isn't necessarily a low dose. My pdoc says "1000mg is the average dose". He also doesn't put as much stock in blood levels and doses based on symptoms and references the blood level if there is an issue. A "therapeutic" level of valproic acid is 50-100mcg/mL with the level for acute mania being more like 80-100mcg/mL. A 600mg dose of Depakote will likely not yield these concentrations, but it does depend on weight. I take 1250mg of Depakote, but I'm also 6 feet tall and weigh 210 pounds. I have a level of around 69 right now. More than likely 600mg isn't the target dose unless your doctor is more progressive in their thinking and will dose based on response. The "therapeutic" blood level isn't necessary for everyone and for those that require it, it may not be necessary for the entire duration of treatment. Some adjustments may be temporary.

So it would be good to go along with your pdoc and see how this goes. When I was first diagnosed with bipolar 2 disorder, my pdoc cut my Cymbalta from 60mg to 30mg and immediately started Lamictal. Then we used Prozac to titrate off the Cymbalta entirely, then discontinued the Prozac. Unfortunately, after trying the usual treatments for bipolar disorder, we did find that my depressive episodes return almost invariably every Fall/Winter if I'm not taking an antidepressant. So going off antidepressants now doesn't necessarily mean you can't take them later if the situation warrants it.

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25 minutes ago, Bobo77 said:

I was just reading about Rexulti, I didn’t know it was an improved ability, sounds also interesting to target my depression.

I’m now on 300mg Depakote together with 25mg Zoloft and 15mg cymbalta. I will do a shift soon so I remove sertralin/cymbalta and go up to 600mg Depakote. I don’t know if that dose is normal, low? I understand Depakote is better targeting the maniac fases than depressive ones. My bigger problem is the depression.

Known for antimanic effects however, might work for acute bipolar depression

https://www.ncbi.nlm.nih.gov/pubmed/19926140

 

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Browri:

It’s a real puzzling to get the right pieces. However I think finally I’m on right track, just need more patience and trial and error to get to some level of stability I believe. 

 

Argh:

Sounds good, thanks for the link!

 

Thank you all for sharing and help, appreciate a lot!

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Argh:

You mentioned in your first post about the function of valproate: “valproate is theorized to work on the gaba and glutamate system via effects on the sodium gated channels.”

Does lamictal work in a whole different way? I thought it also lower glutamate and raise GABA? What other medication is closest by to function the way lamictal does?

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6 minutes ago, Bobo77 said:

Argh:

You mentioned in your first post about the function of valproate: “valproate is theorized to work on the gaba and glutamate system via effects on the sodium gated channels.”

Does lamictal work in a whole different way? I thought it also lower glutamate and raise GABA? What other medication is closest by to function the way lamictal does?

I think I can actually answer this. I've done a lot of research on valproate and lamotrigine since I'm taking both of them right now. They do work differently, and I'll try to explain it.

A primer though. Glutamate and GABA are effectively "opposites" and they form a see-saw in the brain. Glutamate converts to GABA and GABA converts back to glutamate. Activating GABA receptors reduces glutamate release and increased glutamate signaling would reduce GABA signaling. Glutamate is activating. GABA is inhibiting.

Valproate works at both ends of the GABA/glutamate see-saw. It increases the conversion of glutamate into GABA and then inhibits GABA's breakdown back into glutamate. The increased levels of GABA in the brain result in lower glutamate signaling, which is hypothesizes to be one of the core reasons why valproate is so effective for mania. Other reasons would be that it induces MAO-A which would encourage the metabolism of excess serotonin and inhibits the synthesis of catecholamines like norepinephrine and dopamine, which could contribute to mania or depression.

Lamotrigine works a bit differently. It reduces the RELEASE of glutamate from neurons. By reducing glutamate signaling, it too could potentially increase GABA signaling by suppressing the glutamate pathways. It's a different mechanism of action altogether. Therefore, valproate and lamotrigine can be combined to create a pretty formidable cocktail (I mean that in the best possible way). A study was done where the patients in the study were given both valproate and lamotrigine for the first half. Then for the second half, lamotrigine was replaced with placebo for half the patients. The patients who had lamotrigine replaced with placebo said that they preferred the valproate+lamotrigine combo over valproate alone. This was a double-blind trial meaning the doctors and the patients didn't know whether they were on the valproate+placebo or valproate+lamotrigine for the second half of the trial.

Another interesting point is that the metabolism of neurotransmitters like GABA and glutamate occurs intracellularly (inside neurons). This metabolism is responsible for the conversion of glutamate to GABA and GABA back to glutamate. By taking lamotrigine, you reduce glutamate release, leaving more in the cells for valproate to do its job which is to convert that excess glutamate into GABA and "lock it in" that way to keep it from converting back to glutamate.

To answer your other question, the one medication that is most similar to lamotrigine in regards to actual mechanism of action would be topiramate (Topamax). However, there is far less evidence in favor of its use in bipolar disorder than there is for lamotrigine.

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6 hours ago, Bobo77 said:

Argh:

You mentioned in your first post about the function of valproate: “valproate is theorized to work on the gaba and glutamate system via effects on the sodium gated channels.”

Does lamictal work in a whole different way? I thought it also lower glutamate and raise GABA? What other medication is closest by to function the way lamictal does?

Uhhh. What @browri said. Lol

at a high level, the gaba or glutamate systems are how most anticonvulsants function.

to the point, however, not all anticonvulsants are mood stabilizers, however many are used offlabel for that purpose.

the main ones are valproate, Lamotrigine and carbamazepine.

offlabel with scant or no studies...though perhaps clinical wisdom

topamax

gabapentin

oxcarbazapine

pregabalin

keppra

a few which you had tried.

fwiw, when former pdoc was talking about bp spectrum with me, topamax was one of the potential options suggested.

looking at your past med list, as you’ve had zyprexa with no effect as well as carbamazepine, if this medwise, leans more to adhd? Not a doc of course, so hey good luck with the valproate. Definitely worth a shot.

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I took a moment to look back on the meds you took and how you described the "tension". That COULD be antidepressant-induced hypomania, but you may also be one of those people who is genetically predisposed to not respond well to antidepressants. Most modern antidepressants inhibit the serotonin transporter which is encoded by a gene called SERT (or SLC6A4 if you're feeling fancy). This gene has several different SNPs (single nucleotide polymorphisms) which alone may not have much effect, but together can be formidable.

On the SERT, you can have a long or short allele, which I won't get into in great depth, but it's most important to know in this context specifically that short means less transporter, and long means a normal amount of the transporter or more than most. The ratio of shorts to longs varies from person to person. I have 3-4 short "repeats" which predispose me to lower levels of the serotonin transporter. Therefore, inhibition of the transporter with an SSRI should theoretically be bad, right? Not necessarily.

The only correlation that they've been able to find is that people with a few repeats of the short allele are USUALLY more likely to have tolerability issues with antidepressants, but even that is inconsistent, and some people with several short repeats may have tolerability issues in the beginning but may respond really well with long-term treatment. I for example always eventually fall into depression without antidepressants, but without mood stabilizers, antidepressants make me worse. So it's about finding balance. However, if you are one of those people who does adhere to the statistic, then you may do better on something like mirtazapine.

Because you've tried a fair amount of medications already, doing genetic testing may be useful, but not ones that just look at drug metabolism. There are better ones like GenoMind that look into some of the genes that encode brain functions as well. They really aren't perfect. There have been so many stories of people who take the test and then try a medication that the report says they will do well with, and ultimately they find that it wasn't a match. Pharmacogenomics is still kind of an art more than a science. We just don't know enough yet to really be entirely sure what will stick.

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