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Overall I've been pretty stable for the past couple of months and havn't had any Mania or severe depression but I still am having pretty serious anxiety. I've asked my pdoc for Lyrica considering that I usually don't do well on antidepressants and have tried buspar, hydroxyzine and gabapentin with poor results. Effexor seems to be the only thing that has touched my anxiety but then going from 150mg which I'm on to 225mg could risk destabilizing me. He says he doesn't feel comfortable "using me as a guniea pig" for Lyrica. I really feel as if this could be the thing but I don't know. How should I approach this? Thanks

Also any experiences on people being on Lyrica for anxiety would be helpful!

Current meds 

Effexor XR 150mg 

Depakote ER 2500mg

Latuda 100mg

Trazodone 100mg

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15 hours ago, tbs14 said:

Also any experiences on people being on Lyrica for anxiety would be helpful!

I have never tried Lyrica, but I think there are a few people here that take it.....Hopefully someone will reply that has actual experience.

I have severe anxiety, too, and I take a benzodiazepine drug, clonazepam (Klonopin) for it.

Would your doc consider a benzo medication for you?

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My pdoc only perscribes daily benzos short-term or he does them prn

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Just now, tbs14 said:

My pdoc only perscribes daily benzos short-term or he does them prn

Hmmm.......Do you think a prn benzo would be enough coverage for your anxiety?.....have you ever brought up benzos with your doc?

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He said 5 pills of klonipin would would be all he would perscribe and at this point that isn't enough coverage but maybe if my daily anxiety managed better it could be enough

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1 minute ago, tbs14 said:

He said 5 pills of klonipin would would be all he would perscribe and at this point that isn't enough coverage but maybe if my daily anxiety managed better it could be enough

Yes, all docs have their different views on benzos............If your doc won't prescribe a daily benzo, I guess Lyrica would be worth a try..........Again, though, I've never used it.

Sometimes low-dose Seroquel is used for anxiety.......I see you are already on Latuda, though.

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I had been on Seroquel and Seroquel XR for about a year but the weight gain and sugar cravings and the fact it wasn't very effective made me go off of it.

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Posted (edited)
10 minutes ago, tbs14 said:

I had been on Seroquel and Seroquel XR for about a year but the weight gain and sugar cravings and the fact it wasn't very effective made me go off of it.

Oh, okay, I see........I wish I had something else to suggest, but I am going to call on some of our community members who are very knowledgeable about medications...... @mikl_pls  @browri @notloki @argh. would any of you have any suggestions for the OP?

(tbs, it may take a little time for them to respond)

Edited by CrazyRedhead
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Posted (edited)

@tbs14, just a suggestion....It might be helpful to others reading this, to list all your past meds that you've tried and failed at.

You can list them on the signature section of your profile....See my signature below for an example.

Edited by CrazyRedhead

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My Mum was taken off lyrica last year (for nerve pain) after a decent sized study showed that it is the #1 drug for accidental overdose ER visits.

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Posted (edited)
22 hours ago, tbs14 said:

Overall I've been pretty stable for the past couple of months and havn't had any Mania or severe depression but I still am having pretty serious anxiety. I've asked my pdoc for Lyrica considering that I usually don't do well on antidepressants and have tried buspar, hydroxyzine and gabapentin with poor results. Effexor seems to be the only thing that has touched my anxiety but then going from 150mg which I'm on to 225mg could risk destabilizing me. He says he doesn't feel comfortable "using me as a guniea pig" for Lyrica. I really feel as if this could be the thing but I don't know. How should I approach this? Thanks

Also any experiences on people being on Lyrica for anxiety would be helpful!

Current meds 

Effexor XR 150mg 

Depakote ER 2500mg

Latuda 100mg

Trazodone 100mg

What was your reaction to gabapentin, when you said that it went poorly? Was it a lack of efficacy? Or was it a bad reaction? Lyrica is a calcium channel blocker and gaba analogue that is related to gabapentin. The bioavailability is much better however. By most accounts it is said to be more effective, as in a more powerful version of gabapentin. better efficacy, but also known to cause more cognitive issues and some breast tenderness. Weight gain isn’t reported to be as major vs an antipsychotic, but is also a potential issue for lyrica.

id like to try it one day myself, as gabapentin is my miracle drug.

i dont know where you live but in the uk it is approved as an anxiolytic. You could maybe work that angle for lyrica. Lyrica is a scheduled substance, so if your doc is benzophobic, it might be a hard sell, unless he just doesnt like benzos.

Perhaps a different anticonvulsant? These below are weight neutral.

Oxcarbazepine gets pretty good reviews. Like a lesser version of carbamazepine, but no regular blood tests are needed. If you are asian, you will want to be tested for the hlab 1502 allele, as Stevens-Johnson syndrome is significantly more likely if that is present. If it is promising but not quite enough, you could try carbamazepine. 

ive had good experience with Lamotrigine, even if it isn’t quite known as an anxiolytic.  Being on valproate, however, you would have to have a half dose as valproate increases blood levels of Lamotrigine, which may put you at a higher risk of Stevens-Johnson syndrome if the standard titration schedule is adhered to.

if you are looking towards something otc, i can vouch for nac at a 2000mg dose per day, split. It does make me a bit foggy in my personal experience ever since i added Lamotrigine. Nac works as a powerful antioxidant and as a glutamate modulator, similar to Lamotrigine, so perhaps in my situation, its just too much if a good thing going on.

magnesium citrate is possibly an option. I haven’t tried it however as it interferes with gabapentin. 

 

Edited by argh
Nl is not on Lamotrigine, according to his sig

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On 6/8/2019 at 6:02 PM, tbs14 said:

Overall I've been pretty stable for the past couple of months and havn't had any Mania or severe depression but I still am having pretty serious anxiety. I've asked my pdoc for Lyrica considering that I usually don't do well on antidepressants and have tried buspar, hydroxyzine and gabapentin with poor results. Effexor seems to be the only thing that has touched my anxiety but then going from 150mg which I'm on to 225mg could risk destabilizing me. He says he doesn't feel comfortable "using me as a guniea pig" for Lyrica. I really feel as if this could be the thing but I don't know. How should I approach this? Thanks

Also any experiences on people being on Lyrica for anxiety would be helpful!

Current meds 

Effexor XR 150mg 

Depakote ER 2500mg

Latuda 100mg

Trazodone 100mg

Hey @tbs14! Welcome to the boards.

Couple things. You have a very interesting combination....and that is a TON of valproate (Depakote). I'm surprised you're still having anxiety issues with a valproate dose that high, but I suppose it is possible for many.

How do you accomplish a 100mg dose of lurasidone (Latuda), as it only comes in 20, 40, 60, 80, and 120? Do you take an 80+20?

When you say that you don't do well on antidepressants, do you mean to say that they can easily trigger mania for you, or do you just not tolerate them well? Venlafaxine (Effexor) is generally regarded as having some of the highest risk of the SSRIs and SNRIs for inducing mania, but it is also immensely effective for anxiety in many people. Balancing the risks and benefits is an important part of treatment. If your mood is well-controlled with valproate+lurasidone, then the likelihood of venlafaxine triggering mania is lower.

Can you describe in more detail your experience with gabapentin? While pregabalin (Lyrica) has better bioavailability and is just generally more potent, your experience with gabapentin will be a predictor of your experience on pregabalin only in that they are of the same class of medications.

Did you notice that any of this anxiety started or became worse when you started lurasidone? I only say this because lurasidone actually MADE me feel panicky 1-4 hours after taking it, but that was really in the lower doses of 20-40mg.

Your cocktail reminds me of my own only in that we both have to balance stimulation against sedation. You take venlafaxine (stimulating) against valproate+lurasidone+trazodone (sedating) and I take lisdexamfetamine+vortioxetine (Vyvanse+Trintellix - stimulating) against valproate+brexpiprazole (Depakote+Rexulti - sedating).

And speaking of brexpiprazole, I would highly recommend as a replacement for the lurasidone. It's more calming, still helps with sleep like lurasidone, but it doesn't knock you out drooling at night the way lurasidone does. Brexpiprazole is also an incredibly effective antidepressant at doses of just 0.25mg to 0.5mg. I find it to be better for my depression and anxiety than lurasidone was.

I took lurasidone in the very beginning when I was first diagnosed with bipolar disorder. I went to see a new psychiatrist and I was only taking duloxetine 60mg (Cymbalta). I was fairly hypomanic and cycling quickly. He immediately halved my duloxetine dose to 30mg and started me on lamotrigine. We gradually titrated up the lamotrigine over the course of several weeks and eventually swapped the 30mg of duloxetine for 10mg of fluoxetine for a week, and then I discontinued antidepressants until I could stabilize.

I got all the way up to 200mg on lamotrigine, but I was still depressed, and we ultimately added lurasidone. First 20mg, then 40mg, then to 60mg. Around then was when the akathisia started, but it eased up with time and we eventually tried to push it further to 80mg to address residual irritability and agitation, but the restlessness came back with a vengeance. We ultimately cycles through several more AAPs only to find that my akathisia threshold is actually insanely low, so I can't tolerate the full doses of AAPs necessary to stabilize the mood. I needed to combine a calming anticonvulsant with a calming antipsychotic in low to moderate doses to achieve the right effect. It only took me like 5-6 years to figure that out though. That's how I arrived at my current combo:

Trintellix 10mg AM

Vyvanse 40mg AM

Rexulti 1mg PM

Depakote ER 500mg PM

I also take Vascepa, which is a prescription-grade, EPA-only fish oil (omega-3's). Studies have demonstrated EPA (eicosapentaenoic acid) has positive effects in bipolar depression. You'll notice as well that my Depakote dose is at the bottom end of the dose scale and my blood levels aren't even close to being in what's considered the "therapeutic range", but they don't need to be for me to maintain the stability of my mood because I also take Rexulti, which is very calming, improves sleep, reduces my depression in combo with the Trintellix, and really helps significantly with my anxiety. The "fight-or-flight response" is dampened.

If I ever do seem to notice that an episode is "forming", I can always start increasing the Depakote first to 750mg and then to 1000mg and even to 1250mg if necessary, but I've found that 1500mg is not ideal for me unless I were thick in the middle of a manic episode with no medication on-board to control it, but not as a maintenance dose. If I'm not seeing results quickly enough, I can also start taking an extra 0.5mg of Rexulti for a total of 1.5mg. If the Depakote doesn't calm things down quickly, the Rexulti usually does in 2-3 days.

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I use a 20mg in the morning and 80mg at night.

I honestly can't remember what effect gabapentin had on me because I was on some much Seroquel and only got to 900mg of gaba. 

I find that the higher dose of Latuda is more calming and helps significantly with psychosis and mania/ depression. 

I have thought about asking my pdoc for Rexulti. 

At this point my main issues are residual apathy/depression and anxiety/OCD. 

Do you take the Vyvanse for depression? If so has it helped you with the apathy, anhedonia, etc?

I remember when the pdoc in the hospital thought I had ADHD he put me on low dose Ritalin and I finally felt like a cloud had been taken away. 

I don't feel that increasing any of my current meds would have any benefit since I'm not having any concrete epsiodes. It more like this low level simmering anxiety and depression. 

 

3 hours ago, browri said:

Hey @tbs14! Welcome to the boards.

Couple things. You have a very interesting combination....and that is a TON of valproate (Depakote). I'm surprised you're still having anxiety issues with a valproate dose that high, but I suppose it is possible for many.

How do you accomplish a 100mg dose of lurasidone (Latuda), as it only comes in 20, 40, 60, 80, and 120? Do you take an 80+20?

When you say that you don't do well on antidepressants, do you mean to say that they can easily trigger mania for you, or do you just not tolerate them well? Venlafaxine (Effexor) is generally regarded as having some of the highest risk of the SSRIs and SNRIs for inducing mania, but it is also immensely effective for anxiety in many people. Balancing the risks and benefits is an important part of treatment. If your mood is well-controlled with valproate+lurasidone, then the likelihood of venlafaxine triggering mania is lower.

Can you describe in more detail your experience with gabapentin? While pregabalin (Lyrica) has better bioavailability and is just generally more potent, your experience with gabapentin will be a predictor of your experience on pregabalin only in that they are of the same class of medications.

Did you notice that any of this anxiety started or became worse when you started lurasidone? I only say this because lurasidone actually MADE me feel panicky 1-4 hours after taking it, but that was really in the lower doses of 20-40mg.

Your cocktail reminds me of my own only in that we both have to balance stimulation against sedation. You take venlafaxine (stimulating) against valproate+lurasidone+trazodone (sedating) and I take lisdexamfetamine+vortioxetine (Vyvanse+Trintellix - stimulating) against valproate+brexpiprazole (Depakote+Rexulti - sedating).

And speaking of brexpiprazole, I would highly recommend as a replacement for the lurasidone. It's more calming, still helps with sleep like lurasidone, but it doesn't knock you out drooling at night the way lurasidone does. Brexpiprazole is also an incredibly effective antidepressant at doses of just 0.25mg to 0.5mg. I find it to be better for my depression and anxiety than lurasidone was.

I took lurasidone in the very beginning when I was first diagnosed with bipolar disorder. I went to see a new psychiatrist and I was only taking duloxetine 60mg (Cymbalta). I was fairly hypomanic and cycling quickly. He immediately halved my duloxetine dose to 30mg and started me on lamotrigine. We gradually titrated up the lamotrigine over the course of several weeks and eventually swapped the 30mg of duloxetine for 10mg of fluoxetine for a week, and then I discontinued antidepressants until I could stabilize.

I got all the way up to 200mg on lamotrigine, but I was still depressed, and we ultimately added lurasidone. First 20mg, then 40mg, then to 60mg. Around then was when the akathisia started, but it eased up with time and we eventually tried to push it further to 80mg to address residual irritability and agitation, but the restlessness came back with a vengeance. We ultimately cycles through several more AAPs only to find that my akathisia threshold is actually insanely low, so I can't tolerate the full doses of AAPs necessary to stabilize the mood. I needed to combine a calming anticonvulsant with a calming antipsychotic in low to moderate doses to achieve the right effect. It only took me like 5-6 years to figure that out though. That's how I arrived at my current combo:

Trintellix 10mg AM

Vyvanse 40mg AM

Rexulti 1mg PM

Depakote ER 500mg PM

I also take Vascepa, which is a prescription-grade, EPA-only fish oil (omega-3's). Studies have demonstrated EPA (eicosapentaenoic acid) has positive effects in bipolar depression. You'll notice as well that my Depakote dose is at the bottom end of the dose scale and my blood levels aren't even close to being in what's considered the "therapeutic range", but they don't need to be for me to maintain the stability of my mood because I also take Rexulti, which is very calming, improves sleep, reduces my depression in combo with the Trintellix, and really helps significantly with my anxiety. The "fight-or-flight response" is dampened.

If I ever do seem to notice that an episode is "forming", I can always start increasing the Depakote first to 750mg and then to 1000mg and even to 1250mg if necessary, but I've found that 1500mg is not ideal for me unless I were thick in the middle of a manic episode with no medication on-board to control it, but not as a maintenance dose. If I'm not seeing results quickly enough, I can also start taking an extra 0.5mg of Rexulti for a total of 1.5mg. If the Depakote doesn't calm things down quickly, the Rexulti usually does in 2-3 days.

 

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10 minutes ago, tbs14 said:

I use a 20mg in the morning and 80mg at night.

Makes sense. Higher dose would be more sedating and would be better at night, whereas the lower doses are stimulating.

10 minutes ago, tbs14 said:

I honestly can't remember what effect gabapentin had on me because I was on some much Seroquel and only got to 900mg of gaba. 

Makes sense. Will if you do remember any differences as you think about it, you can likely expect a similar but more potent effect from pregabalin.

10 minutes ago, tbs14 said:

I find that the higher dose of Latuda is more calming and helps significantly with psychosis and mania/ depression. 

I ended up getting to 80mg but even though it was fairly good in combo with lamotrigine for depression, it didn't fully address my irritability/agitation and I was really restless. 60mg was tolerable from an akathisia standpoint but it didn't effectively control my manic symptoms. Lamotrigine didn't either which isn't surprising. In retrospect I wonder if I would have done better on lurasidone if I had taken it with divalproex. I've never tried the combo before so it'll definitely be something I consider if I need to change it up.

10 minutes ago, tbs14 said:

I have thought about asking my pdoc for Rexulti. 

At this point my main issues are residual apathy/depression and anxiety/OCD. 

I would say from my own experience that Rexulti helped with those. I felt less anhedonic and even noticed a bit of an improved sex drive when I started Rexulti. Unfortunately it leveled off after a while lol. But I wouldn't say Rexulti causes me any sexual dysfunction. If anything I think it wards off any sexual dysfunction I might be getting from the Trintellix.

Rexulti is also very calming. It has activity at more adrenergic receptors than lurasidone and is more potent at those receptors, thus calming the adrenaline system and easing anxiety. My pdoc and I arrived at Rexulti after trials on olanzapine and loxapine, and we found their calming and antidepressant effects to be an important part of my treatment. My pdoc said his experience with other patients was that Rexulti would be similarly calming (unlike its predecessor, aripiprazole [Abilify]) and good for depression in low doses. It does have more weight gain potential than aripiprazole but still far less than quetiapine or olanzapine.

10 minutes ago, tbs14 said:

Do you take the Vyvanse for depression? If so has it helped you with the apathy, anhedonia, etc?

My original motivation to get Vyvanse was for my depression, but my pdoc didn't buy that. However, he did note that he thought ADHD was a possible diagnosis for me and that if we got my mood sorted out and I still experienced issues with focus/concentration, he would consider it. After quite a bit of time exploring the merry-go-round and arriving at a combo that stabilized me, I still complained about concentration issues and general cognitive problems. He gave me an Adult ADHD diagnosis questionnaire of sorts and then basically added on Adderall to my existing regimen. Once I found my dose using the immediate release tablets, I eventually converted to a single XR daily dose. Then I eventually switched to Vyvanse because I was having issues with poop-out starting around 2PM, feeling generally zombified in the afternoons, and also feeling like I have a fire lit under my ass, which Vyvanse doesn't really do. Smoother release throughout the day, easier comedown, and less jitters.

What I learned through this exercise though is that you shouldn't waste your time on stimulants for motivation or energy because you really only feel those two positive effects in the first 1-2 weeks taking it. It wears off after a while as you adjust to it, and you're left with lots of focus and concentration and you might feel generally less sleepy. But long-time stimulant veterans will tell you that for motivation, you'll just be endlessly increasing your stimulant dose to keep that going until you max it out or have a heart attack, whichever comes first.

However, I did learn that even when the energizing effects went away after the first few weeks, I did appreciate the positive impact it had on my productivity. I found I was able to do complex "desk-work" tasks that would normally take a long time and several sittings I could do in fewer sittings or all at once because I could actually get focused and keep from getting distracted.

Vyvanse does help a lot with my depression/apathy/anhedonia though. Trintellix mixes well with it because they enhance each other in my experience. Like I can take a lower dose of each than if I was taking either of them separately. Vyvanse I would normally need 50mg, but I do fine on 30-40 depending on my Trintellix dose. And I would normally need 20mg of Trintellix for the extra energy and stimulation but I don't need it while I'm taking Vyvanse. So it's a happy medium.

10 minutes ago, tbs14 said:

I remember when the pdoc in the hospital thought I had ADHD he put me on low dose Ritalin and I finally felt like a cloud had been taken away. 

If you wanted to talk to your doctor about it, they may be more receptive to prescribing methylphenidate (Ritalin, Concerta, Metadate) or dexmethylphenidate (Focalin) for lingering fatigue or anhedonia and apathy related to your depression than prescribing amphetamine-based stimulants like Adderall or Vyvanse.

10 minutes ago, tbs14 said:

I don't feel that increasing any of my current meds would have any benefit since I'm not having any concrete epsiodes. It more like this low level simmering anxiety and depression. 

If you feel depression, consider as well that your valproate dose could be high, but I also see that you're under control and it sounds like it took some trying to get there, so that may not be an option. How long have you been taking Latuda? Curious if at this point you've given it a solid go (i.e. 12+ weeks). If so, maybe it is time to switch to something more calming that will have a similar antidepressant effect. If you were already thinking about talking to your doctor about Rexulti, maybe now's the time. I know others on here like it a lot.

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21 hours ago, browri said:

Makes sense. Higher dose would be more sedating and would be better at night, whereas the lower doses are stimulating.

Makes sense. Will if you do remember any differences as you think about it, you can likely expect a similar but more potent effect from pregabalin.

I ended up getting to 80mg but even though it was fairly good in combo with lamotrigine for depression, it didn't fully address my irritability/agitation and I was really restless. 60mg was tolerable from an akathisia standpoint but it didn't effectively control my manic symptoms. Lamotrigine didn't either which isn't surprising. In retrospect I wonder if I would have done better on lurasidone if I had taken it with divalproex. I've never tried the combo before so it'll definitely be something I consider if I need to change it up.

I would say from my own experience that Rexulti helped with those. I felt less anhedonic and even noticed a bit of an improved sex drive when I started Rexulti. Unfortunately it leveled off after a while lol. But I wouldn't say Rexulti causes me any sexual dysfunction. If anything I think it wards off any sexual dysfunction I might be getting from the Trintellix.

Rexulti is also very calming. It has activity at more adrenergic receptors than lurasidone and is more potent at those receptors, thus calming the adrenaline system and easing anxiety. My pdoc and I arrived at Rexulti after trials on olanzapine and loxapine, and we found their calming and antidepressant effects to be an important part of my treatment. My pdoc said his experience with other patients was that Rexulti would be similarly calming (unlike its predecessor, aripiprazole [Abilify]) and good for depression in low doses. It does have more weight gain potential than aripiprazole but still far less than quetiapine or olanzapine.

My original motivation to get Vyvanse was for my depression, but my pdoc didn't buy that. However, he did note that he thought ADHD was a possible diagnosis for me and that if we got my mood sorted out and I still experienced issues with focus/concentration, he would consider it. After quite a bit of time exploring the merry-go-round and arriving at a combo that stabilized me, I still complained about concentration issues and general cognitive problems. He gave me an Adult ADHD diagnosis questionnaire of sorts and then basically added on Adderall to my existing regimen. Once I found my dose using the immediate release tablets, I eventually converted to a single XR daily dose. Then I eventually switched to Vyvanse because I was having issues with poop-out starting around 2PM, feeling generally zombified in the afternoons, and also feeling like I have a fire lit under my ass, which Vyvanse doesn't really do. Smoother release throughout the day, easier comedown, and less jitters.

What I learned through this exercise though is that you shouldn't waste your time on stimulants for motivation or energy because you really only feel those two positive effects in the first 1-2 weeks taking it. It wears off after a while as you adjust to it, and you're left with lots of focus and concentration and you might feel generally less sleepy. But long-time stimulant veterans will tell you that for motivation, you'll just be endlessly increasing your stimulant dose to keep that going until you max it out or have a heart attack, whichever comes first.

However, I did learn that even when the energizing effects went away after the first few weeks, I did appreciate the positive impact it had on my productivity. I found I was able to do complex "desk-work" tasks that would normally take a long time and several sittings I could do in fewer sittings or all at once because I could actually get focused and keep from getting distracted.

Vyvanse does help a lot with my depression/apathy/anhedonia though. Trintellix mixes well with it because they enhance each other in my experience. Like I can take a lower dose of each than if I was taking either of them separately. Vyvanse I would normally need 50mg, but I do fine on 30-40 depending on my Trintellix dose. And I would normally need 20mg of Trintellix for the extra energy and stimulation but I don't need it while I'm taking Vyvanse. So it's a happy medium.

If you wanted to talk to your doctor about it, they may be more receptive to prescribing methylphenidate (Ritalin, Concerta, Metadate) or dexmethylphenidate (Focalin) for lingering fatigue or anhedonia and apathy related to your depression than prescribing amphetamine-based stimulants like Adderall or Vyvanse.

If you feel depression, consider as well that your valproate dose could be high, but I also see that you're under control and it sounds like it took some trying to get there, so that may not be an option. How long have you been taking Latuda? Curious if at this point you've given it a solid go (i.e. 12+ weeks). If so, maybe it is time to switch to something more calming that will have a similar antidepressant effect. If you were already thinking about talking to your doctor about Rexulti, maybe now's the time. I know others on here like it a lot.

Latuda has helped me so much I'd hate to give up the progress that I've made with it. Would it be unwise to ask my pdoc rexulti and to possibly stay on latuda. 

 

 

My OCD is very bad too. I think I've had it all my life it's just that the obsessions and compulsions have changed. I believe this might also be contributing to my depression. 

Ability which is rexulti's cousin is used to augment antidepressants for OCD so maybe it it's worth a shot. 

I've heard the vraylar can help more with apathy, cognition, etc. Is this true or is this subjective to the person

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1 hour ago, tbs14 said:

Latuda has helped me so much I'd hate to give up the progress that I've made with it. Would it be unwise to ask my pdoc rexulti and to possibly stay on latuda. 

Yeah if you're a lurasidone-responder then it's best to stick with it because it has demonstrated efficacy in the bipolar depression space. Rexulti technically isn't approved yet for any bipolar disorder indications (mania/mixed, depression, maintenance), so to your pdoc it may be just as much of a gamble as pregabalin if there's limited data to support its use in this space. Additionally, Lundbeck and Otsuka's first Phase 3 trial of Rexulti for manic/mixed episodes in bipolar disorder didn't yield the outcomes they were hoping for.

What does Rexulti have going for it then? Reductions in anxiety and depression markers as well as a trove of evidence supporting its positive impacts on sleep. Any good psychiatrist knows that a critical part of correcting a bipolar episode in progress (whether manic/mixed or depressed) is to ensure that sleep is not being disturbed by existing medications and that it be corrected with sedative medication to sort of "resynchronize" the circadian rhythm. Therefore a good doctor would know that any medication which has a positive impact on sleep should also provide some benefit in bipolar disorder.

What I truly see happening for Rexulti is that they don't get a manic/mixed indication or it's only approved for that use when used in combination with Li or VPA (lithium or valproate). But I do see it EASILY getting a bipolar depression monotherapy indication as well as an indication for bipolar maintenance in combination with Li or VPA. I don't see lamotrigine ever being part of the mix because while it can delay the time to episodes or rather increase the time between episodes of any type (acting as a prophylactic only) it doesn't have the necessary utility as an acute treatment agent to make up for Rexulti's purported lack of anti-manic activity.

1 hour ago, tbs14 said:

My OCD is very bad too. I think I've had it all my life it's just that the obsessions and compulsions have changed. I believe this might also be contributing to my depression. 

Ability which is rexulti's cousin is used to augment antidepressants for OCD so maybe it it's worth a shot. 

Possibly. I know someone who is using risperidone for this purpose. I believe risperidone and quetiapine have the most evidence in the OCD space with aripiprazole being a close third. Although I'm curious how aripiprazole goes about calming obsessive-compulsive thoughts as aripiprazole itself is known for increasing certain behaviors like impulsive shopping and gambling. Regardless, my personal experience with 10 days on aripiprazole up to 7.5mg and my current experience on Rexulti at 1mg are totally different. Rexulti is much more calming whereas I found aripiprazole to be extremely activating/agitating.

1 hour ago, tbs14 said:

I've heard the vraylar can help more with apathy, cognition, etc. Is this true or is this subjective to the person

Vraylar can supposedly help with apathy at the 1.5mg dose after several weeks of treatment, but I don't think any additional benefit is seen at the 3mg dose or higher. I believe it's currently in trials for an FDA indication to be used as an adjunct at 1.5mg with an antidepressant for MDD. Vraylar, unlike Rexulti also has a true acute manic/mixed indication, where Rexulti does not. Rexulti has more data reinforcing its antidepressant effects where Vraylar doesn't, and where Rexulti improves sleep, Vraylar can actually cause insomnia for a good portion of its patient population. Insomnia and akathisia are two of the most common side effects. And speaking to akathisia, Rexulti has a statistically lower rate of akathisia than either Vraylar or aripiprazole.

I think @mikl_pls will be able to provide more color on the Vraylar experience.

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6 hours ago, browri said:

I think @mikl_pls will be able to provide more color on the Vraylar experience.

Vraylar, IME, was stimulating yet it seemed to only affect me from above and dampen me from below (kept me from being hypomanic yet worsened my depression, anhedonia, and apathy over time). It was kind of physically stimulating, and it caused RLS-like symptoms (constantly needing to move my legs, especially at night, during which I felt compelled to move my legs in a sort of bicycling motion... It was bizarre). I was on 3 mg for months, then between my pdoc and me, we decided to try 4.5 mg. Bad idea. OMEGA-BAD akathisia, dysphoria, weepiness, crying, etc. It was a nightmare.

I'm not trying to give you a bad impression of Vraylar, but this was just my experience.

I did try going down to 1.5 mg at one point and just simply went hypomanic. It was awful. Being that the half-life is so freaking long, it takes forever to start working, and forever for dose changes to take effect (except when I went up to 4.5 mg... Jexus...).

It could be your miracle med. I've personally found two meds that act as "brain glue": Abilify and Stelazine.

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So as you can see, @mikl_pls has demonstrated how Vraylar can be a no-go because of akathisia. However, there are plenty who don't get akathisia at all. I believe clinical trials nailed the akathisia rate at about 20% for 3-6mg and not much higher for 9-12mg.

However, now that I'm checking the Vraylar website, apparently they completed the trials necessary to get their bipolar depression indication! So now, not only is Vraylar approved for the acute treatment of manic or mixed episodes associated with bipolar 1 disorder as well as schizophrenia, but now it's also approved as monotherapy for bipolar depression!

There were 3 studies. Two of them demonstrated 1.5mg being superior to placebo and one study demonstrated that both 1.5mg and 3mg were superior to placebo. Therefore, the dosage for the acute treatment of mania is a starting dose of 1.5mg with a recommended range of 3-6mg a day, whereas for bipolar depression, that starting dose is 1.5mg with a recommended range of 1.5-3mg per day. However, from the statistics in the studies, not a lot of additional benefit was seen at the 3mg dose.

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