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Help with meds for mixed states...


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Hey all,

Been a while since I've posted. I'm not doing so well right now. I'm pretty sure that I'm BPII with mixed states/dysphoria predominant and periodic depression. Possibly also ultra rapid-cycling, although that's hard to seperate out from a mixed state for me.

Current meds:

1) low-dose Lithium (60-120 mg/day) - any higher and I get more anxious (and my kidneys don't like it); lower and I get a full-blown mixed-state.

2) Klonopin (0.675 mg/day) - decent for dysphoria, but leaves me feeling a little blue

This combo is definitely way better than nothing, but there are still a lot of ups and downs.

My pdoc has started me on Neurontin, but I'm very wary. I think a brief trial of it last week after sending my Lithium too low completely exacerbated the manic dysphoria. And Neurontin, from what I understand has a crappy rep as a mood stabilizer.

So, any thoughts on another mood stabilizer? Ideally, something good for mixed states? I've been looking at Tegretol and Keppra (or maybe re-trialing low-dose Depakote at a super low-dose, see below). Thoughts?

Also, is Tegretol likely to be very similar to Trileptal? I had a bad reaction to the latter (again, see below).

Trials of mood stabilizers:

1) Depakote - increased depression, fractured sleep and cognitive blunting throughout a 6 week trial. But started at 250 mg/day, jumped to 500 mg after 4 days and got up to 1000 mg-1250 after a couple weeks. This might have been too much for me too fast since I'm incredible med-sensitive, so maybe this merits retrialing at pediatric doses.

2) The atypical antipsychotics - akathisia from Zyprexa and Geodon; severe dry mouth and some agitation from Seroquel. I think I'm leaving these alone for a while.

3) Trileptal - agitation and pretty bad cognitive dysfunction during 10 day trial at 75 mg BID

4) Lamictal - increased agitation, muscle aches, sexual dysfunction at 25 mg, panic attack at 50 mg. Conservative titration. Granted, this was an incredibly stressful period of my life, but retrialing this would be pretty far down on my list

Thanks for any input you might have!

Best,

cache-monkey

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Paradoxical reactions can happen with GABA enhancers so keep close eye on that. Have you tried a nighttime dosing of your lithium? It may help you increase you dose with minimizing the side effects. Topamax may also be a good option. Perhaps even a different form of Lithium.

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Paradoxical reactions can happen with GABA enhancers so keep close eye on that. Have you tried a nighttime dosing of your lithium? It may help you increase you dose with minimizing the side effects. Topamax may also be a good option. Perhaps even a different form of Lithium.

<{POST_SNAPBACK}>

Thanks for the reply. As far as the Li, I've been on the regular and both time-release versions of the carobonate form. I'm actually going to try the citrate next (just got my script) if at the minimum to be able to get a more consistant amount every day. (LiC03 doesn't divide neatly.)

I'm not sure what you mean in terms of paradoxical reactions to GABA-enhancers. Could you explain?

Best,

cache-monkey

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I'm not sure what you mean in terms of paradoxical reactions to GABA-enhancers. Could you explain?

Best,

cache-monkey

<{POST_SNAPBACK}>

It all goes towards my personal theory that the underlying pathology of a certain type of BD is related to GABA depolarizing and becoming excitatory (as opposed to inhibitory). This is caused by an increase of intracellular chloride. There are case reports of this paradoxical reaction. Of course synaptic GABA levels are regulated by blood levels of GABA so this may be a time limited scenario.

PS. This is my personal thoughts not based on any real science so take with a grain of salt.

PPS. Don't forget to ask your doctor about nighttime dosing for your lithium. It is still a wonder drug and is worthy of your full efforts in establishing as a therapy.

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I'm liking Tegretol right now.

Didn't believe it would work, it took some time to kick in and really start helping, but by golly my pdoc was right about it. We have stability for the first time in a couple of years. It's wonderful.

She tells me it's the drug of choice for rapid cycling BP. My cycling varies from several weeks at slowest to only several hours at fastest (ie mood switches from one state to another occurs after that time).

Might work for you, might not. Thought I'd share though.

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I started a similar thread a little while back.  From my experience over the last few months, I'm going to have to agree with Glen.  Since starting Lithium, I have been much better overall than I was with Lamictal alone.  There are still plenty of crappy days, but there are just as many, if not more, good days. 

And I would agree that Topamax is a something you should consider too.  From anecdotal evidence, it works really well for rapid cycling and mixed states for some people.  Some people it doesn't do anything but make them stupid.

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I'm not sure what you mean in terms of paradoxical reactions to GABA-enhancers. Could you explain?

Best,

cache-monkey

<{POST_SNAPBACK}>

It all goes towards my personal theory that the underlying pathology of a certain type of BD is related to GABA depolarizing and becoming excitatory (as opposed to inhibitory). This is caused by an increase of intracellular chloride. There are case reports of this paradoxical reaction. Of course synaptic GABA levels are regulated by blood levels of GABA so this may be a time limited scenario.

PS. This is my personal thoughts not based on any real science so take with a grain of salt.

<{POST_SNAPBACK}>

Hmm. That's an interesting theory. I've not heard of the role of chloride in BP. In any case, I don't think this is an issue for me. My experience with GABA-enhancers (Klonopin and Depakote) is that they aren't particularly exitatory. They generally calm me down, but leave me feeling a bit down.

PPS. Don't forget to ask your doctor about nighttime dosing for your lithium. It is still a wonder drug and is worthy of your full efforts in establishing as a therapy.

<{POST_SNAPBACK}>

Yeah, this makes sense. I guess I didn't specify this, but based on some experimenting with bit the timing of my lithium, for me Lithium turns out to be activating. If I take it too late in the day, forget about falling asleep in an orderly fashion or sleeping deeply. (The extra trips to bathroom tend to fracture my sleep, too.) Maybe it'll be different with the citrate, though, so I'll give it a shot when I get the script.

Thanks for the input,

cache-monkey

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whatsgoingon-

Thanks for the post about Tegretol. Out of curiosity were mixed state a big problem for you before the Teg? Also, did you by any chance try Trileptal? (I'm interested in how the two compare because I didn't do well on Trileptal...)

Thanks,

cache-monkey

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Unfortunately I've never tried Trileptal, so can't give you any help there! I get no side effects at all from Tegretol though.

Mixed states were a problem for me- sometimes I'd be sat manically laughing and crying at the same time. Or I'd be depressed as hell, talking at high speed and fidgeting constantly with my mind jumping around. Or I'd get the one minute manic, next depressed thing. I think a lot of my depressions were actually mixed states as I was so agitated and my sleep was so poor.

Hope that helps, and best of luck with finding the right drugs for you.

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Thanks, whats going on. I'm glad that the Tegretol's working for you. I'm hoping to find something that does it for me. I'm getting frustrated by my cycles from mixed state agitation to being tired, slow and anxious.

Best,

cache-monkey

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Ive been on both tegretol and am currently on Keppra...both for epilepsy...but I am also dx'd with mood disorder so my meds all effect eachother (Im a big medical pain in the ass). My experience with Tegretol was this: When I first started on it, I felt down, alot...really down. I eventually got used to the side effects, but it was the wrong med for my type of seizures, and wasnt doing much for controlling my moods....I then switched to Keppra (a HIGH dose) and topamax. I had a bad reaction at first. I am one of those rare cases, unfortunately, that got a little rage from the high dose of Keppra (this only happens in a very small percentage of people)...My keppra was lowered in half, and Depakote ER was added...I feel better now...

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Thanks, Lisa. Out of curiosity, what is your DX?

<{POST_SNAPBACK}>

I have JME...(juvenile myoclonic epilepsy) I have 2 docs that have kinda argued over my other DX...both saying that it is a result of my epilepsy and the stirring of electrical/chemical wackiness in my brain...but either cyclothymia or type 2 bipolar...ptsd, SI, etc. The med cocktail Im on has helped alot...but when I was on Tegretol alone...I was definately a rollercoaster, not to mention the fact that it wasnt helping with the seizures. It was like trying to walk on a thread to not have a seizure. I was afraid of spring and fall because my allergies would set off a seizure while I was on Tegretol...but JME, and tegretol..dont always work...I was misdiagnosed when I was young as having general epilepsy...therefore was put on the same ol' same ol' meds by a doc who just wanted to get me in and out of the office. I could go on...but I wont bore you...haha.

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I've been on Teg. for the past several months for recurrent depression and general temporal lobe weirdness.  I'm working my way off it as it made me just too out of it all the time.  It definitely helped with my anxiety though.  I've not had to take klonopin in over a month.  It also eliminated an urge to drink that I didn't even realize I had until it went away.

How do you define agitation anyway?  Is it like antsy only taken to the next level?  Restless but more so? Teeth grinding, leg bouncing, rocking back and forth?  I definitely get like that and Teg definitely helped with it. 

I'm looking at trileptal or lycria next, with topomax also being an option.

Have you looked at any of the APs?  Seroquel did wonders for me but I'm workng my way off it, mostly for health reasons.

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