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Catnapper

Treatment-resistant BPII depression - considering anti-psychotics vs. ECT

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I am running out of options on meds and am considering ECT since my existing health issues make me very wary of second-generation anti-psychotics, which is what my pdoc thinks will help the most now, if only on a temporary basis to get me out of this acute crisis of a bad mixed episode, mostly depressive in nature. I am at high risk for developing diabetes, and am considering ECT as alternative to more meds. What are your thoughts for both short and long term treatment if you were choosing between the two?

I haven't been here in a few years and my signature is way out of date, so please disregard it. I was recently doing okay on Lamictal, lithium, and trazadone, but then I went into acute kidney failure a couple of weeks after surgery, so the lithium and trazadone were suddenly stopped, which has pushed me right over the edge. (Luckily I made a good recovery from the kidney failure, but lithium is off the menu forever.)

Over 20 years (I'm 60, wasn't dx'ed till 40) I have been through many med changes in all med classes, currently on 300 mg of Lamictal. My pdoc added remeron to the Lamictal, but I stopped after two weeks due to huge appetite increases (with pdoc okay). I ate 6000 calories yesterday, and my pdoc wants me to switch to risperidone. Not quite a year ago, a couple month trial of Abilify left  me with mild tardive dyskinesia that is still ongoing, so I'm pretty tired of second generation anti-psychotics.

However, the intensity of this new mixed episode is really concerning to my pdoc, who I've been seeing weekly for over a year (he also does therapy). He and I talked about ECT in the past, but then I got more or less functional on the meds, so it wasn't pursued.

Every depressive episode just keeps getting worse and worse over the years, which I was aware would happen, but I didn't have any idea how bad it was actually going to be. 

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1 hour ago, Catnapper said:

I am running out of options on meds and am considering ECT since my existing health issues make me very wary of second-generation anti-psychotics, which is what my pdoc thinks will help the most now, if only on a temporary basis to get me out of this acute crisis of a bad mixed episode, mostly depressive in nature. I am at high risk for developing diabetes, and am considering ECT as alternative to more meds. What are your thoughts for both short and long term treatment if you were choosing between the two?

I haven't been here in a few years and my signature is way out of date, so please disregard it. I was recently doing okay on Lamictal, lithium, and trazadone, but then I went into acute kidney failure a couple of weeks after surgery, so the lithium and trazadone were suddenly stopped, which has pushed me right over the edge. (Luckily I made a good recovery from the kidney failure, but lithium is off the menu forever.)

Over 20 years (I'm 60, wasn't dx'ed till 40) I have been through many med changes in all med classes, currently on 300 mg of Lamictal. My pdoc added remeron to the Lamictal, but I stopped after two weeks due to huge appetite increases (with pdoc okay). I ate 6000 calories yesterday, and my pdoc wants me to switch to risperidone. Not quite a year ago, a couple month trial of Abilify left  me with mild tardive dyskinesia that is still ongoing, so I'm pretty tired of second generation anti-psychotics.

However, the intensity of this new mixed episode is really concerning to my pdoc, who I've been seeing weekly for over a year (he also does therapy). He and I talked about ECT in the past, but then I got more or less functional on the meds, so it wasn't pursued.

Every depressive episode just keeps getting worse and worse over the years, which I was aware would happen, but I didn't have any idea how bad it was actually going to be. 

What other antipsychotics have you tried? The newest one, Vraylar, treats (or is at least approved to treat) all forms of BP episodes and is typically not as bad on the metabolic side. Definetly not the fastest response though. Latuda would be another option. Have u ever tried Wellbutrin? That can be good for some with BP but you’d have to get any hypomania/mixed issues locked down first. 

Im on a phone so can’t see if you already ruled any of those out in your sig. 

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Reading through everything - sounds like it's been really rough for you and you're not in a good place. I hope you're able to get some improvement soon.

If it were me, I would try ECT. I've done the whole ECT procedure many, many times. Maybe 50 times. I've never had any serious issues, and no issues at all with memory loss. Just some soreness the next day. In a lot of cases, doing maintenance treatment (going in once monthly) is effective at maintaining whatever improvement you get. Any medication you try will take a lot longer to show if it's effective.

In my experience, a full course of ECT was extremely effective at treating some severe depression, but only in the short term. Maintenance treatment didn't really work for me. I've tried quite a few AAPs as well, not successfully. However, I second the idea to look into Vraylar; I'm taking it now and it has been very effective for treating depression. I wouldn't say I'm better, but I'm a lot better than I was.

 

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7 hours ago, 0112358 said:

Reading through everything - sounds like it's been really rough for you and you're not in a good place. I hope you're able to get some improvement soon.

If it were me, I would try ECT. I've done the whole ECT procedure many, many times. Maybe 50 times. I've never had any serious issues, and no issues at all with memory loss. Just some soreness the next day. In a lot of cases, doing maintenance treatment (going in once monthly) is effective at maintaining whatever improvement you get. Any medication you try will take a lot longer to show if it's effective.

In my experience, a full course of ECT was extremely effective at treating some severe depression, but only in the short term. Maintenance treatment didn't really work for me. I've tried quite a few AAPs as well, not successfully. However, I second the idea to look into Vraylar; I'm taking it now and it has been very effective for treating depression. I wouldn't say I'm better, but I'm a lot better than I was.

@0112358   Is there a max number of times you can do ECT...it seems it loses benefit each time.  What was the duration that you had the 50 treatments (like within 1 year, 5 years?) I looked into it at one point, and was turned off when told that it requires regular sessions every few weeks, for years, effects can be short term. I wondered if possible to maintain a job around the treatments, since it's not like you pop in for an hour over lunch and head back to work after.

That's good to hear that you have not had any cognitive effects or memory loss (although severe depression causes plenty of that too...)if someone were depressed (but not suicidal) would you still recommend it? I've wondered if it's worth the risk if you aren't suicidal or dealing with SH. Seems most everyone must stay on meds afterwards too.

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On 11/7/2019 at 12:56 AM, Iceberg said:

What other antipsychotics have you tried? The newest one, Vraylar, treats (or is at least approved to treat) all forms of BP episodes and is typically not as bad on the metabolic side. Definetly not the fastest response though. 

Anecdotally, I recently had a great and fast response to Vraylar (added onto my lamotrigine and Depakote, which weren't doing it), and went from complete instability and crying jags with obsessive thoughts to functional and stable in about a week. I know it has a long half life, but as it happens it turned things around for me very quickly. It did give me huge anxiety, but we seem to have mitigated that finally by my taking it every other day instead of daily.

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18 hours ago, argh said:

Can you bump the bupropion to 450mg?

Thanks for all the replies. I'm looking at this on my phone so I can't see or change what's in my signature. Please disregard whatever it shows as it is literally years out of date. I am no longer taking Wellbutrin.

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3 hours ago, Catnapper said:

Thanks for all the replies. I'm looking at this on my phone so I can't see or change what's in my signature. Please disregard whatever it shows as it is literally years out of date. I am no longer taking Wellbutrin.

Gotcha.

olanzapine is said to be fast and can be used as a prn. Would not recommend it long term, due to  your conditions

latuda, rexulti, vraylar are supposed to be weight neutral

if we can get an updated list of the graveyard, it would help.

Tangent

how about oxcarbazepine or carbamazepine? Both handle the Hypomania and mixed episodes without causing weight gain. Would have to up your lamotrigine if you do take that with it.

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