Should I Give Up?
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Give up? (Judy)

Q: I have been dxed with bipolar 1, rapid cycling and panic disorders. Currently I am only taking klonopin 2mgs t.i.d. because I 
was recently pregnant and went off all other meds (I miscarried a month ago anyway). I see a new psychiatrist next week and 
want to be knowledgeable about what medication regime I wish to be on. I have proven to be quite treatment-resistant (I have 
cycled almost monthly for 3 years), although the panic attacks are under control with klonopin. I have been on depakote, tegretol, 
neurontin, lamictal and combos; zyprexa and risperdal (risperdal makes me pretty agitated- but works well for auditory 
halluciantions). I no longer take anti-depressants. I will not take lithium. Are there any possible meds I am missing, or should I just 
give up- which is what I feel like doing.

Dear Judy -- 
First of all, don't give up: almost a quarter of the patients in my practice are like you, tried a bunch of stuff, never really stopped 
cycling. However, almost all of them (with about 3 or 4 exceptions) get some substantial symptom relief that makes med's better 
than nothing. Here are some ideas. First, get a psychiatrist you trust, if you have to look and look. Sounds like you've done pretty 
well so far. 

Next, try combos of low doses of a bunch of things at a time (things meaning mood stabilizers of course). Repeat any trials of 
things you already had if Risperidone was in the mix at the time: it seems to have a destabilizing influence that could overwhelm 
any subtle successful combo you make of the others. Try Topiramate if you haven't yet; and don't get discouraged by side effects 
-- lower the dose and go up more slowly again. And whatever bummed you out about lithium, figure out a way around it (unless 
you've never had it for some philosophical reason, in which case you need to change philosophies because you're missing probably 
the best agent of them all). 

Finally, maximize non-med strategies (you've probably figured out a lot of this, but there's almost always room to do more: strict 
schedule; daily (or almost) aerobic exercise; daily relaxation exercise, like yoga or tai chi or something that you really like to do 
that really relaxes you -- better if it has a spiritual component; and finally, there's the light restriction gig. Dimmers on all the lights 
you use after 9 pm, and start turning them down then. The goal is to eliminate night-owling, which may, for some people, be a 
cycle-provoker. If one of these things really works for you, write back and I'll note that. Good luck. 

Dr. Phelps

Published October, 2000

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