Cure worse than the disease
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Cure worse than the disease?
(LaVerne, Traci )

Q: My 25 year old daughter was just diagnosed 2 mos. ago with Bipolar 2 and began rapid cycling after having been on Effexor for major recurrent depression which began again in Feb. 2000. She then began Depakote 1200 mg and took for 6 weeks. She gained 20 lbs., lost a lot of hair and was even more depressed than when she began. Has a new Psychiatrist - 1st visit on Monday and was started on Topomax (200 mg) and Neurontin (900 mg). She can barely stay awake and feels very drugged. My question - was this not a high doseage to start on? Should she cut back some and then gradually increase. Has only been on this for 3 full days. Thanks just for information.

Q: I was Dx about 8 yrs ago I am 28 now.Until recently I was in deniel just figured everything I was feeling was coming from being a survivor of sexual abuse.Latly I have been extemely moody.mostly on the the high end.took depakote but it made me spacey and I have to think at my job next i tried effexor?it made me sick felt like i had the flu.Is there any RX that actually workd w/o all the crazy side effects which are sometimes worst than the disease.I am afraid I will lose my fiance if i dont become more stable.

Dear LaVerne and Traci --
You can see why I would lump your letters together.  After about 5 years of learning how to "tinker" with doses of mood stabilizers I've come to rely on two principles:

a) low doses, below the level producing these kinds of severe side effects you describe, can work if combined with other low dose mood stabilizers.  Sometimes you can end up on 5 different med's, but all at low doses to avoid side effects from any of them: e.g. 3 mood stabilizers and a med for sleep like Ambien and a low dose of a benzodiazepine (Valium family) like Ativan or Klonopin.  Sometimes it takes that much but if the result is 100% symptom control, with 0% side effects, sometimes it's worth it.  The "patient" gets to decide which is better, a few side effects and fewer drugs, or none but more pills.  Secondly,

b) any mood stabilizer you try with an antidepressant on board has to be repeated later without the antidepressant (i.e. don't give up on it without that).

You don't have to put up with weight gain from Depakote -- most people can lower the dose, their appetite comes down, and they stop gaining weight.  But you'll end up taking some other med to make up the difference.

And you don't have to put up with being zonked by topiramate (Topomax) either.  I've had good luck starting very low doses and going up slowly: people can handle doses arrived at slowly that wipe them out if they get there too fast (I've seen this repeatedly -- sometimes my patients don't follow my "slowly, slowly" directions).  I start people at 12.5 mg (one half pill -- yes, you can cut it in half, the pharmacist will say no, but it works out fine) and go up by that size step every 4 days, just under 25mg per week but with smaller steps.  My colleagues go 25mg per week but I've seen that be too fast for some who tolerated the medication if they went slower.  Works pretty well to suppress the appetite from Depakote, allowing you to take more Depakote without weight gain -- even at low doses like 25 mg twice daily (the topiramate dose, that is).

Dr. Phelps

Published October, 2000

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