Requests Opinion of Treatment Plan
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Q:  Requests Opinion of Treatment Plan

I need a second opinion re: medications. My doc has recently taken me off of lamictal (100mg) while maintaining 1200 mg lithium, then added resperdal (.5mg), then added 300 mg lithium, then gave a two starter packs of effexor in case my depression broke through. All in response to my conitnued bouts of depresssion (1 day per week or so ) Mania subsided. This all occurred over a 4 week period.

I am loopy, dizzy, I stumble easily, have big trouble concentrating, and generally feel awful. Does this course of treatment sound right? Thanks.

Dear Dave --
Well, as you can imagine it's really tricky for me to offer commentary on somebody else's treatment when they know you and have your chart in front of them, and I don't. But I will try to answer some specifics in your question.

First off, you're now on 1500 mg of lithium, and in my area it would be routine to know, usually within a week or so, what your new blood level is on this higher lithium dose. This is especially necessary for you now given that lithium can cause all the bad stuff you named (loopy...awful); most doc's don't like to maintain a blood level over about 1.1 (funny unit: mEq/L).

Risperidone in this dose can be really help: for many people it has a mood stabilizer-like effect; and for quite a few, perhaps less, it has an antidepressant-like effect (enough so that I worry it can be too much like that, and have definitely seen that in a few patients; but I've also seen some great responses to these little doses, especially in more elderly folks). And, it works very fast when it works well, so one would be able to know very quickly if that was going to be a helpful part of some mix of medications, try it, and get it out, all within as little as a week and a half or so -- so this part of your story sounds okay, and suggests the doc' does indeed know about treating bipolar disorder (many other doc's might have used a higher dose, or waited longer to decide if that was going to work, but in this case I'd tend more to agree with your doc', I think).

And what about the Effexor? Well, this suggests to me a little too much emphasis on treating depression when one could view your problem as "cycling" at least as much as a problem with "depression"; but this is my routine complaint about all sorts of doctors' treatment of bipolar disorder, and we have precious few data to actually inform this debate (here's a summary of that controversy regarding antidepressants in bipolar). In my personal experience, I've had better luck trying to stop the cycling and letting the depression get treated indirectly that way, than by trying to treat the depression, which I worry may turn back into cycling later even if it's much improved now (maybe years later; and how would we know that? our current research studies only look at most at about a year later).

Finally, about rapid changes like this: that can be driven by the doc's anxiety to treat your symptoms; or perhaps to some degree by the amount of desire you come across with, when you see her/him, for your current symptoms to be lessened. When somebody is really suffering, I go faster with medication trials, unless they've had so many already that we have to now slow down and be ultra-systematic about ruling out a possible response to every agent we try so as to make "backtracking" unnecessary later. You might be able to get the doc' to slow down a bit if you make it clear that you'd rather keep some symptoms for a time and be systematic about your trials of things. Good luck to you in any case.

Dr. Phelps

Published December, 2003


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