Klonopin & Bipolar Disorder
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Q:  Klonopin & Bipolar Disorder

In 1972 was diagnosed as a unipolar depressive.  I have had many depressive episodes lasting as long as two years at a time.  I have seen the top doctors in New York and finally after seeing a specialist in Connecticut have been diagnosed as Bipolar 2.  My question is, after breaking out in the Lamictal rash, and having to stop this very effective medication, what about Klonopin and its used in treating Bipolar 2.  I have done some research and the only downside I see is that it is addictive.  I would appreciate your imput.


Dear Claire -- 
Two thoughts:  #1, on lamotrigine:   it used to be routine to simply stop this medication for any sign of rash.  However, I've heard Drs. Joe Calabrese and Lauren Marangell, who've studied this medication quite extensively, both say that you don't have to stop if it's a simple skin rash.  You have to stop if you're sick overall, if some of your blood tests change, and if you have symptoms in or near your mouth (some say anywhere on your face).  But short of that severe version, if it's just red itchy patches on your arms, legs or trunk, these experts advocate turning the dose back down one step and waiting to see if the rash will go away (using Benadryl in the interim if needed for itching).  Now of course you'd need to do this under the direct and close supervision of your doctor; and don't restart on the basis of this note, but it is something that you could discuss with your doctor if you didn't have the bad version of that rash. 

#2, on Klonopin:   this may have a little more clout than its cousins like Valium and lorazepam (Ativan), but it's not widely regarded as a "mood stabilizer" as such.  It may add to a mood stabilizer, even synergize somewhat with it, but it isn't on the list (e.g. the American Psychiatric Association's Bipolar Treatment Guidelines) on it's own (well, if you make it as far as Part B, Section V, number 9, paragraph 2, there's a very brief mention of the benzodiazepine family -- Valium and all it's cousins, of which as you've learned, Klonopin is one).   

You'll also hear people fret about its addictive potential, because like other benzodiazepines, your body gets used to it over time and it may lose some of its oomph.  You have to move the dose up to get back to where you were.  But if you don't move the dose up (because that pattern just repeats itself at the higher dose), but instead talk with your doctor about a ceiling you're going stay below from the outset (many of us use 3 mg as this ceiling we won't go beyond), there is probably at least some benefit in terms of mood stabilizing effect.  The cost is not great, perhaps some mild sedation for most folks.  You'd have to watch out for additive sedation with other medications and especially alcohol.  

Dr. Phelps

Published January, 2003


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