Effectiveness of a Med & Number of Times it's Tried?
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Q:  Effectiveness of a Med  & Number of Times it's Tried?

Doc - I've been diag. w/ bipolar by 3 different pshychs, hospitalized 2ice. They used to call me bp 2 w/mixed states and psychotic features. Sounds like a new cat. to me. Psych features are just visual and tactile hallucinations. These days I'm almost always in a mixed state (bp 1 ?). Never had a full blown manic that I remember. The list of drugs I've been on is long, even by my BP Support Groups standards. I begining to feel that we'll never find a combo that will work (currently Tegratol, Abilify, Clonipin, Celexa & Trazadone w/ Atavin as needed). I've been told that if you go off one drug too early, its effectiveness will be reduced the 2nd time you try it, and a third time it may not work at all. Is this true? Is it possible my only option will be ECT? I'm starting to feel hopeless about ever feeling "right" again.

Dear Scott --
That's complicated. Here are few thoughts on the highlights. First, "bipolar II" is not supposed to have psychotic features by definition, just for the record (per DSM-IV criteria, the official rule book for this kind of thing). So much for that cat.

Visual and tactile hallucinations are, as you probably know, very uncommon and often are thought to merit investigation with an EEG (electroencephalogram) looking for seizure-like activity in your brain that might be associated with your symptoms. If it was at all suggestive, then a combination that might be warranted would emphasize mixing anticonvulsants and less emphasis on antipsychotics, some of the older ones of which can make seizures worse sometimes.

EEG or no, if you haven't had most of your previous medication combinations conducted without an antidepressant in the mix, then there's certainly hope in simply trying combo's that don't include one. Very often I encounter patients who have tried many different things but always with an antidepressant in there; fairly frequently they do better when we try taking it out, but this must be done with your doc's participation, and generally I taper over at least 4 months to avoid having my patient go right into a depression and be wondering why this is such a great idea. Done more slowly, that's much less a problem. And I try to get a really strong picture, before going that route, that the current situation is completely useless as far as being able to function, so that even if more depressed for a while, but with some hope of improvement a month or so later, it's worth proceeding.

As for the notion of "effectiveness reduced the 2nd time, none the third" -- this is not accurate. There may be a grain of truth, in that sometimes we see that progression, but it's far from "always". It would not keep me from trying something now, the idea that I'd be "wasting a turn".

Dr. Phelps

Published January, 2004


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