Questions re: Abilify, Treatment Plan, Anxiety
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Q:  Questions re: Abilify, Treatment Plan, Anxiety

I cant seem to find the right meds. Sometimes I feel that I am ADD. But I am definitely Bi Polar. What do you think about abilify. 39yrs old, 204 lbs ( down from 235 in the last 3 months) The meds I am on now just dont seem to work except for the Lamictal. ( current med stack/..lamictal 200mg. Zoloft 100mg. seroquel. 25mg)Litium was no good as well as nuerontin and depakote. Zyprexa worked well but skyrocked my cholesterol (replaced by seroquel) seroquel gives me a hangover and very nasty..grouchy in the AM) What would I need to add to abilify..?? Lamictal and an anti depressant?  I am thinking that Zoloft may not be the best choice. Also .. I have anxiety.. used to take kolonopin or valium. My throat closes up/..gag refelex to the point I vomit..I have gone into vomiting fits where I need to get Adavan injection to stop it.  ( 30 mins or more) Currently I vomit or gag  in the morning for 10 minutes before work or before a large appt in front of a CEO or board of directors (highly stressful job) Sales.. I also run 2 corporations as a Pres. and a CFO. Please advise.. I am at the point where my wife is going crazy and I am sure my 4 yr old and 6 yr old are being effected.


Dear Darrin -- 
As you can imagine, it would be inappropriate for me to tell someone what to do with their medications; instead I generally try to point people toward information they can use as they discuss with their doctor how to proceed. From your comments, here are a couple of ideas. I don't know much about aripiprazole (the one with the smarmy trade name we should all boycott which appears in the 4th sentence of your note) because I still haven't used it much.  I try to avoid using new medications for as long as I can stand it and let other people find out what the real problems and real applications of the medication are. But I've tried it in 10 or so patients. My colleagues wonder why I'm still holding back, that's for sure. So, I can't tell you about aripiprazole.  

The other idea is one which will sound familiar if you've read much of my stuff: in general when things are not going well for someone trying to find an effective mood stabilizer, there is one first question I always want to ask; I think this might be pretty close to a 100% always, in fact: "are you on an antidepressant?"  I always hope the answer is yes, because that means one of the most effective tools for stopping cycling, in my experience, is still available: taper slowly off the antidepressant.  Again, this is something to be discussed with your doctor, not to be done on your own. In your case, that's particularly so because of the anxiety symptoms you describe.  As a general way of thinking, I'd encourage you and your doctor to consider (not to expect this is true; it may well not be) that the ADHD-like symptoms, and the anxiety-like symptoms, could be part of the bipolar process. There is a substantial precedent for this way of thinking, which you'll find discussed in the review article by Freeman and McElroy which I've summarized on the Anxiety and Bipolar page on my website. But this is not a common way of thinking about anxiety symptoms so don't be surprised if your doctor, or other people, look at you like "where did you get that idea?" 

However, if you consider the anxiety symptoms this way, look what happens: the emphasis only falls more strongly on finding a mood stabilizer combination that will stop cycling of symptoms.  That's where I cross my fingers and hope that taking the antidepressant out might help things smooth out and lower anxiety overall, but I would expect you'd still have substantial anxiety symptoms left over. However, those that remained might be much more amenable to a cognitive-behavioral strategy such as outlined in the treatment workbook for CBT in Generalized Anxiety Disorder (in case you can't find a skilled CBT therapist in your area; you can buy two manuals and work through it with any therapist who is smart and wants to learn). Go to Amazon and search for Mastery of Your Anxiety and Worry -- the workbook, not the therapist manual; or the little cards that go with it, you can make those on your own. Here's a link to the book unless they move it. That's one treatment I can recommend and describe because it would be very difficult to harm yourself with this one!  Most people even with no particular symptoms could still benefit from the techniques in this book!

As you can see, what I'm talking about here all falls under the very well accepted general principle of treating bipolar disorder when "co-morbid" conditions (ADHD, some anxiety thing) are present:  treat the bipolar disorder first.  (I just extend that principle a little further: treat the bipolar first, then try to find any way to manage the remaining symptoms without adding an antidepressant.  There are many psychiatrists who would disagree with that extension). Good luck with the process. I hope it enables you to get those corporations running well (and then hand off some of the responsibility, perhaps, and thereby lower stress levels? Just a thought... -- which surely has occurred to you many times as well). 

Dr. Phelps

Published February, 2006


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