Q:  Continued Cycling - Change Treatment Plan?

It seems like my meds need to be adjusted too often.  Two months ago I was feeling manic, and saw a psychiatrist, who increased my Lamictal from 100mg 2x/daily to 150 and decreased my Lexapro from 20mg to 10.  And that worked well, and my mood went back to normal, and everything was good.  But now I'm on the upswing again. 

It seems like that should have been a significant enough change to tide me through for a while - I've definitely experienced a pattern of the bipolar "overriding" my meds, have had to increase the Lamictal every six months or so, but this seems too fast. 

I'm considering asking a psychiatrist about the possibility of switching to lithium.  (I live in a rural area and there's no longevity with psychiatrists - you see whoever you can, only if you really need to, if they can fit you in.)  I'm hesitant to switch the meds, though, because they were my "first" and pulled me out of a severe depression, and I've had no depressive symptoms whatsoever since starting them. 

So I'm kind of trapped.  On one hand, I want to stay safe, stay away from the  depression - and my current meds do that perfectly.  But on the other hand, I'm think the Lamictal's "not doing it" for the mania - and I think I could find a med combination that keeps me stable on both ends.  But I'm hesitant to mess with a good thing. 

So.  Yeah.  What now?

Dear Maria --

Your situation is a very common one, unfortunately: many people find that their mood symptoms are a "moving target", at least for a while.  And many people have difficulty getting access to a knowledgeable psychiatrist. 

If I understand correctly, Lexapro is still in the mix, at 10 mg -- which is the standard dose for this medication, not a low dose.  If so, one of your options would be to gradually taper that to zero. The evidence behind this is summarized on my website, on the antidepressant controversies page. See controversies number two and three in particular.  Even if the language is a bit over your head, you can use these references in talking with your doctors if necessary (I wrote this particular page mostly for doctors, so it is a little denser than the rest of the website). 

Make sure that you do not do this on your own.  You need physician closely supervising the process, even if it is a rotating doctor.  In general, when things are going smoother than before, smoothly enough to take the time, we might go as slowly as 25% reductions per month.  Going any faster risks destabilizing the situation, at least somewhat.  In other words, the process of reduction can be a "bumpy road". 

Obviously, trying to solve a problem (such as continued cycling) by removing a medication is better than solving it by adding another one.  As long as it works. 

If not, then adding a low dose of lithium to the lamotrigine is a reasonable next step.  If the addition leads to a dramatic improvement, then later, perhaps much later, it would be reasonable to try tapering off the lamotrigine to see if lithium alone was sufficient.  Fortunately, after more than 15 years of experience with it, lamotrigine seems not to be associated with any long-term risks.  Since most people can take it without side effects, this decreases the need to try to taper it out of their when something else has been added and a substantial improvement has occurred.  In other words, don't be in a hurry on that step. 

I hope some of those thoughts prove to be useful.  Good luck with the process --
 

Dr. Phelps




Published July, 2008