BP2 and GAD, Concerned about Treatment Plan
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Q:  BP2 and GAD, Concerned about Treatment Plan

I was diagnosed in spring 2008 with BP (cyclothymia bordering on BP2).  Previously, in 1994, I was diagnosed with GAD. On your site, you describe an overlap between BP2 and GAD. My symptoms fit that description exactly. (What a relief!) 

I'm on 600mg/day quetiapine and 150mg/day venlafaxine. The latter dates back to my diagnosis with GAD, before my diagnosis with BP. I don't think the venlafaxine is helping with the anxiety any more; i get a lot of breakthrough waves of anxiety. I also find it makes me a bit too high. And I'm worried about the long-term risk of this. 

I'd like to stay on the quetiapine but replace the venlafaxine with something else that will tackle my anxiety more effectively and with less risk. What do you recommend I should discuss with my psychiatrist, please? I've read positive reports in this respect about benzodiazapines (but am wary of these because I've self-medicated with alcohol in the past), carbamazapine, oxcarbamazapine and gabapentin.


Dear S --
I would not presume to make a recommendation for a medication to add, because -- as you point out -- there are numerous options to consider.  Instead, I will present one more choice for you and your physician to discuss. 

You may already have had this discussion, although your description does not strongly suggest so.  But it is fairly simple logic, with one twist. First, the logic: since venlafaxine was there before quetiapine; and since things may be better with the quetiapine -- judging from your explanation; at some point, almost under any circumstances, you'd want to determine whether quetiapine alone might be sufficient.  In other words, you'd be trying to figure out whether venlafaxine was contributing anything at this point. The only really sure way to know is to try tapering it off.

 But here's the twist: it's possible that venlafaxine is actually contributing to whatever symptoms you still have.  So one of the things you should discuss with your psychiatrist is whether she/he thinks this might be so in your case.  Obviously, if so you have the option, instead of adding another medication, of getting rid of one.  It is always nice to solve a problem by taking medications out rather than putting them in. 

When you get around to tapering the venlafaxine, you might also want to discuss with your psychiatrist my perspective on taper rates

Beyond that, and all of the medications you have named are either widely used or considered in bipolar disorder, with the possible exception of gabapentin, which has been studied for use in bipolar disorder and found not to add value greater than a placebo (and in one study, it was worse than a placebo (those studies are reviewed on my Neurontin page).  

Good luck with the process --

Dr. Phelps

Published January, 2009


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