RE: Bi-polar Mania on Mood Stablizers?

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RE: Bi-polar Mania on Mood Stablizers? - 5/27/2007 1:21:33 AM

Aswad

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quote:

ORIGINAL: maybemaybenot

It is not uncommon to use a combination of SSRI's in the treatment of depression.

There's a number of different combinations that are common when treating depression.

Many of these have not been studied, some have been studied, and a few have been scientifically studied. SSRI+Wellbutrin has not been scientifically studied; i.e. there have been no placebo-controls.

Generally speaking, if there is negligible or no response to the SSRI, taper and discontinue; unfortunately, the docs often forget this, giving some occasionally "interesting" interactions.

There are exceptions, of course, but in general, if an SSRI isn't giving any response by the end of 2-4 weeks, the whole cycle of "increase-wait-increase-wait-swap-wait-lather-rinse-repeat" can be skipped, as the likelyhood of response, compared to the waste of time and the chance of spontaneous remission in the meantime, just doesn't justify it at a GP level. Unfortunately, the GP level is where this cycle is most common, arguably because of cost and low short-term toxicity, combined with limited information.

But, yes, there are plenty of combinations that work well, and some of them involve SSRIs.

Some of them are also, technically speaking, contraindicated in the literature. Mostly to keep anyone from trying it without having a solid idea of what they're doing. I've seen doctors advocate 1.3mg/kg/dy Parnate with 25mg BID dexamphetamine; should give a bit of an impression of just how far some will go to solve the problem, if needed.

Really, it depends on the patient, their medical history, the specific characteristics of their depression, what they've tried in the past, and so forth.

And, of course, the treating physician. My first pdoc, when he transferred me to another, said at the time, "You know the one about the wizard's apprentice and the crystal ball, right? I'm passing the buck to the wizard himself," or something to that effect. I love it when a doc is honest about their own limitations; makes it a no-brainer to trust them when they say they are on top of things.

The most complicated stack I've been on was 50mg QID tranylcypromine, 5mg BID dexamphetamine and 4mg QID buprenorphine, with 0.5-2mg flunitrazepam used on occasion until the insomnia subsided, and the equivalent of 200-400mg meprobamate used as required to control breakthrough episodes. I'm still here, and it did make it so I don't even have to think about that stack again.

No regrets, but I no longer need that, and to anyone who hasn't "been there" (i.e. that bad), the side-effects alone, in retrospect, would seem like a decent reason to go kill oneself; at the time, I didn't significantly notice them above the "background noise", though.

My GP wouldn't touch me with a ten foot pole at the time; between them, those drugs cover just about every liver enzyme there is, inhibiting some and inducing others. Me and the doc in charge of the treatment would sit with these binding affinity tables and work out anything that I needed to take, how we would adjust the dosages, etc... Even for OTC stuff.

Glad that bit is in the past.

Anyway... have done a bit of research over the years, and talked to more than a few pdocs, profs and so forth, and would be happy to pass on tips and advice to anyone who bears in mind that I'm not their doc, and that they need to run this stuff by their GP, pdoc or whatever. I need some details to do that, though, whether on the board or in a collar-mail/PM.

Bits like having recently been through heart surgery drastically affect the picture. That's both why I need more details than "would X + Y work?", and a big part of why my reply needs to be run by a doc who knows the patient.

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From then on I knew: God doesn't make the world this way.
We do." -- Rorschack, Watchmen.

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RE: Bi-polar Mania on Mood Stablizers? - 5/27/2007 1:40:03 AM

Aswad

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quote:

ORIGINAL: minnetar

Sir i appreciate Your response.

You're welcome. Though my next reply will have to be in some hours; off to bed for me

quote:

i have not been diagnosed as bi-polar but have been treated for depression i know based on my heart disease that the use of those two anti depressants have a concern about seizure.

Seizures, blood pressure and cardiac function are the ones I'd be taking a close look at. Good reason to get the heart doc and the mind doc in the same room, or on the phone to each other, just to make sure they're on the same page.

An interesting question would be which one you went on first, or if you went on them at the same time. If the former, what was the original effect, if any, and how long did that last before they added the second? If the latter, why did they choose to start off with those two at the same time in a patient taking heart meds?

quote:

Sir what is funny is that i have found a lack of feeling or being argumentative.

A lack of feeling (roughly "flattened affect" in doc-speak) is most likely due to the Zoloft. Any SSRI can cause flattened effect in a particular subsegment of depressed patients. To me, that would be an unacceptable side-effect, but I don't know how much it affects you, so you'd have to consider that for yourself. If it is a problem, in your opinion, then I would suggest tapering off the Zoloft; if the Wellbutrin works by itself, and the heart doc says OK to that, everything is dandy; if the Wellbutrin doesn't work by itself, it's time to be looking at a different stack.

If you send me (or post, whichever you prefer) a description of your symptoms, how the meds affect you, and preferably a few other tidbits (if you'd like, I can post a list of questions tomorrow, or something), then that'd be helpful in providing advice.

As for being less argumentative, I don't know you well enough to comment on whether that constitutes an improvement or a problem, and the tone of your post was not entirely clear on this. Wellbutrin has a norepinephrine-reuptake inhibiting effect, which will usually increase argumentativeness and irritability IIRC, but it can have a paradoxically opposite effect in some people. There's a whole slew of things it does, so without a more detailed description of this aspect of things, I can't comment very well. It could also be improved impulse control due to the Zoloft, or flattened impulse response due to the Zoloft.

quote:

Sir You know dealing with depression is an inexact science.

That it is. Although, the limited time the docs have to keep up to date with the research, and the strong monoculture in the mainstream research establishment, confuses the picture more than is strictly necessary.

It isn't engineering yet, but it's not quite the lottery, either.

Anyway... take this post with a grain of salt. I got caught up in some stuff here on the PC and stayed up "a bit" late, so I haven't proofread it. It's 10:40am here, so I'm off to bed.

I'd love to have a closer look at things tomorrow.

_____________________________

"If God saw what any of us did that night, he didn't seem to mind.
From then on I knew: God doesn't make the world this way.
We do." -- Rorschack, Watchmen.

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RE: Bi-polar Mania on Mood Stablizers? - 5/27/2007 10:26:43 AM

Celeste43

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Aswad's right about flattened response however some people respond to depression by becoming angry. Most commonly men get the 'no sad' depression. If the argumentativeness was due to this, then the absence of the argumentativeness could be attributed to the meds working appropriately.

I also hope your psychiatrist and cardiologist are in contact with each other, you may have to give them both written permission to do so as speaking without such permission is a violation of privacy rights. Additionally, I would not use a large chain pharmacy. The pharmacists there tend to change frequently and are overworked. You need someone who knows who you are and pays sufficient attention to not just fill a scrip but also look up what other meds you are on and see if there's a conflict. And never get scrips filled at more than one pharmacy because that way there's no chance to catch a medication interaction problem.

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RE: Bi-polar Mania on Mood Stablizers? - 5/27/2007 11:10:14 AM

Monts

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I would make sure you arent actually unipolar. I was diagnosed with bipolar and was medicated for it. I was actually unipolar with more manic episodes than depressive episodes. I had a very bad reaction to typical bipolar medication.

Monts

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RE: Bi-polar Mania on Mood Stablizers? - 5/27/2007 7:33:39 PM

zindyslave

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Monts, I don't know if your post was directed at me or not...but I know I am bi-polar for one it runs in my family, after I am on bi-polar meds for awhile they work right. I have more depression that mania, but usually when I am manic it tends to be at least a week long in course, and my depression seems to be in longer stretches two weeks or longer mostly. I have anger snaps all the times unless I am being treated with the right meds, I have only had problems, like problems I couldn't live with, when I was on Prozac which made me feel like I had no feelings. But since I haven't been on an anti depressant I don't have that problem. The meds I am on are helping. But anyway, all in all, I know I am bi-polar, I don't know the symptoms of unipolar but since bi-polar is in my family I am about positive that I am. Esspecially since the meds work for me.

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RE: Bi-polar Mania on Mood Stablizers? - 5/29/2007 1:45:18 AM

Aswad

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quote:

ORIGINAL: Celeste43

Aswad's right about flattened response however some people respond to depression by becoming angry.

True, some people respond to depression by becoming angry; if we're talking severe anger, it will often become significantly worse if treated with SSRIs. Mere irritability, on the other hand, would indicate that trying an SSRI or RIMA might be a good idea.

The bit about "flattened affect" (emotional deadening, from suppression of the strong (but appropriate) peaks in the response to an undifferentiated impassive state) is distinct from this, however, and to the best of my recollection is fairly exclusive to serotonergic medications (e.g. SSRIs) and sedatives (incl. antipsychotics).

quote:

Most commonly men get the 'no sad' depression.

I wasn't aware that there were statistics on this, but it could very well be the case. Do you have a source I could add to my to-read list?

Absence of sadness isn't a good prognostic marker in my experience, however; that is, it is still treatable, but the docs quite often don't get it right. Dopaminergic and noradrenergic drugs tend to work better on this. Unfortunately, those are frequently abusable if effective, and that limits research. Wellbutrin is somewhat promising in this regard.

quote:

If the argumentativeness was due to this, then the absence of the argumentativeness could be attributed to the meds working appropriately.

Definitely. The question is really whether it's a reduction in unreasonable argumentativeness or a "don't care"-type response or somesuch. The latter isn't an improvement, while the former usually is.

quote:

Additionally, I would not use a large chain pharmacy. [...] You need someone who knows who you are and pays sufficient attention to not just fill a scrip but also look up what other meds you are on and see if there's a conflict.

Isn't this really supposed to be the doctor's problem?

I mean, I'm on a first name basis with two senior pharmacists (the ones who handle special orders, adverse reaction reports, etc.) at my local pharmacy, and they're good at what they do, but there's no way their knowledge extends to the point of properly evaluating potential interactions between various drugs. Mostly, they just know a lot of "known bad" combos and catch errors that an attentive patient would also catch.

Checking for conflicts involves evaluating both pharmacokinetic interactions (e.g. barbs will lower serum concentrations of various drugs), pharmacodynamic interactions (e.g. MAOIs will potentiate any sympathomimetic drugs), and effects on other illnesses (e.g. you don't generally give stims to someone who's just had a coronary).

Just seems to me like that should be handled by the doctor before writing the scrip.

_____________________________

"If God saw what any of us did that night, he didn't seem to mind.
From then on I knew: God doesn't make the world this way.
We do." -- Rorschack, Watchmen.

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RE: Bi-polar Mania on Mood Stablizers? - 5/29/2007 1:48:48 AM

Aswad

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quote:

ORIGINAL: zindyslave

I have only had problems, like problems I couldn't live with, when I was on Prozac which made me feel like I had no feelings.

That's the flattened effect bit I mentioned. The SSRIs do have some variability in this regard, but it is a more common side-effect than the "regular" numbers indicate.

_____________________________

"If God saw what any of us did that night, he didn't seem to mind.
From then on I knew: God doesn't make the world this way.
We do." -- Rorschack, Watchmen.

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RE: Bi-polar Mania on Mood Stablizers? - 5/29/2007 4:11:00 PM

zindyslave

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Yeah, I know that is was the flattened effect thing you mentioned Aswad, I don't know if Monts was talking to tho or not, but I added that bit in there for that reason.

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RE: Bi-polar Mania on Mood Stablizers? - 5/29/2007 9:11:56 PM

zindyslave

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I don't know who that was directed to, but I can't just deal with the depression since I have other problems and also all medicine has side effects. Natural or not.

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RE: Bi-polar Mania on Mood Stablizers? - 5/31/2007 7:51:14 PM

Monts

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I am not quite sure what your question was to me. I am kind of lost now. But it was prozac that I had difficulty with. But again, I am considered unipolar. I am much more manic than depressed, although I get very depressed when I am there, however it is usually for a short period of time. I am extremely irritable, and always have been. No medication or cocktail thereof helped that.

Monts

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RE: Bi-polar Mania on Mood Stablizers? - 5/31/2007 8:48:38 PM

zindyslave

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I don't think I asked a question was just saying that I am pretty sure I am bipolar not unipolar. I am lucky that meds help me in my bi-polar some bi-polar people have a hard time finding the right cocktail, I was lucky that when they diagnosed me they found a cocktail that helped all the symptoms, but the prozac left me with no feelings but it did control the bi-polar. Now I am not on any anti depressant and I pretty much think I need it right now anyway....I am so stressed and I have nothing to help my stress and I just end up crying all the time lately and sleeping all the time. If I ever get to a place where I am not stressed I will be surprised at how I will feel. But anyway, that is for a different discussion.

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