Posted by Ron Hill on February 18, 2003, at 13:31:51
In reply to Re: Lamictal + Prozac » Ron Hill, posted by colin wallace on February 18, 2003, at 5:53:07
Colin,
Thanks for your detailed response. Clearly, you are doing very well. I had got the impression from one of your earlier posts (in this thread, I think) that the gray clouds and the reduction in Lamictal dose (due to your pdoc's poor decision) had caused you to fall back into a depression. But, as is evident from your post today, you are doing well. So obviously, if it ain't broke there's no reason to fix it!
I will likely continue to have a bias against the use of SSRI's to treat bipolar II depression (even with a moodstabilizer in place). I can say without hesitation that SSRIs do not work for me. However, I need to allow for the fact that not all BP II's have the same response to SSRIs. Even with a good functioning moodstabilizer, the slightest pinch of an SSRI gives me a couple days of hypomania (euphoric type), followed by a couple days of normal non-depressive state, and then it turns me into what my wife affectionately calls her "do nothing boy". In the latter state, I'm not really depressed and I'm not irritable. But I have no motivation, my energy is low, and I'm completely numb emotionally. When I'm healthy (i.e.; not depressed and not on an SSRI), I am an emotional person.
For me, of all the SSRIs, Prozac is the least offensive and Paxil is the worst. I attribute these adverse SSRI side effects to the fact that; “Chief among the brain’s reactions to artificially elevated serotonin levels is a compensatory drop in dopamine.” I took this quote from page 20 of the introduction in a book entitled "Prozac Backlash" by Joseph Glenmullen, M.D. He is a clinical instructor in psychiatry at Harvard Medical School, is on the staff of Harvard University Health Services, and is in private practice in Harvard Square. His credentials look impressive, but he appears to be somewhat extreme in his views regarding the dangers of SSRIs. If you want, you can read the Introduction and Chapter 1 in their entirety for free at the following link:
http://www.glenmullen.com/prozacBacklash.html
I thought it was worth the time I spent scanning the available portions of his book. There have been numerous discussions on this board regarding the issue of SSRIs adversely affecting dopaminergic pathways and, thereby, inducing atypical depressive symptoms. However, this is the first time that I personally have seen a doctor state this in print (I'm sure there are others, however, that I have not come across).
I suspect that the main reason I cannot tolerate even a pinch of an SSRI add-on these days is because I took a ton of the stuff prior to getting the correct dx. In the time period between 1996 and 1998 my initial pdoc had me labeled ADHD and was feeding me a bunch of Ritalin and SSRIs (primarily Paxil). At one point, I was taking 80 mg/day of Paxil! Boy, I wish I knew then what I know now about mental disorders and medications. I don't know a lot about these issues even today, but I knew almost nothing when I went to my initial pdoc appointment. Never again will I subject myself to a doctor’s care without first doing my homework! Enough rant, Ron; move on.
Colin, I'm very happy for you regarding your new job. You're a good man with a lot to offer. The Stanford Research Institute did a study a few years ago showing that a person's chances of success in the workplace depends only 13% on the worker’s specific job skills and an incredible 87% on their people skills. Work hard (as I know you will) and, even more importantly; play nice with your co-workers and your management. If I stay well, which I think I will, I want to get back into the workforce. I want to be a contributing member to our society. If you don't mind my asking, what type of work is your new job?
It's too early in my trial to be recommending Enada NADH, and besides, you sound like you are currently doing well on your current cocktail. Just keep it in the back of your mind in case problems arise for you (God forbid) in the future. Also, keep an eye out for you ole pal Ron "NADH Ginny Pig" Hill's posts to see if it works long-term.
The following is my current list of meds to try if Enada NADH poops out on me. The list is not necessarily in order of preference:
Add-on Another Mood Stabilizer to my current Lithobid:
Tripetal (Dr. Phelps likes this med, however, might cause a rash for me). Neurontin (not a strong moodstabilizer but might help irritability). Lamictal (I really wish I could take this, but my pdoc feels sure it will cause rash even if we go low-and-slow).Add-on Benzo:
Use a long acting benzo like Klonopin on an ongoing basis or use a short acting benzo on an as needed basis. The purpose of the benzo add-on is to keep irritability in check. I would not expect any AD or mood stabilization benefits.Dopaminergic Medications (I use this term loosely):
Provigil. Selegiline (use in low dose range of 5-10 mg/day to retain MAOI-B selectivity). Mirapex. The thinking here is that since I believe the primary benefits of Enada NADH for me is dopaminergic, if it poops out then maybe the benefits could be replicated and sustained with one of these medications.Add-on MAOI antidepressant:
Nardil. Parnate. Selegiline (at higher doses). Dietary restrictions might be a pain. MAOIs can be destabilizing to some bipolar's, although not typically as bad as SSRIs, SNRIs, and TCAs.Low Dose of an atypical anti-psychotic:
Zyprexa. Respreidol (sp?). These might help, but the side effects are problematic and the risk of TD scares the heck outta me.Any comments or input on my list, Colin? Best wishes and be nice to the people you come in contact with on your side of the pond.
-- Ron
-----------------------------------
> Greetings Ronald old chum!
>
> Let's start with the depression;around six months ago, if you recall,I'd relapsed badly and slid into a dangerous mixed-state.This was due to a combination of ugly factors,the ugliest of which was a parent having been diagnosed with brain cancer, unrelenting rain,chronic body-pain(fibromyalgia type-stuff),numerous med. failures,no job and precious little social contact for three years- and an 'unopposed' SSRI to ensure that I finally blew my lid!!!
> I had no access to a psych., and looking back, was in pure unadulterated mania-I very nearly did away with myself if I'm honest.After crashing my car at breakneck speed, I found a hospital and begged to be placed on a mood stabilizer... but valproate and lithium made things worse.
> Then came my nifty little box of Lamictal in the post, and the rest you know.
> Today,I feel better than I have in years;my mind is sharp and clear, I have ABSOLUTELY no depression to speak of,no swings or dysphoria(I no longer fall into my personal mantrap of fixating on a subject and spinning off into anger) clear plans for the future, a semblance of a social life- and I start a new job next week.I'm actually looking forward to it(inasmuch as anyone looks forward to work!)In short, I feel normal.
> Lamictal is responsible for my revival, and I thank God I followed my own instincts and placed myself on it.
> So, currently I'm taking 200mg Lamictal,2mg diazepam,100mg Neurontin at night(neuropathic pain/stiffness), along with just 10mg Amitryptaline for sleep.
> The Prozac 'sprinkle' probably amounts to maybe 2mg/4mg max. , meaning I can get over a weeks mileage from a 20mg capsule.As I mentioned before,it feels entirely different with the Lamictal in place-nice little uplift, but not the silly 'high'or irritability it previously caused.
> This may seem like trying to fix something that ain't broken, but there's reason behind my madness?!Although I have no depression symptoms, my problems begin and end with the weather.After around three weeks of continuous rain and gloom, I begin to slide.It's more a slip towards hypomania than pure depression.Feels like cogs in my head loosing their synchronicity and coming unmeshed.My head hurts,I begin to seriously contemplate jumping on a plane(with hardly any money!)and just flying the hell away to anywhere on earth where there's sunshine.I get frustrated and angry, and spit out sentences like "this stinking ****** country is unfit for human habitation!!You get my drift.Not pleasant.
> Now I agonized about how to tackle this for some time, and I seem to be defenceless against it.
> SSRI's(the dreaded enemy)have proven efficacy against SAD(or a downward bipolar seasonal swing)but we all know the risks.I read an up to the minute article yesterday challenging the hypothesis of the long-term destabalizing effects of using(low dose)AD's with BP(with a mood stabilizer of course)- in this study at least, those on concurrent AD's actually fared slightly better.But I think this debate won't be solved for years.
> In my case,I need to 'marshall my troops' to the North rampart and prepare to fend of(next years)bad weather.I believe that, unfortunately, I will need to risk a low dose AD for as long as I'm stuck in the UK.I seem to have little choice.TCA's sem to be the worst culprits for precipitating mania, and(low-dose) Prozac actually compares quite well all in all(Zoloft one of the worst, as we both know!!)
> Feeling normal right now is a good starting point to gauge my reactions-any irritability or aberrant thoughts, and Prozac gets the boot.
> A retrial of lithium in combo with Lamictal is then an option, and then failing that,I'd have no qualms in trying an MAOI.But I don't think it'll come to that.There's also Topomax, but that doesn't really grab me either.
> I like the idea of this ENADA stuff, although I haven't done too much research yet.I may well give it a whirl, and if it feels good, who knows?
> By the way, our old friend SAM-E doesn't mix with Lamictal AT ALL- sends me clawing up the wall straightaway!
> My med regime is doing it's job perfectly right now, but like you, I'm always looking ahead in case of pitfalls.Fingers crossed.
> What are your personal 'med. contingency' plans?
> I know you bottomed out with Lamictal once on silly doses, but have you ever thought of a re-trial(like Amy)?At least we both have options still.
> Anyway, glad you're feeling well over there, and keep me posted with your progress.Keep bouncing any thoughts, advice and ideas too!!Always welcome.
>
>
> Col.
>
>
poster:Ron Hill
thread:138803
URL: http://www.dr-bob.org/babble/20030214/msgs/201537.html