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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 3 to 27 of 281. Go back in thread:
Posted by sam K on July 3, 2009, at 11:00:44
In reply to Going back to old-school - lithium., posted by SLS on July 3, 2009, at 6:42:30
I took lithium yesterday too. Its motivating for me in my head. But my body is tired. And last time i took it I had a hard time getting myself to take showers at all. It raises my sex drive!! pretty cool. I feel more anxious, but that might go away soon. I wish ya the best of luck scott cya
Posted by Phillipa on July 3, 2009, at 12:13:03
In reply to Going back to old-school - lithium., posted by SLS on July 3, 2009, at 6:42:30
Scott I didn't know you're manias were drug induced must have revealed this before I was a member. I do know what I saw when working as had a great pdoc working on our unit and he was bipolar. Hence all patients that came in he said they were misdiagnosed and put them on lithium. He didn't believe in the having to obtain a certain range for the med to be theraputic. I saw miracles in his patients. Someone who came in with meanness and wrinkles on his forehead looked and acted relaxed after about a week. He even believed the PMS could be helped with extremely low levels of lithium. So I guess my point is that the low dose may just be the thing. I am playing with a lot of alternative stuff myself. Now one more question and I'll go away from the thread is since so much time has gone by since the original diagnosis are they and you sure it's correct? Could not be MDD? In and of itself and the manias since drug induced just make it isn't it bipolar lll? Love Phillipa
Posted by SLS on July 3, 2009, at 12:25:14
In reply to Re: Going back to old-school - lithium. » SLS, posted by Phillipa on July 3, 2009, at 12:13:03
> Could not be MDD?
Right now, I am of the opinion that drug-induced manias are indicators of a bipolar diathesis. I feel the same way about ultra rapid cycling, even though the patient may never experience overt mania or hypomania.
I am not sure where drug-induced manias will be placed in the new DSM V when it comes out in 2012. As early as 1986, people were already designating this presentation as BP III. However, I have seen other proposals for diagnostic subtyping.
- Scott
Posted by ricker on July 3, 2009, at 12:41:08
In reply to Going back to old-school - lithium., posted by SLS on July 3, 2009, at 6:42:30
Hi Scott,
Yes, I did find my moods lifting and more stable on a dose of 300mgs!
I wish I could have stayed on it but I experienced akathisia like symptoms when performing tasks that required attention to detail? That's the only way I can think to describe it but yes, other than that, it did help at 300mgs.
Sorry to hear of your current struggle. Perhaps the lithium trial will yield positive results for you this time...your current cocktail may be different than that of your previous lithium trial?
All the best.... Rick
Posted by Phillipa on July 3, 2009, at 13:08:54
In reply to Re: Going back to old-school - lithium., posted by SLS on July 3, 2009, at 12:25:14
Scott I know you know you and you stuff. Would never doubt the validity of what your research and post. I do sure hope it works as I know you also do. Love Phillipa
Posted by Sigismund on July 3, 2009, at 14:20:19
In reply to Going back to old-school - lithium., posted by SLS on July 3, 2009, at 6:42:30
Scott, given that you don't like the effect of it, what do you hope that it will do for you?
Do you hope for some further effect down the track?
I dunno anything about this, particularly about bipolar illness where the patient is always stuck down the depressed end of the scale.
Posted by SLS on July 3, 2009, at 15:30:59
In reply to Re: Going back to old-school - lithium. » SLS, posted by Phillipa on July 3, 2009, at 13:08:54
> Scott I know you know you and you stuff. Would never doubt the validity of what your research and post.
WRONG! Always question the validity of my posts.
:-)
- Scott
Posted by SLS on July 3, 2009, at 15:34:00
In reply to Re: Going back to old-school - lithium., posted by Frustratedmama on July 3, 2009, at 10:24:11
> Scott
> Thinking of you and praying the lithium helps you! What else are you taking right now (I forget- sorry). Wish you well! (Know you aren't alone in this as i am feeling like crap too)
> FMThanks for the prayers. They are going to be much needed.
Currently:
Parnate 80mg
nortriptyline 150mg
Lamictal 200mg
Abilify 20mg
lithium 300mgI started the lithium just last night.
I wish for you better days also.
- Scott
Posted by SLS on July 3, 2009, at 15:38:50
In reply to Re: Going back to old-school - lithium., posted by sam K on July 3, 2009, at 11:00:44
> I took lithium yesterday too.
Funny coincidence. Weird.
> Its motivating for me in my head. But my body is tired. And last time i took it I had a hard time getting myself to take showers at all.
There is that pacifying and amotivational stuff that I dread.
> It raises my sex drive!!
I could use some of that myself.
> I feel more anxious, but that might go away soon.
Might. I hope so. So far, anxiety has not appeared for me.
> I wish ya the best of luck scott
Thanks. Ditto.
- Scott
Posted by SLS on July 3, 2009, at 15:48:18
In reply to Re: Going back to old-school - lithium. » SLS, posted by ricker on July 3, 2009, at 12:41:08
Hi Rick.
> Yes, I did find my moods lifting and more stable on a dose of 300mgs!
Wow. Did you split it to 150mg b.i.d.?
> I wish I could have stayed on it but I experienced akathisia like symptoms when performing tasks that required attention to detail?
Hmmm. That's different, but it might make sense if one looks at lithium as being pro-serotonergic, which it seems to be. In fact, there are cases of serotonin-syndrome associated with the use of SRI drugs combined with lithium.
> That's the only way I can think to describe it but yes, other than that, it did help at 300mgs.
Frustrating. How are you feeling now? What else are you currently taking?
> Sorry to hear of your current struggle. Perhaps the lithium trial will yield positive results for you this time...your current cocktail may be different than that of your previous lithium trial?
:-)
You are brilliant!
Wouldn't that be a kick in the butt if, after having tried countless exotic treatments, it turns out that lithium ended up being the last key necessary to unlock the cage door?
Life can be so enigmatic sometimes.
> All the best
Right back at ya'...
- Scott
Posted by Zana on July 3, 2009, at 15:57:50
In reply to Re: Going back to old-school - lithium. » ricker, posted by SLS on July 3, 2009, at 15:48:18
I have never had mania but out of desperation my pdoc put me on lithium. I have uni-polar depression and it was a terrible drug for me, deadened me completely. I was like a zombie on it. Why are you trying it now?
Zana
Posted by SLS on July 3, 2009, at 16:21:31
In reply to Re: Going back to old-school - lithium., posted by Zana on July 3, 2009, at 15:57:50
> I have never had mania but out of desperation my pdoc put me on lithium. I have uni-polar depression and it was a terrible drug for me, deadened me completely. I was like a zombie on it. Why are you trying it now?
I can't think of anything else to do. It is a decision made out of desperation, but is also very logical. The logic is simply that I have not yet tried lithium in combination with the other drugs I am currently taking.
I am using it at a reduced dosage compared to times in the past. Even 600mg affects me precisely as you describe. I am hoping that I don't experience those negative effects at 300mg. The people at Harvard / Mass General did some good work demonstrating that adding lithium at dosages of 300mg-600mg could work when added to Prozac for unipolar depression. It has been observed since the late 1970s that when added to a tricyclic antidepressant, lithium can produce miraculous results within days of starting it. In the old days, lithium had also shown favor in being combined with Parnate. All of this was for unipolar depression.
Believe me, it takes a lot of courage to return to a drug that you know has the potential to make you feel like crap. The nice thing about lithium when used in this augmentation role is that you only have to suffer for a week or so before you have your answer. And of course, I can stop taking it at any time. We'll see. I have a funny feeling about this. I hope I get hit with a severe case of irony.
Be well.
- Scott
Posted by linkadge on July 3, 2009, at 16:55:25
In reply to Re: Going back to old-school - lithium., posted by SLS on July 3, 2009, at 12:25:14
>Right now, I am of the opinion that drug-induced >manias are indicators of a bipolar diathesis.
Its a convenient little hypothesis which protects the supposed integrity of psychiatry. Why is it that some antdidepressants are more likly to induce mania than others? I trust Dr. Manjii and his quote "It seems that given the right conditions, anyone can have a manic episode"
Linkadge
Posted by linkadge on July 3, 2009, at 17:27:21
In reply to Re: Going back to old-school - lithium. » Frustratedmama, posted by SLS on July 3, 2009, at 15:34:00
Well, what have your moods been like over the past year? Any major manic episodes?
Of course, I hope the lithium helps, but, I am not a fan (personally) of trying drugs that have failed in the past. Lihtium, for me, is a very hard drug to handle. It always has a good acute AD effect which peters out over about 2 weeks. I want to take it for the neurotrophic effects, but for some reason just can't handle it for too long. 300mg might be tollerable. Are you taking it for depression?
Lithium works best for non rapid-cycling disorders. Not great for mixed states either.
Your meds are prety pro-catecholamine. I find sometimes too much adrenergic activity without enough serotonergic can lead to a form of endless emotionally ruminative dysphoria.
What about the following:
Parnate 10-40mg
Magnesium 50mg + 5-htp 25mg + lithium 150-300mg
Nortriptyline 150mg
Lamictal 200mg
Abilify 20mgLinkadge
Posted by SLS on July 3, 2009, at 17:28:37
In reply to Re: Going back to old-school - lithium., posted by linkadge on July 3, 2009, at 16:55:25
Linkadge, what the hell took you so long?
:-)
> >Right now, I am of the opinion that drug-induced >manias are indicators of a bipolar diathesis.
> Its a convenient little hypothesis which protects the supposed integrity of psychiatry.I don't understand. What exactly would upset the integrity of psychiatry if it were found that drug-induced manias were not necessarily the result of an underlying bipolar disorder.
> Why is it that some antdidepressants are more likly to induce mania than others?
They are probably more heavily catecholaminergic. Anyway, in what way is this fact relevant to your beliefs regarding drug-induced manias?
> I trust Dr. Manjii and his quote "It seems that given the right conditions, anyone can have a manic episode"
I would like to see the text which surrounds the quote. I would be interested to know under what circumstances he feels he can produce mania in a mentally healthy person. Even prednisone can produce psychosis. I have no problem with the concept, just its execution.
- Scott
Posted by SLS on July 3, 2009, at 17:35:59
In reply to Re: Going back to old-school - lithium., posted by linkadge on July 3, 2009, at 17:27:21
> What about the following:
>
> Parnate 10-40mg
> Magnesium 50mg + 5-htp 25mg + lithium 150-300mg
> Nortriptyline 150mg
> Lamictal 200mg
> Abilify 20mg
The Mg is a good idea. I might add that after I see where this lithium thing is going. I am concerned that the 5-HTP might induce serotonin-syndrome. Is 25mg considered a low dosage?What do you think about taking N-acetylcysteine (NAC)?
- Scott
Posted by linkadge on July 3, 2009, at 18:11:33
In reply to Re: Going back to old-school - lithium., posted by SLS on July 3, 2009, at 17:28:37
>I don't understand. What exactly would upset the >integrity of psychiatry if it were found that >drug-induced manias were not necessarily the >result of an underlying bipolar disorder.
Then, it could be seen as (what I believe it is) a side effect of certain drugs in certain patients. Biology is way too complex to classify a disorder based on a reaction to a drug IMHO.
If it is the patient and not the drug, there is no fault with psychiatry.
>They are probably more heavily >catecholaminergic. Anyway, in what way is this >fact relevant to your beliefs regarding drug->induced manias?
Well, if all drugs are equally effective in elevating mood, you'd expect them to be equally likely to induce mania. That is, if the mania is the result of the drug acellerating a cycle.
Because some drugs are more likely to induce mania, suggests to me, that there is some biochemical target which is more fundimentally linked to the manic processes.
Some AD's like survector had to be pulled because it was too good an AD. Basically meaning that it must have induced euphoria as a side effect.
I think there are separate processes for affect and reward. Some of the AD's (notably parnate) have effects on affect and reward. Its all about the brain region that the drug hits. If it hits the right (or wrong) brain region, it can be like cocaine - able to give anyone a buzz.
For instance, the first MAOI's were noted to cause notably elevated mood in the TB patients they were first administered to - beyond what would be expected from TB symptom recovery. From the biological theory of depressive disorders, it is suprising that these patients experience any improvmente in mood (let alone to the point of hypomania).Nextly there is are the TCA's. The wikipedia article on imipramine suggessts that it has been known to cause a very high rate of manic reactions. The TCA's induce sensitization of limbic dopaminergic circuts faster and to a greater extent than the SSRI's. This is increasing reward sensitivity a core aspect of mania. In addition, anticholingerics (especially m1 antagonists) have been know to produce reinforcing effects in animal models. They have also been asocaited with manic and psychotic like effects in animals an humans.
I remember feeling better (very quickly) on TCA's - as in the next day. My mother too noted the effect. This was much unlike the SSRI's which took a month to produce a very modest apthetic improvement. My mother only had 1 manic epsiode which was on a high dose TCA. Never before, nor since.
>Even prednisone can produce psychosis. I have no >problem with the concept, just its execution.
Explain further.
Linkadge
Posted by linkadge on July 3, 2009, at 18:21:31
In reply to Re: Going back to old-school - lithium. » linkadge, posted by SLS on July 3, 2009, at 17:35:59
25mg is a lowish dose of 5-htp. I have used it intermittently with an MAOI without problem (not sure about with nortriptyline though).
>What do you think about taking N-acetylcysteine >(NAC)?
I personally don't like the stuff - but it depends on your symtpoms. I found NAC made me very irritable. Alpha lipoic acid was better (for me at least).
You might try sleep deprivation in combination with lithium. There is some evidence of sustaining the AD effect of lithium with periodic SD.
I remember when I was taking lithium + clomipramine. I would be fine for about 4 days then start to crash into depression. At this point I would skip the evening medication dose, pull an all nighter and take meds as usual the next night. This would last for another 4-5 days.
It can be a little taxing on the system (you have to prepare a completely stress free day the next day). But it quickly got me out of a bad funk.
Its great though. I remember feeling like trash (all anxious, worthless, hyper ruminative), then about 2:30 something started to shift over the course of about 5 minutes. Then all of a sudden..normal.
Linkadge
Posted by ricker on July 3, 2009, at 19:14:35
In reply to Re: Going back to old-school - lithium. » ricker, posted by SLS on July 3, 2009, at 15:48:18
> Wow. Did you split it to 150mg b.i.d.?
No, 300mg 1xday
> Hmmm. That's different, but it might make sense if one looks at lithium as being pro-serotonergic, which it seems to be. In fact, there are cases of serotonin-syndrome associated with the use of SRI drugs combined with lithium.Yes, when I told my p/doc he said "anythings possible, it doesn't matter what the cause, you felt it so we'll discontinue"?
> Frustrating. How are you feeling now? What else are you currently taking?
Somewhere around 75-85%
Zoloft - 100mg
Lamictal - 100mg
Zyprexa - 5mg
Clonazepam - 0.5 bid> Wouldn't that be a kick in the butt if, after having tried countless exotic treatments, it turns out that lithium ended up being the last key necessary to unlock the cage door?
Yes it would my friend! Good luck Scott!
Regards, Rick
Posted by floatingbridge on July 3, 2009, at 19:17:47
In reply to Going back to old-school - lithium., posted by SLS on July 3, 2009, at 6:42:30
Scott,
My best wishes for you in the days to come! I like the old key in a different combination metaphor.....
Posted by Frustratedmama on July 3, 2009, at 21:17:22
In reply to Re: Going back to old-school - lithium. » Frustratedmama, posted by SLS on July 3, 2009, at 15:34:00
Hey Scott,
Wish things were better for you! I know that the lamictal pooped out on me the first trial so could be that... Second time it didn't work for me.... Wishing you well and hoping the lithium is the answer.... Why does this happen? Why can't this stuff just work and do its job.... Aspirin doesnt poop out why do our psych meds? Hope you find some releif....
FM
Posted by Frustratedmama on July 3, 2009, at 22:57:37
In reply to Re: Going back to old-school - lithium. » Frustratedmama, posted by SLS on July 3, 2009, at 15:34:00
Scott,
weren't you taking topomax before?
Posted by SLS on July 4, 2009, at 2:52:31
In reply to Re: Going back to old-school - lithium., posted by Frustratedmama on July 3, 2009, at 22:57:37
> Scott,
> weren't you taking topomax before?Nothing escapes your attention!
Yes. Although I thought I received some mild benefit from it a few years back, I experienced no improvement this time around. I wasn't too crazy about the side effect of muscle weakness (asthenia) and fatigue upon mild exercise.
- Scott
Posted by SLS on July 4, 2009, at 3:32:15
In reply to Re: Going back to old-school - lithium., posted by linkadge on July 3, 2009, at 18:11:33
> >I don't understand. What exactly would upset the >integrity of psychiatry if it were found that >drug-induced manias were not necessarily the >result of an underlying bipolar disorder.
> Then, it could be seen as (what I believe it is) a side effect of certain drugs in certain patients.
Yeah. Those with occult bipolar spectrum disorders.
> Biology is way too complex to classify a disorder based on a reaction to a drug IMHO.
It is done all the time for diagnostic purposes in many different fields of medicine. I can't give you an example right off the top of my head. Even depression can be parsed using the body's reaction or non-reaction to the administration of the drug, dexamethasone.
> If it is the patient and not the drug, there is no fault with psychiatry.
I just don't think that this kind of mentality went into the decision reached by William Potter (NIH) in 1992 to understand my illness as being a variety of bipolar disorder.
> > They are probably more heavily >catecholaminergic. Anyway, in what way is this >fact relevant to your beliefs regarding drug->induced manias?
> Well, if all drugs are equally effective in elevating mood, you'd expect them to be equally likely to induce mania.
I would have no expectation of this. I don't find any logic in extrapolating to every antidepressant the same clinical properties, whether they be therapeutic or adverse.
> Because some drugs are more likely to induce mania, suggests to me, that there is some biochemical target which is more fundimentally linked to the manic processes.
Perhaps. The question is whether or not it is downstream from the pharmacological actions of the drug. Wellbutrin and Prozac hit different targets even though many downstream effects are the same.
> Some AD's like survector had to be pulled because it was too good an AD. Basically meaning that it must have induced euphoria as a side effect.
I have never heard that. Stimulating, yes. It might be closer in effect to methylphenidate (Ritalin) or amphetamine (Dexedrine).
> I think there are separate processes for affect and reward.
I think so too.
> Some of the AD's (notably parnate) have effects on affect and reward.
Its all about the brain region that the drug hits.
You are preaching to the choir, my friend.
> If it hits the right (or wrong) brain region, it can be like cocaine - able to give anyone a buzz.
You see, this is where I don't see the execution of the concept. Nice on paper, but show me. I do understand where you are coming from with all of this. If you really want to do some digging, you might want to try some empirical research. For example, at what rate does the general population respond to amphetamine with a manic episode versus people who seek treatment for depression.
If Manji can make rats "depressed", I guess he can make them "manic". How would he go about making a person manic? Where on the Net can I find the Manji quote you cited?
I still believe that if you are treating someone for a depressive disorder, and a drug brings out a manic reaction, the odds are that they are displaying a phenotype that lies somewhere along the bipolar spectrum. These people are not representative of the general population, and I am betting that manic reactions to antidepressants are more likely an indicator of bipolarity than a simple side-effect.
Soon, our debate here will be moot, as functional imaging studies will be able to identify bipolar brains. They already do, but it might be awhile before they see general clinical application.
Oh, well. For now, I guess we must continue to disagree on this one.
- Scott
Posted by SLS on July 4, 2009, at 5:57:26
In reply to Re: Going back to old-school - lithium., posted by SLS on July 4, 2009, at 3:32:15
I found these interesting:
- Scott
********************************************************
1: Biol Psychiatry. 2006 Nov 1;60(9):1005-12. Epub 2006 Aug 30.Click here to read Links
A pilot study of antidepressant-induced mania in pediatric bipolar disorder: Characteristics, risk factors, and the serotonin transporter gene.
Baumer FM, Howe M, Gallelli K, Simeonova DI, Hallmayer J, Chang KD.Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California 94305-5540, USA.
BACKGROUND: Antidepressant-induced mania (AIM) has been described in bipolar disorder (BD) and has been associated with the short-allele of the serotonin transporter gene (5-HTT). We wished to investigate the frequency of and risk factors for AIM in pediatric patients with or at high risk for BD. METHODS: Fifty-two children and adolescents (30 with BD and 22 with subthreshold manic symptoms, 15.1 +/- 3.4 years old), all with a parent with BD, were interviewed with their parents for manic/depressive symptoms occurring before and after past antidepressant treatment. The 47 subjects with serotonin reuptake inhibitor (SSRI) exposure were genotyped for the 5-HTT polymorphism. RESULTS: Fifty percent of subjects were AIM+ and 25.5% had new onset of suicidal ideation. The AIM+ and AIM- groups did not differ significantly in relation to allele (p = .36) or genotype (p = .53) frequencies of the 5-HTT polymorphism. The AIM+ subjects were more likely to have more comorbidities (3.2 vs. 2.4; p = .02) and be BD type I (p = .04) than AIM- subjects. CONCLUSIONS: Youth with or at high risk for BD may be particularly vulnerable to SSRI AIM and thus should be monitored if given SSRIs. In this preliminary study, we did not find that the 5-HTT polymorphism significantly influenced vulnerability to AIM.
PMID: 16945343 [PubMed - indexed for MEDLINE
******************************************************************
1: Arch Gen Psychiatry. 2001 Jun;58(6):539-44.Click here to read Links
The role of serotonin transporter protein gene in antidepressant-induced mania in bipolar disorder: preliminary findings.
Mundo E, Walker M, Cate T, Macciardi F, Kennedy JL.Neurogenetics Section, R-31, Centre for Addiction and Mental Health, Clarke Site, 250 College St, Toronto, Ontario, Canada M5T 1R8. James_Kennedy@CAMH.net
BACKGROUND: The occurrence of mania during antidepressant treatment is a key issue in the clinical management of bipolar disorder (BP). The serotonin transporter (5-HTT) is the selective site of action of most proserotonergic compounds used to treat bipolar depression. The 5-HTT gene (SLC6A4) has 2 known polymorphisms. The aim of this study was to investigate the role of the SLC6A4 variants in the pathogenesis of antidepressant-induced mania in BP. METHODS: Twenty-seven patients with a DSM-IV diagnosis of BP I or II, with at least 1 manic or hypomanic episode induced by treatment with proserotonergic antidepressants (IM+ group), were compared with 29 unrelated, matched patients with a diagnosis of BP I or II, who had been exposed to proserotonergic antidepressants without development of manic or hypomanic symptoms (IM- group). The 2 known polymorphisms of the SLC6A4 were genotyped, and allelic and genotypic association analyses were performed. RESULTS: With respect to the polymorphism in the promoter region (5HTTLPR), IM+ patients had an excess of the short allele (n = 34 [63%]) compared with IM- patients (n = 17 [29%]) (chi(2)(1), 12.77; P <.001). The genotypic association analysis showed a higher rate of homozygosity for the short variant in the IM+ group (n = 10 [37%]) than in the IM- group (n = 2 [7%]) and a lower rate of homozygosity for the long variant in the IM+ group (n = 3 [11%]) compared with the IM- group (n = 14 [48%]) (chi(2)(2), 12.43; P =.002). No associations were found for the polymorphism involving a variable number of tandem repeats. CONCLUSION: If these results are replicated, the 5HTTLPR polymorphism may become an important predictor of abnormal response to medication in patients with BP.
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