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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 10 of 10. This is the beginning of the thread.
Posted by judy1 on November 2, 2000, at 17:57:32
I've been posting on social-babble the last few days- and everyone has been incredibly kind to me. I have just gone back on medication (following my miscarriage) and had some specific questions that hopefully some of you can answer. My pdoc put me back on pretty much everything I was on 6 months ago. Depakote at 1000mgs, klonopin 6mgs, risperdal 2mgs and celexa 10mgs. I have had AD induced mania several times, so I know why the celexa is low. I've had a great number of panic attacks recently, and that is why the klonopin is high. I am told I'm having delusions (risperdal), but I used to take 4mgs of that. My questions are- this shrink doesn't like the klonopin- he said it may be worsening my dissociation which leads to cutting. This is the dose I had taken (until recently) for 3 years. Would you expect a reaction like that when I had been tolerating it so well before? I have had movement under my skin (I cannot remember what that is called)- probably the risperdal? And it seems as if no matter what pdoc it is, they all seem to love to give me depakote, even though I say it makes me depressed. They say it is the drug of choice for me- bipolar 1, rapid cycling (and panic disorder and God knows what else). Thank you in advance for any insights, it is amazing how much better it is for me to ask this board than my own shrink. Take care and sorry for the length of this- Judy
Posted by judy1 on November 2, 2000, at 19:06:23
In reply to back on meds, posted by judy1 on November 2, 2000, at 17:57:32
Sorry, I meant to ask this also. After my son's birth (8 years ago), I developed post partum psychosis. Is it possible that there is some role of hormones now (I was 5 months pregnant) and I definitely feel a lot of changes in my body. Thank you.
Posted by noa on November 2, 2000, at 19:27:46
In reply to P.S- hormones, posted by judy1 on November 2, 2000, at 19:06:23
I am not a doctor, but I would say that YES it is possible.
I didn't know your pregnancy had gone that long. How traumatic the loss must have been.
BTW, you should have your thyroid checked because of postpartum thyroiditis, which can cause or exacerbate psychiatric symptoms.
Posted by judy1 on November 2, 2000, at 20:18:12
In reply to Re: P.S- hormones, posted by noa on November 2, 2000, at 19:27:46
Noa, what type of tests do I ask for when checking the thyroid? I have had a thyroid screen before, but it just gave 1 value and I remember you talking about T3 and T4 supplements(?) before.
Thanks, Judy
Posted by JohnL on November 3, 2000, at 4:07:32
In reply to back on meds, posted by judy1 on November 2, 2000, at 17:57:32
Hi Judy,
I'm very sorry about your situation. I feel for you. One thing that really popped out at me though was your will and your strength. You seem like a very strong person. That can only be for the good, and will pay off eventually.I couldn't even begin to second-guess your doctors. But I did have a lot of questions right off the bat. In your shoes I would probably be asking my doctor these questions.
Why Depakote and not Lithium? Here's why I ask. Lithium is the gold standard, not Depakote. Depakote is a next best alternative. Lithium is often effective at much lower levels than they used in the old days. Also, if you think Depakote adds to your depression, your instinct is probably correct. It is a possible side effect listed in literature. If they tell you that you would require such a high dose of Lithium that it borders on toxic, that may likely not be true. It was true in the old days. Lithium has also been completely effective in 22% of anxiety/panic patients when the other more appropriate drugs didn't work well. This is interesting and important, because Lithium is not clinically justified for panic. But it worked anyway. It just goes to show how complicated the brain can be, how various chemistries can cause identical symptoms, how an unsuspected drug can work very well, and futile it is sometimes to try to match a drug to a particular diagnosis.
Why not Zyprexa instead of Depakote and Risperdal? Zyprexa is generally a better drug than Risperdal in clinical trials. Not always, but generally. In addition, it is now FDA approved for treating mania, and it is being used to treat depression. It works on depression, mania, mood swings, bipolar, psychosis, and is generally a calming medication so it might be helpful for panic too. I wouldn't be surprised if the panic and the psychosis-like symptoms are closely related, and could be treated with a single drug. Zyprexa could do all that.
Why Klonopin and not another benzo? I think it's important to try and compare several drugs within a particular class of drugs in order to find your favorite. Your favorite will make itself known. For whatever reasons, you will clearly like it better than the others. I just wonder if there is a better benzo for you?
It just sounds to me that even though your situation seems complicated, with a whole lot of troubling symptoms, it is probably a lot simpler to treat than your doctors may realize. In psychiatry, the general procedure is to first make a diagnosis, and then choose drugs to match that diagnosis. For the most part this works. But in a substantial minority of patients, this doesn't work. Other drugs that do not have clinical justification need to be tried. If a drug happens to be partially effective, then other drugs within it class should be tried for comparison. None of this sounds to me like something that could be done without a doctor. But I would strongly urge the doctor to try things you haven't tried. Top choices in my mind would be Lithium and Zyprexa.
The chart below shows what percentage of patients got well with which drugs in panic/anxiety. Notice that from Lithium on down to Tegretol, these drugs generally are not considered for treating anxiety/panic. But they worked nonetheless. That's important. It would be nice to know how and why they work, but it's not really important. All that matters is that they worked. There is also a chart for 'bizzarness', not printed below. It is slightly different, but basically the same, with the main difference being antipsychotics were effective 65% of the time instead of 13% as shown below.
Serotonin antidepressants Worked in 37% of patients
Benzodiazapines Worked in 24%
Lithium 22%
Stimulants 14%
Antipsychotics 13%
Depakote 11%
Tegretol 3%
Thyroid 24%
Combinations were used in 35% of patients, not reflected in the chart.
Stimulants often required an antipsychotic combination.
Beta blockers such as Inderal were sometimes helpful for panic, especially palpitations, but not recorded in the chart.Basically what all this means is:
1) It's important to try other things, even if they aren't clinically justified. One patient suffered anxiety/panic his whole life and was never treated very well with usual drugs. Only in his later years did another doctor say, what they heck, let's try Lithium. It worked so well it was like a miracle, and the patient wondered why it had taken decades to discover that. Nobody ever thought of it. It was important to have an open mind and try. In psychiatry, anything's possible. If you're not doing that well, and your doctor is in the match-the-drug-to-the-diagnosis mode, you may never get well. Keep an open mind, try anything. The more drugs that should work but don't, the greater the odds become that one that has no clinical justification will work. It becomes a priority to try other less common or even seemingly inappropriate drugs.
2) It's important to try several drugs within the same class to discover a favorite. There will likely be one, but you'll never have a chance to discover it if you aren't allowed to try.In your shoes I would be asking my doctor to ditch the Depakote and Risperdal, and replace them with Lithium and Zyprexa. If they told me I would need to take high doses of Lithium, nearly toxic, I would say hogwash. Let me try 900mg to 1500mg, and if that doesn't do it, then let's try something else. But let's not go back to Depakote until we've tried everything else. Just my opinions. But that's what I would do in a similar situation.
Hope something here is helpful.
John
Posted by noa on November 3, 2000, at 9:15:59
In reply to thyroid » noa, posted by judy1 on November 2, 2000, at 20:18:12
See the following for info on thyroid tests:
http://thyroid.about.com/health/thyroid/library/weekly/bltest-values.htmAlso, see the thyroid and depression folder at pscyho-babble-tips links
Posted by judy1 on November 3, 2000, at 9:44:15
In reply to Re: back on meds, posted by JohnL on November 3, 2000, at 4:07:32
Dear John,
The lithium denial is entirely my fault- I probably should have made that clear. It was the "drug of choice" in my father's suicide, and despite a lot of work I cannot seem to get over that fact. And yes I know he killed himself, not the drug. My sister (who is agoraphobic and has bipolar 2), there are some very strong genetics going on in my family, is on verapamil along with klonopin- it seems to help her. And I think it is a similar action? I think you are entirely correct about Zyprexa, I was more stable on that than any other drug until I got pregnant (although not cycle free). I took 20 mgs/day and gained over 20 pounds in about 3 weeks. And to make everything more complicated- I have a history of an eating disorder- so that really affected me. But I am willing to try it again, maybe at a lower dose and I hear topamax would probably counteract the weight gain. Thank you for validating my depakote experience, I bet it will be one of those drugs that in a few years shrinks will say causes depression. As always, you were a tremendous help- Take care, Judy
Posted by judy1 on November 3, 2000, at 9:48:06
In reply to Re: thyroid, posted by noa on November 3, 2000, at 9:15:59
Perfect! My TSH value was 5.5, and I will ask my Internist to run the other tests, since I seem to remember the shrink I was seeing last year didn't seem to think it necessary, he said my TSH was in the normal range. Take care and I'll let you know the values- Judy
Posted by noa on November 3, 2000, at 10:44:58
In reply to Re: thyroid » noa, posted by judy1 on November 3, 2000, at 9:48:06
Judy, yes, 5.5 is on the high side, and for some people it is much too high.
Mine was around that level originally, and I felt awful, and ADs weren't working very well. Now that I am on thyroid meds I finally feel better.
Posted by noa on November 3, 2000, at 10:47:06
In reply to Re: thyroid » noa, posted by judy1 on November 3, 2000, at 9:48:06
BTW, if your GP and psychiatrist don't take this seriously, try seeing an endocrinologist. On the thyroid-info.com site, there is a page where you can find reccommendations for endos and other docs who listen to patients about their hypothyorid symptoms. That is how I found my endo and he has been really helpful.
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