![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 5 of 5. This is the beginning of the thread.
Posted by Bob on December 2, 2005, at 1:21:13
I'm taking Lithium with a tiny amount of Klonopin right now, and am experiencing nasty fatigue and depression which is at its worst in the morning and sometimes cycles into restless discomfort in the evening (although not always). My question is, how can something that is not the same throughout the day be treated? I feel like I need an AD to bring me out of the deep fatigue, drowsiness and depression which characterizes most of my day, but then if it kicks into that restlessness for a few hours, the last thing I need is something adding to that.
Posted by med_empowered on December 2, 2005, at 2:51:58
In reply to cycling?, posted by Bob on December 2, 2005, at 1:21:13
hi! some depressions are like that--they vary by time of day. Its not something that docs seem to talk about a lot, but there's a lot of mention of it in the literature, especially the pre-SSRI days. Anyway, the first thing to do when you have depression in bipolar is to: up the mood-stabilizer or "optimize" the mood stabilizer, sually by adding another mood stabilier. My guess would be that upping the mood-stabilizer or adding Lamictal would be good first-line moves for you. It may also be that Lithium isn't the best mood-stabilizer for you; although Lithium has a protective effect against suicide, some people get better anti-depressant responses with Tegretol/Trileptal, Depakote, Lamictal, or the new atypicals.
Antidepressants really aren't that great for BP disorders, particularly BP I disorder, so that should probably be something you do *after* working on the mood-stabilizer(s). Personally, I'd try adding Lamictal short-term, maybe also upping the Klonopin a bit (it can help some people with depression, and its pretty good for anxiety and bipolar disorders as well). This is also a time to bust out those obnoxious mood-charts patients are all familiar with and start charting...see if little interventions (avoiding caffeine/cigarettes at a certain point, changing alcohol consumption patterns, etc.) show any improvement. If not, you'll probably want to try more med jiggling till you feel better.
Posted by Bob on December 2, 2005, at 17:12:23
In reply to Re: cycling?, posted by med_empowered on December 2, 2005, at 2:51:58
> hi! some depressions are like that--they vary by time of day. Its not something that docs seem to talk about a lot, but there's a lot of mention of it in the literature, especially the pre-SSRI days. Anyway, the first thing to do when you have depression in bipolar is to: up the mood-stabilizer or "optimize" the mood stabilizer, sually by adding another mood stabilier. My guess would be that upping the mood-stabilizer or adding Lamictal would be good first-line moves for you. It may also be that Lithium isn't the best mood-stabilizer for you; although Lithium has a protective effect against suicide, some people get better anti-depressant responses with Tegretol/Trileptal, Depakote, Lamictal, or the new atypicals.
>
> Antidepressants really aren't that great for BP disorders, particularly BP I disorder, so that should probably be something you do *after* working on the mood-stabilizer(s). Personally, I'd try adding Lamictal short-term, maybe also upping the Klonopin a bit (it can help some people with depression, and its pretty good for anxiety and bipolar disorders as well). This is also a time to bust out those obnoxious mood-charts patients are all familiar with and start charting...see if little interventions (avoiding caffeine/cigarettes at a certain point, changing alcohol consumption patterns, etc.) show any improvement. If not, you'll probably want to try more med jiggling till you feel better.First off, thanks for your response. Well, I guess you're telling me something I don't want to hear, but has to be said. I've actually tried Lamictal (rash), and Depakote (severe, unremitting , heavy drowsiness for the year or two that I took it - only relieved somewhat by Welbutrin). Tegretol I tried also, but it wasn't a long trial, and I don't remember what happened. I guess that leaves atypicals, which frankly really scares me. I would certainly think that there would have to be something better than Li out there, but I've thought that about every drug that I've ever taken. I have to find some way to get my courage and/or motivation up and move forward.
Posted by Phillipa on December 2, 2005, at 22:13:15
In reply to Re: cycling? » med_empowered, posted by Bob on December 2, 2005, at 17:12:23
The Nike saying just do it! Fondly, Phillipa
Posted by med_empowered on December 3, 2005, at 3:08:26
In reply to Re: cycling? » Bob, posted by Phillipa on December 2, 2005, at 22:13:15
hey! if you tried tegretol, you could still try trileptal, which could possibly cause fewer problems. Its also possible to just reduce the lithium and add in some depakote, tegretol, or trileptal. Keppra is another possible option; the problem there would be drug-induced depression..other than that, its a remarkably clean drug in terms of side effects and drug-drug interactions. As for the atypicals..I've taken them, and I wasn't impressed. Really..they're not so great. I think you're better off sticking with Lithium.
Another, last-ditch option would be Dilantin (Phenytoin); its an old-school anticonvulsant, but it seems to work in some bipolar patients. If the dosage is adjusted correctly you can avoid cognitive impairment.
Just boosting your Lithium can help, as long as you can handle the side effects. Calcium channel blockers help some people (probably not a good idea at this point, but your doc might want to try it). You could also benefit by adding a low-ish dose of another mood-stabilizer--depakote, etc. I dont think the adjustment has to be permanent; from what I understand, your doc can adjust the mood stabilizers downwards once your depression has resolved itself.
This is the end of the thread.
Psycho-Babble Medication | Extras | FAQ
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.org
Script revised: February 4, 2008
URL: http://www.dr-bob.org/cgi-bin/pb/mget.pl
Copyright 2006-17 Robert Hsiung.
Owned and operated by Dr. Bob LLC and not the University of Chicago.