![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 4 to 28 of 28. Go back in thread:
Posted by utopizen on April 21, 2003, at 20:52:36
In reply to Should I be annoyed with pdoc?, posted by Dinah on April 21, 2003, at 19:48:57
Have you tried veganism yet?
I don't think anyone's gotten diabeties after over-consuming brocolli and tofu
Posted by Ritch on April 22, 2003, at 0:07:39
In reply to Should I be annoyed with pdoc?, posted by Dinah on April 21, 2003, at 19:48:57
> After my tongue thrusting incident, I was a bit concerned about taking Risperdal. My pdoc appt was today and I discussed my concerns with him. He said that there was no chance of permanent movement disorder since I was taking the lowest dose on an as needed basis. He said I'd have to be on it for six months or so continuously to have any real risk of permanent problems.
>
> Well, I'm not sure about that, but the thing that really annoys me is this. He gave me a prescription for seroquel instead, saying it was less likely to cause trouble. I just did a bit of research this evening and found that was true. But I also found that placebo controlled studies showed a 17% increase in triglycerides and an 11% increase in cholesterol (that was not dependent on weight gain) in three to six week studies. My triglycerides are already high, my internist is trying to get them under control, and I'm just shy of prediabetic.
>
> Now, I may or may not have told him this. I think I gave him copy of my last test results because of elevated liver enzymes and to show the depakote levels. But whether or not I did, I'm a large person. It wouldn't take a large cognitive leap to guess that I might have trouble with triglycerides and cholesterol. I'm really annoyed that he didn't inform me. I'm wondering if our five minute sessions are really sufficient (seven minutes today due to meds change).
>
> Is my annoyance justified? Maybe I'm reading outdated Seroquel information. Or maybe it really is normal not to mention these things.
Dinah, I think annoyance is clearly justified. Especially since your pdoc appears to be going through a lot of justification! Interesting that you have been taking a low-dose of Risperdal and then get flipped to low-dose Seroquel. That's the sequence I went through. Yes, it might be true that it would take months of exposure to that low-dose of Risperdal to cause a *permanent* problem, but who wants to go there? Given you are not experiencing psychosis, I would just be assertive here about not wanting to take an AP at all-period. So there--now where do we go from here with meds, therapy, etc.?
Posted by Viridis on April 22, 2003, at 1:01:27
In reply to Should I be annoyed with pdoc?, posted by Dinah on April 21, 2003, at 19:48:57
Aside from the health-specific issues that you raised (which a psychiatrist, who by definition is an MD, should consider), the 5 minute session point struck me as weird. My first session with my current psychiatrist lasted about 1 1/2 hrs, and my 3-month "15 minute" drug consultations almost always last 30 minutes or more (although he only charges for 15 minutes).
My pdoc does like to chat, but he also is very astute in asking key questions about how the meds are working, how my life is going in general, etc. In that sense, he's pretty "holistic", although ultimately it's all about whether the mix of meds is really working. The downside is that he often runs late on appointments, and when I ask the receptionist how long I'll have to wait, she just laughs and says "you know how he is". But I prefer this approach, because he really cares about his patients and takes the time to treat them properly. He's lamented to me several times that his practice is growing too much, and I'm not surprised -- people come to see him from all over.
My GP, on the other hand, wants me in and out as fast as possible -- just prescribe something and get on to the next patient. Questions of any kind annoy him -- just take the drugs, they have no side effects, etc.
It took me 13 years to find my pdoc, but I'm very happy with him. It's really worth searching for someone who cares -- 5 minutes (or 7) just isn't enough.
Posted by noa on April 22, 2003, at 8:13:39
In reply to Re: Should I be annoyed with pdoc? » Dinah, posted by Greg on April 21, 2003, at 20:41:46
>>IMHO, 5 minutes with a pdoc or Psych isn't sufficient under any circumstance.
And, Dinah, you are probably paying for a 15 or 20 minute med consult!! Check the bills or the insurance statements.
I agree that you should ask for more time. In the meantime, call him?
Posted by noa on April 22, 2003, at 8:19:33
In reply to Re: Should I be annoyed with pdoc? » Dinah, posted by jerrympls on April 21, 2003, at 20:24:51
Jerry,
here is some info on triglycerides from the Am. Heart Assoc.
http://www.americanheart.org/presenter.jhtml?identifier=4778
usually, the thing to do is diet and exercise. Diet to reduce intake of "bad" fats and also of total calories if needing to lose weight, and exercise. My doc told me I would get more results from exercise in reducing my triglycerides than I would from diet change. I'm not sure why--maybe because I don't eat meats, etc.? Don't know.
Posted by noa on April 22, 2003, at 8:20:55
In reply to Re: Should I be annoyed with pdoc? » Dinah, posted by Viridis on April 22, 2003, at 1:01:27
Sounds like my pdoc!
Posted by Dinah on April 22, 2003, at 9:07:46
In reply to Re: Should I be annoyed with pdoc? » Dinah, posted by jerrympls on April 21, 2003, at 20:24:51
Triglycerides are one of the things that make up total cholesterol, but they aren't *caused* by eating fat. When your body eats more sugar/carbohydrateds than it can use for energy, high triglycerides are the result. In my case, given my family history of diabetes and my relatively high fasting blood sugars, a less than perfectly functioning pancreas is probably also involved. My doctor wants me on one of the Atkins diet variants. :(
Posted by Dinah on April 22, 2003, at 9:08:36
In reply to Re: Should I be annoyed with pdoc?, posted by utopizen on April 21, 2003, at 20:52:36
> Have you tried veganism yet?
>
>
> I don't think anyone's gotten diabeties after over-consuming brocolli and tofuYa call that living?!!!
(grin) I aspire to vegetarianism, but not veganism.
Posted by Dinah on April 22, 2003, at 9:17:46
In reply to Re: Should I be annoyed with pdoc? » Dinah, posted by Greg on April 21, 2003, at 20:41:46
I pay myself, as this guy isn't on my PPO's provider list. It reimburses me for a small part of his cost. I *think* I pay for a ten to fifteen minute session. I don't know if it was ever discussed.
After my last, totally overintrusive and frankly frightening pdoc, this guy was wonderfully understated and low key. The length of the visit really didn't matter because I haven't had many adjustments to my meds. He put me on depakote right away. I've stayed on Depakote and Klonopin the whole time I've seen him (except one brief trial at no meds). I withdrew from Luvox. And the only two meds I've added were a brief but disastrous Effexor trial and the Risperdal. So it's basically just prescription renewals.
I guess it does have its drawbacks though. He's strictly meds oriented and really isn't interested in anything but meds and side effects. My therapist wants him to know a few things that I have been unable to tell him because the nonverbal cues are pretty clear. If it isn't meds he doesn't want to hear it.
But I really really like the way he accepts it if I don't want to continue a drug. My past pdocs have pushed meds and med combinations in a way I didn't like. This one accepts that I don't want to be on an SSRI for example. My last one kept upping the doseages, adding disastrous adjuncts, and blaming me if it didn't go well. :(
Posted by Dinah on April 22, 2003, at 9:27:58
In reply to Re: Should I be annoyed with pdoc? » Dinah, posted by Ritch on April 22, 2003, at 0:07:39
Meds wise. I wish I knew.
Risperdal was the first medication that really did what I needed it to do. Since I'm ok most of the time, I only took it as needed. So it didn't change how I felt or was most of the time. I liked that.
My meltdowns are probably some form of agitated dysphoric hypomania. I've never been able to pin them down. They happen periodically, more frequently when I'm under stress. The Risperdal affected them as both an excellent tranquilizer, and as (as I heard someone describe it) ego glue that helped me from shattering into pieces. Klonopin might put me to sleep, but it doesn't calm me during these periods. Oddly, I was on Thorazine for a year or so as a preteen, I think for my sleeping problems (my medical records say for sleep terrors), but I guess it also helped control the same symptoms I have in my meltdowns. I know I wasn't psychotic at the time, but I was very very agitated.
Does anyone have any idea of a class of medications other than antipsychotics that might work as well for the meltdowns?
Posted by Snoozy on April 22, 2003, at 11:12:35
In reply to Re: Five minute appointments, posted by Dinah on April 22, 2003, at 9:17:46
I'm sorry you've had some pretty bad experiences with pdocs. I've been through that myself. I don't think it's asking too much to have a doc that doesn't push meds and takes at least *some* interest in your overall wellbeing, not just your meds.
Does anyone out there have any advice on how to find a good pdoc?
> I pay myself, as this guy isn't on my PPO's provider list. It reimburses me for a small part of his cost. I *think* I pay for a ten to fifteen minute session. I don't know if it was ever discussed.
>
> After my last, totally overintrusive and frankly frightening pdoc, this guy was wonderfully understated and low key. The length of the visit really didn't matter because I haven't had many adjustments to my meds. He put me on depakote right away. I've stayed on Depakote and Klonopin the whole time I've seen him (except one brief trial at no meds). I withdrew from Luvox. And the only two meds I've added were a brief but disastrous Effexor trial and the Risperdal. So it's basically just prescription renewals.
>
> I guess it does have its drawbacks though. He's strictly meds oriented and really isn't interested in anything but meds and side effects. My therapist wants him to know a few things that I have been unable to tell him because the nonverbal cues are pretty clear. If it isn't meds he doesn't want to hear it.
>
> But I really really like the way he accepts it if I don't want to continue a drug. My past pdocs have pushed meds and med combinations in a way I didn't like. This one accepts that I don't want to be on an SSRI for example. My last one kept upping the doseages, adding disastrous adjuncts, and blaming me if it didn't go well. :(
Posted by Dinah on April 22, 2003, at 11:52:12
In reply to Should I be annoyed with pdoc?, posted by Dinah on April 21, 2003, at 19:48:57
As long as it's on an as needed basis. So I guess I'll not be annoyed.
Posted by jemma on April 22, 2003, at 17:26:09
In reply to Should I be annoyed with pdoc?, posted by Dinah on April 21, 2003, at 19:48:57
Hi Dinah -
I find that my pdoc has good and bad qualities, so I'm willing to put up with some negative as long as there's enough positive. The main reason I like him is that he's willing to try anything, and goes along with most of my suggestions. But, like yours, he's not very careful, or even that concerned, about possible complications. When I told him my ritalin had raised my blood pressure from 100 over 60 to 155 over 90, he told me to start blood pressure medication!
I decided to be amused rather than annoyed, and came back the next time with an invented side effect - a rash - that I knew he'd respond to. Then I gently eased him into the idea of selegiline, until finally he came up with the idea all on his own! I know, I know - it's manipulative, even a bit dishonest, but I'm now on a cocktail that works for me without high blood pressure.
I guess all I'm saying is that perfect pdocs may be out there, but god only knows how long it may take to find one. My doc is reasonably decent and reasonably responsive to my needs and ideas. The rest I can work around, with more than a little help from everyone here at psychobabble.
- jemma
Posted by jemma on April 22, 2003, at 17:36:15
In reply to Re: Where to go from here?, posted by Dinah on April 22, 2003, at 9:27:58
Have you tried Serzone? It stopped a meltdown of mine right in its tracks, though I found it too sedating to stay on for more than a few weeks. The other drug you might consider is Neurontin, which worked very well for someone I know to relieve anxiety and feelings of uncontrollable anger.
- jemma
Posted by Dinah on April 22, 2003, at 19:50:49
In reply to Re: Where to go from here? » Dinah, posted by jemma on April 22, 2003, at 17:36:15
I have some worrisome liver ALT and AST elevations, and an enlarged liver. So I don't think I'd better try Serzone. Neurontin was a weird drug for me. It gave me sleep paralysis? I think. And also made me feel overall odd. You know I had completely forgotten that meds trial. That one was my idea, not my pdocs. He was happy to drop that one at the first odd experience I had.
When I think about how hard it is to do a search for a new mental health professional, I think I'll just stick with mine. But your blood pressure story made me laugh, because it was very much what my old pdoc would have said. He wanted to keep adding adding meds until I don't think any of us remembered which were to address symptoms and which were to address side effects.
Posted by Ritch on April 23, 2003, at 0:00:29
In reply to Re: Where to go from here?, posted by Dinah on April 22, 2003, at 9:27:58
> Meds wise. I wish I knew.
>
> Risperdal was the first medication that really did what I needed it to do. Since I'm ok most of the time, I only took it as needed. So it didn't change how I felt or was most of the time. I liked that.
>
> My meltdowns are probably some form of agitated dysphoric hypomania. I've never been able to pin them down. They happen periodically, more frequently when I'm under stress. The Risperdal affected them as both an excellent tranquilizer, and as (as I heard someone describe it) ego glue that helped me from shattering into pieces. Klonopin might put me to sleep, but it doesn't calm me during these periods. Oddly, I was on Thorazine for a year or so as a preteen, I think for my sleeping problems (my medical records say for sleep terrors), but I guess it also helped control the same symptoms I have in my meltdowns. I know I wasn't psychotic at the time, but I was very very agitated.
>
> Does anyone have any idea of a class of medications other than antipsychotics that might work as well for the meltdowns?
I read your response to the Serzone suggestion. You might consider trazodone instead (if you haven't already tried that one). It has been around longer than Prozac and it doesn't have a boxed warning yet. :) You also have mentioned the utility of Luvox. What about Luvox makes it unacceptable now?
Posted by Ron Hill on April 23, 2003, at 2:06:42
In reply to Re: Where to go from here?, posted by Dinah on April 22, 2003, at 9:27:58
Dinah (aka Sweetie Pie Girl),
How much Depakote do you take? For many people Depakote works really well in controlling dysphoric mood states. Do you think that your Depakote is providing any amount of usefulness in this area? Do you think that increasing the dosage of the Depakote would help bring the foul moods under control?
Leaving all of the adverse side effects of the SSRI's off to the side for the moment, did the increase in serotonin eliminate (or at least minimize) the dysphoric mood states?
Have you ever tried Trileptal as an add-on to your Depakote?
Have you ever tried lithium as an add-on to your Depakote?
You’re currently taking just Depakote and Klonopin, correct?
-- Ron
Posted by Dinah on April 23, 2003, at 10:10:41
In reply to Re: Where to go from here? » Dinah, posted by Ritch on April 23, 2003, at 0:00:29
:-) Ron
Luvox helped with my OCD and with my tendency to get overstimulated. It may have spaced the meltdowns farther apart but didn't make them less intense. And oddly I was less able to control my self injury urges on Luvox. So the meltdowns caused more physical harm.
I'm not even sure I'm characterizing them correctly as dysphoric hypomanias. They may be the week long tempertantrums of someone with the nervous system of an overtired two year old.
I'll look into all the meds you mentioned and bring them up with my pdoc next time.
I readily admit that much of the fault is mine. The problem is this. My mood cycles are eight to ten weeks in length barring excess stress. Approximately one of those eight weeks is spent in meltdown. Appproximately two weeks are spent in grogginess, where thoughts struggle to make it through the quicksand of my brain and where staying awake is a challenge. I don't feel bad or depressed, just stuporous. The remaining five or so weeks are fine, maybe even better than fine. Depakote has done a pretty good job controlling better than fine, and that rarely happens any more. I find that I am unwilling to affect the five weeks of feeling fine, or worsen the two weeks of stupor, in order to lessen the week of meltdown. Most drugs seem to extend those two weeks to most of the time. Apathy and unproductivity reign. And I'm not who I'd like to be with my family. Increasing the Depakote does that.
That's why I liked Risperdal. It was slightly energizing, worked directly on the symptoms of the meltdown, and since I only took it as needed, didn't affect me the rest of the time.
Perhaps I should just accept the very slight risk of movement disorders.
Posted by Ritch on April 23, 2003, at 23:18:28
In reply to Re: Where to go from here? Ron and » Ritch, posted by Dinah on April 23, 2003, at 10:10:41
> :-) Ron
>
> Luvox helped with my OCD and with my tendency to get overstimulated. It may have spaced the meltdowns farther apart but didn't make them less intense. And oddly I was less able to control my self injury urges on Luvox. So the meltdowns caused more physical harm.
>
> I'm not even sure I'm characterizing them correctly as dysphoric hypomanias. They may be the week long tempertantrums of someone with the nervous system of an overtired two year old.
>
> I'll look into all the meds you mentioned and bring them up with my pdoc next time.
>
> I readily admit that much of the fault is mine. The problem is this. My mood cycles are eight to ten weeks in length barring excess stress. Approximately one of those eight weeks is spent in meltdown. Appproximately two weeks are spent in grogginess, where thoughts struggle to make it through the quicksand of my brain and where staying awake is a challenge. I don't feel bad or depressed, just stuporous. The remaining five or so weeks are fine, maybe even better than fine. Depakote has done a pretty good job controlling better than fine, and that rarely happens any more. I find that I am unwilling to affect the five weeks of feeling fine, or worsen the two weeks of stupor, in order to lessen the week of meltdown. Most drugs seem to extend those two weeks to most of the time. Apathy and unproductivity reign. And I'm not who I'd like to be with my family. Increasing the Depakote does that.
>
> That's why I liked Risperdal. It was slightly energizing, worked directly on the symptoms of the meltdown, and since I only took it as needed, didn't affect me the rest of the time.
>
> Perhaps I should just accept the very slight risk of movement disorders.
Hmmm. Having definite cyclic patterns indicates a bipolaroid spectrum disorder of sorts...maybe. However, you didn't specifically mention being *depressed* after your "meltdown". You just mentioned "stuporous". That sounds an awful lot like seizure-like phenomena. Many folks that experience temporal lobe seizures (i.e.) can have fits of rage and temper spells (associated with partial seizure activity) and then they crash. Sometimes they get depressed, but very often they just get dulled out seriously and feel very fatigued (and sometimes feel extreme and sometimes suicidal guilt over the previous temper spells-which is also common for people that have rage spells caused by brain tumors). Another thing to check out might be depersonalization/derealization disorder and what meds seem to target those symptoms. I know what you mean about more Depakote making things flat and icky and not really that worthwhile attempting. Perhaps adding to Depakote an anticonvulsant with a little different action than Depakote like Ron suggested (Trileptal/Lamictal)?? As far as DP/DR disorder goes I *believe* Zoloft, Lamictal,and Topamax are high on the list of meds that seem to help. Perhaps a different AP?? Abilify??
Posted by Ron Hill on April 24, 2003, at 2:59:45
In reply to Re: Where to go from here? Ron and » Ritch, posted by Dinah on April 23, 2003, at 10:10:41
Dinah,
I wrote most of this post on Wednesday afternoon but I had to lay it aside until now before I had time to finish it up. However, by now Ritch has posted back to you and I like his response better than mine. I’m gonna send mine anyway, though, ‘cause I spent a bunch of time on it and I hate throwing work product away.
Have you ever tried Lamictal?
Did you watch Dr. Bowden's recent presentation on Grand Rounds?
Have you read the relevant portions of the following documents?
http://www.psych.org/clin_res/bipolar_revisebook_index.cfm
http://www.psychguides.com/gl-treatment_of_bp2000.html
I wonder if the dysphoric mood states would abate if you targeted the rapid cycling with your medication.> Luvox helped with my OCD and with my tendency to get overstimulated. It may have spaced the meltdowns farther apart but didn't make them less intense. And oddly I was less able to control my self injury urges on Luvox. So the meltdowns caused more physical harm. I'm not even sure I'm characterizing them correctly as dysphoric hypomanias. They may be the week long tempertantrums of someone with the nervous system of an overtired two year old.
Yeah, I’m all too familiar with the mood state to which you’re referring. However, it sounds like you have a much more severe case than I have. SSRI’s always did a good job in taking away my dysphoric mood states, but they all (and yes I tried almost all of them) eventually adversely effected my dopamine pathways and, as a result, they left me completely unmotivated, apathetic, and emotionally blunted.
As you probably know, for about three months I’ve been enjoying success using Enada NADH to treat the atypical depressive side of my BP II disorder (I also take 600 mg/day of Lithobid). I have been taking one 2.5 mg tablet every four days. I like it a lot but it can make me irritable on the day that I take it (i.e.; Day One in the dosing sequence). This irritability is above and beyond my “normal” periodic foul mood that was apparently included free of charge in my bipolar disorder mood package menu.
Enada NADH increases dopamine and I’ve recently come to believe that the irritability is due to my getting the serotonin-to-dopamine balance slanted too much in favor of dopamine. If the teeter totter tilts too far toward the serotonin, then low motivation and apathy results. If it leans the other way, irritability raises its growly head (GRRRRRR!).
So a couple days ago I set out to fix the problem. I’ve added a low dose (25 mg max on any given day) of 5-HTP for use PRN. (As an aside, I also added TMG a couple days ago and I’m also keeping it, but for reasons unrelated to the topic at hand (the growls)).
It’s only been a couple of days so far, and who knows what it will do long-term, but so far it works great. From what I’ve read, I want to minimize the dose and only take it on the days that I need it so that it retains its effectiveness. I cut 50 mg 5-HTP tablets into pieces, and then I place a piece under my tongue as if it were a sublingual tablet. Within thirty minutes or an hour my irritability is gone.
I say all this to ask, have you ever tried 5-HTP during your meltdown periods?
> That's why I liked Risperdal. It was slightly energizing, worked directly on the symptoms of the meltdown, and since I only took it as needed, didn't affect me the rest of the time.
>
> Perhaps I should just accept the very slight risk of movement disorders.Yeah, perhaps. Tough decision. How much do you take on the days that you do take it?
-- Ron
Posted by Dinah on April 24, 2003, at 18:19:47
In reply to Re: Where to go from here? » Dinah, posted by Ron Hill on April 24, 2003, at 2:59:45
Thanks you guys. You've given me a lot to think about. I'll research the information you've given me. I'll also actually keep my mood chart current between now and the next time I see my pdoc in mid-July. I know the meltdowns last about a week (usually) and end with either a day of obsession or a sleep attack. But I need more information on the exact duration of each phase.
Then I'll present the whole package to him next time (and insist on taking my entire 15 minutes). Maybe we'll be able to come up with something that won't compromise my better days while controlling the worst. My, I'm hopeful today.
Thanks for all your help!
Dinah
Posted by Dinah on April 24, 2003, at 18:22:43
In reply to Re: Where to go from here? Ritch and » Ron Hill, posted by Dinah on April 24, 2003, at 18:19:47
I like that conception of what happened with the Luvox. I always remember the apathy, sleepiness, and stupidity after I had been on it for 4 years, but forget the feelings of relief from overstimulation that I got at first.
Posted by Ritch on April 24, 2003, at 23:40:26
In reply to Re: P.S., posted by Dinah on April 24, 2003, at 18:22:43
> I like that conception of what happened with the Luvox. I always remember the apathy, sleepiness, and stupidity after I had been on it for 4 years, but forget the feelings of relief from overstimulation that I got at first.
It is tough sometimes (because of polypharmacy and choices) to prioritize the positive benefits of meds versus their adverse effects. Today I started low-dose Zonegran as an add-on to my Depakote and Klonopin with no antidepressants (I really don't need them now anyways). I have been a little high lately to say the least and my pdoc wanted to even add-on some lithium. I hope this stuff works (Zonegran). It does have a risk of SJS/TEN skin reactions like Lamictal, but not as great. The bottom line IS what works. Then you sort out what works that is most tolerable. It is very confusing and complicated. I hope you can find an alternative to the Risperdal.
Posted by medlib on April 26, 2003, at 0:18:54
In reply to Re: Where to go from here? Ron and » Ritch, posted by Dinah on April 23, 2003, at 10:10:41
Hi Dinah--
Ron and Mitch have offered some excellent ideas. So long as you'll be researching, I thought I'd add a couple of thoughts to your mix.
Re APs: Either Abilify or Geodon might be able to chill out your meltdown week without the EPS or the 2 week hangover. Both are considered slightly activating, I think. Certainly, neither will mess with your triglycerides. Geodon has appetite suppressant effects for most. I don't know if either has been taken PRN; you might need to blaze a trail there. If you decide to experiment, I'd begin with the lowest possible dose as soon as you feel an MD coming on. (And I'd keep some Klonopin or Xanax and Benadryl in reserve for potential disaster control.) I think you could ramp up during the week if the lowest level isn't enough. (With Geodon, I'd take half the 10 mg. size twice a day to start with.) Seroquel, on the other hand, might turn your stupor into a coma; I slept 'round the clock on the lowest dose of S. Your pdoc should have samples of both A and G. If neither of those APs do the job, you might have to ask him to let you try some low dose Cogentin with your Risperdal. It helps control movement disorders. That would be my third choice, though. If you do have to continue with R., a mild stim. such as Provigil might help with the post-MD fog. Stims usually are easy to PRN.
After you establish the best meltdown med and dose, you could try finding a mood stabilizing drug or drugs which might lengthen or eliminate your cycling. For the record, I wouldn't consider Lithobid as an anti-cycling agent, adjunct or stand alone. Most gain weight on it, and I imagine you know what that does to triglycerides and insulin resistance. Augmenting Depakote to better control rapid cycling sounds good (especially with an AED that's less sedating than Depakote); both Lamictal and Trileptal are often prescribed as adjuncts. Unfortunately, Depakote (valproic acid) does not play well with other AEDs (they squabble over liver metabolizing enzymes). This isn't an insurmountable problem, but it would require careful titration. Definitely not a 5 minute job. I've summarized the effects on plasma concentrations (PC) of various combos below.
VPA (Depakote) + Trileptal -> lower Trileptal PC
VPA + Lamictal -> lower VPA PC
VPA + Topamax -> lower PCs of both medsTrileptal is somewhat sedating, so it probably wouldn't help. But, you might want to ask your pdoc if either Topamax or Lamictal alone could stabilize your cycling as well as Depakote. Since neither is sedating, if either worked at all, you might be able to take enough to reduce or eliminate cycling.
Bottom line? I think you've done a good job identifying the dynamics of your problem--and I think that a med solution that will improve upon your current results is quite doable. You may end up with a med cocktail which varies with the phases of your cycles; but, once established, those changes would be regular and predictable. I suspect you'll have to be your own bartender, though. The problems that may arise playing musical meds probably will be with your pdoc and your patience. To deal with the first, I'd ask for a "double" appointment (minimum 30 min.) as soon as you finish researching--to discuss your options, formulate an overall strategy and establish a viable between-appointment method of communication. You could ask him up front if he's willing to work *with* you on an intensive basis to find the best mix for you. If you're not satisfied, value yourself enough to find someone better. I expect that you know better than I what to do about the second problem. For all of us, doing it's the rub.
Btw, I can empathize re pdoc problems. Mine recently retired--in his 40's! Hope I didn't drive him to it. Can you imagine having *me* as a patient? I go see his replacement in June. Hope she has a sense of humor.
Good luck!---medlib
Posted by Dinah on April 27, 2003, at 14:23:00
In reply to Re: Where to go from here? » Dinah, posted by medlib on April 26, 2003, at 0:18:54
Thanks Medlib,
Some more things for me to think about and research. And I think I may call him now to see if he can change that Seroquel to Geodon or Ablify. I was never thrilled with the Seroquel idea since I tend to overrespond to drugs that make you sleepy. Remeron put me out for a weekend.
You're right in that the hardest part is following through. It's been three days since my resolve to keep my daily mood chart. I did one day. :( I'll catch up today, I guess. But it doesn't bode well.
I guess the other hurdle is that I just plain distrust and dislike psych meds. The only ones I've ever been happy with are Klonopin and the Risperdal (although I guess I wasn't on that one long enough to hate it). Most of them are so... untargeted, I guess would be the right word. They don't do just X, they do X,Y,Z, etc. And usually at least one of those other things is something I just don't like. It makes me halfway inclined to go with the chemicals the good lord gave me. Oh well, I've got a three months to work on my attitude too, along with my research. (grin)
And you think your pdoc has it rough? :) I'm sorry yours is retiring and I hope the new one is someone you can work with. Good luck with her!
This is the end of the thread.
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