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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 SLS on December 7, 2003, at 8:21:39
Wishing you all the best...
- Scott
Posted by JoshM on December 8, 2003, at 1:15:59
In reply to Ron Hill - How are you?, posted by SLS on December 7, 2003, at 8:21:39
Hi Scott,
You don't know me, but I have learned a great deal reading your posts in the archives. Thanks for your contribution over the years, it's been helpful to myself and many others!! Hope you are doing well
best wishes,
Josh
Posted by Ron Hill on December 8, 2003, at 19:53:23
In reply to Ron Hill - How are you?, posted by SLS on December 7, 2003, at 8:21:39
> Ron Hill - How are you?
> Wishing you all the best...
> - Scott
--------------------SLS,
Thanks for caring Scott!! Are you continuing with your add-on trial of Gabitril? What’s next on your “must-try” list? You’re such a nice guy and I wish I knew the answer for your treatment resistant depression.
In answer to your question, I do really well when I cycle into my "normal phase" (which is where I am today). My BP II cycling goes like this: I begin to fall into a subtle atypical depression. Then I stop exercising and start sleeping excessively both of which cause me to spiral into a very deep atypical depression within about two days. It’s easy to spiral down, but it feels impossibly difficult to climb out of the pit. The depressive phase typically lasts about five days and I just watch TV and sleep. The depression is immediately followed by a dysphoric mood phase (GRRRRRRR!), which I hate even more than I hate the depression. However, in my dysphoric mood state I get back some energy (albeit negative energy), and if I use this energy to engage in rigorous exercise, I cycle into my normal mood state (which is excellent!!).
I suspect that I will always cycle to some degree, but I am convinced that (for me) rigorous exercise plays a key role in minimizing the cycling and maintaining good mental health. Ironically, I intuitively self-medicated with exercise for more that twenty years prior to being misdiagnosed as ADHD in 1996, and given Ritalin and antidepressants (both of which completely screwed up my life including the loss of my engineering career). Oh well, it’s time to get over my bitterness toward my original pdoc for his misdiagnosis. He did not intentionally destroy my life.
In addition to what I’ve identified above, there is one more mood state associated with my BP II disorder. I call it hypomania (or euphoric hypomania) and it is characterized by flight of ideas, distractibility, creativity, talkativeness, insomnia, etc. However, I’m able to control my hypomania by chasing the symptoms with increased amounts of lithium. Currently, I take 300 mg/day of Lithobid (under normal circumstances). But, if I start to feel hypomanic (I can recognize it right away), I bump up my Lithobid to 450 or 600 mg/day to reel-in the symptoms. Hypomania is the most treatable aspect of my BP II. The atypical depression and dysphoric mood states are more problematic when it comes to treatment. However, thanks in large part to the information I learn from people on this site, I continue to make progress in these problem areas as well.
In case anyone is wondering about my current medication/supplement cocktail, here it is:
300 mg/day Lithobid (moodstabilizer)
300 mg/day St. John’s Wort (provides some antidepressant effectiveness)
400 mg/day L-theanine (increases dopamine and GABA, reduces cortisol; treats irritability)
Small pocket-full of vitamins and minerals per day (most notably, 800 mg/day of magnesium)
Three teaspoons of Carlson’s Fish Oil per day
Exercise (1 – 2 hours/day; reduces depression and irritability but can increase hypomania, thereby, requiring a temporary increase in the amount of moodstabilizer)
NO REFINED SUGAR!!
Zone diet
I’ve not been posting lately because I’m tied up with projects on my desk and projects around the house. The end is not yet in sight, so I'll continue to be tied up for a while. Thanks for staying in touch, Scott, and let me know if I can help you in any way.
-- Ron
Posted by SLS on December 9, 2003, at 9:15:24
In reply to Re: The Joys of Being Bipolar » SLS, posted by Ron Hill on December 8, 2003, at 19:53:23
Hi Ron.
Nice to see you again.
> Are you continuing with your add-on trial of Gabitril?
Thanks for keeping an eye on me. Gabitril was a bust. It made my depression somewhat worse, gave me anxiety, and helped contribute to the appearance of suicidal ideation. I stopped it last Friday. I feel better now.
> What’s next on your “must-try” list?
At the top of the list is duloxetine (Cymbalta), Eli Lilly's new SNRI. That I'm partially responsive to Effexor gives me hope that it might work. Unfortunately, its approval date keeps getting pushed backwards. Now, it is not due be approved until next summer. My doctor wants me to try Aricept (donepezil) next. I'm worried that this drug, too, will make things worse, so I'm going to wait awhile before starting it. Pro-cholinergic drugs sometimes produce depression. Aricept is a ACh cholinesterase inhibitor. It's like an MAOI for cholinergic neurons.
I have a somewhat radical idea that involves the pulsing of TCA on top of MAOI, allowing for an exaggerated TCA-discontinuation rebound improvement. I wish I didn't have to go to such lengths, though.
> In answer to your question, I do really well when I cycle into my "normal phase" (which is where I am today). My BP II cycling goes like this: I begin to fall into a subtle atypical depression. Then I stop exercising and start sleeping excessively both of which cause me to spiral into a very deep atypical depression within about two days. It’s easy to spiral down, but it feels impossibly difficult to climb out of the pit. The depressive phase typically lasts about five days and I just watch TV and sleep. The depression is immediately followed by a dysphoric mood phase (GRRRRRRR!), which I hate even more than I hate the depression. However, in my dysphoric mood state I get back some energy (albeit negative energy), and if I use this energy to engage in rigorous exercise, I cycle into my normal mood state (which is excellent!!).
> I suspect that I will always cycle to some degree,
What was your reaction to Lamictal?
No more TMG?
> 400 mg/day L-theanine (increases dopamine and GABA, reduces cortisol; treats irritability)
Where can I find more information on L-theonine? I'd love to try it.
> In addition to what I’ve identified above, there is one more mood state associated with my BP II disorder. I call it hypomania (or euphoric hypomania) and it is characterized by flight of ideas, distractibility, creativity, talkativeness, insomnia, etc.
I know what that feels like. I had a brief hypomanic reaction to Nardil. It can be a lot of fun, but can also be disruptive. I found myself not only talking more, but talking louder.
> However, I’m able to control my hypomania by chasing the symptoms with increased amounts of lithium.
Lamictal is not a good anti manic agent per se, but is supposed to help stabilize rapid cyclicity. Lithium is a good antimanic agent, but is not usually of any value to prevent or mitigate depressive episodes, despite its occasional us as an augmentor of antidepressants. A combination of the two (Lamictal + lithium) has been shown to increase the time before relapse of both manic and depressive phases of bipolar disorder. Maybe I can dig up some of the material I came across that describes this observation.
> Currently, I take 300 mg/day of Lithobid (under normal circumstances).I might end up trying that myself. Do you find that 300mg flattens your affect or leaves you more passive and apathetic? Higher dosages of lithium leave me feeling worse.
But, if I start to feel hypomanic (I can recognize it right away), I bump up my Lithobid to 450 or 600 mg/day to reel-in the symptoms. Hypomania is the most treatable aspect of my BP II. The atypical depression and dysphoric mood states are more problematic when it comes to treatment.
I found that Depakote or Zyprexa did a good job of curbing the few manic-dysphoric reactions I have experienced. Zyprexa is interesting. It seems that it possesses mood-stabilization properties in addition to its acute anti-manic effects.
> However, thanks in large part to the information I learn from people on this site, I continue to make progress in these problem areas as well.
You are certainly persistent enough! I'm glad that it has payed-off for you.
> Zone dietWhat is the Zone diet?
> I’ve not been posting lately because I’m tied up with projects on my desk and projects around the house.
This is a good thing.
> The end is not yet in sight, so I'll continue to be tied up for a while. Thanks for staying in touch, Scott, and let me know if I can help you in any way.
Much thanks.
Sincerely,
Scott* What is the meaning of life?
* Life is its own meaning.
Posted by Ron Hill on December 9, 2003, at 13:55:27
In reply to Re: The Joys of Being Bipolar » Ron Hill, posted by SLS on December 9, 2003, at 9:15:24
Hey Scott,
> My doctor wants me to try Aricept (donepezil) next.
Aricept is used in the treatment of Alzheimer’s, no?
> I have a somewhat radical idea that involves the pulsing of TCA on top of MAOI, allowing for an exaggerated TCA-discontinuation rebound improvement. I wish I didn't have to go to such lengths, though.
What does your pdoc think of your idea? Could it cause serotonin syndrome?
> What was your reaction to Lamictal?
Yeah I hear ya. The problem is that I developed a severe rash on Lamictal when I tried it years ago (Depakote also causes rash problems for me). However, there is a small caveat regarding my prior Lamictal trial.
Back in 1996 I was having trouble focusing on my work so I made an appointment with a pdoc. I knew virtually nothing about mental disorders and even less about p-meds. Looking back now I suspect that my distractibility at work was caused by a combination of hypoglycemia and mild BP II hypomania.
My original pdoc initially diagnosed me as ADHD and gave me Ritalin which was absolutely incredible (almost euphoric) until it started making me VERY moody after a couple months. So I went back to the pdoc and told him that although I loved the initial focusing effect that I experienced with Ritalin, I needed to take myself off of it due to the moodiness. In response to my concerns, he convinced me to continue the Ritalin and add Paxil. Big mistake!! The Paxil/Ritalin combo pushed me into a full blown drug induced mania which began to screw up every segment of my life. But, the mania caused me to think that life was great.
This mania went on for several months and then I started rapid cycling. At that point my pdoc changed my dx to ADHD with comorbid BP II and he added Lamictal to the Ritalin and Paxil. He started me out at 200 mg/day and he increased it to 300 mg/day a week later. I liked how Lamictal felt in my brain but I developed severe rashes over a large portion of my body. Not SJS but a bad rash none-the-less.
I bring all this up only to say that there is a possibility that the Lamictal rash might have been avoided if the pdoc had implemented a start low and go slow approach in the dosing. Therefore, I sometimes toy with the idea of trying Lamictal as an add-on to my Lithobid starting at about 5 mg/day and slowly titrating up trying to avoid the rash. However, my current pdoc (a good one) is of the opinion that Lamictal will cause a rash even if I go low and slow. But, I’m sure he would let me try it if I asked him to do so.
> No more TMG?
TMG is in the “small pocket-full of vitamins and minerals”. I don’t take it everyday, however.
> Where can I find more information on L-theonine? I'd love to try it.Here you go: http://www.dr-bob.org/babble/alter/20031104/msgs/281539.html
> Lamictal is not a good anti manic agent per se, but is supposed to help stabilize rapid cyclicity. Lithium is a good antimanic agent, but is not usually of any value to prevent or mitigate depressive episodes, despite its occasional us as an augmentor of antidepressants. A combination of the two (Lamictal + lithium) has been shown to increase the time before relapse of both manic and depressive phases of bipolar disorder. Maybe I can dig up some of the material I came across that describes this observation.
Yeah I hear ya, Scott. As I indicated above, I periodically toy with the idea of a trial of a Lamictal add-on to my Lithobid.
> > Currently, I take 300 mg/day of Lithobid (under normal circumstances).
> I might end up trying that myself. Do you find that 300mg flattens your affect or leaves you more passive and apathetic? Higher dosages of lithium leave me feeling worse.The flattening effect is why I reduced my dosage from 600 mg/day to 300 mg/day (except on those days when I need more to reel-in some hypomania). The flattening is greatly reduced at the lower dosage, but the very fact that lithium curbs hypomania might cause some patients to feel that it has some amount of flattening at any dosage. I like Lithobid. I’ve been on it for over four years.
> I found that Depakote or Zyprexa did a good job of curbing the few manic-dysphoric reactions I have experienced. Zyprexa is interesting. It seems that it possesses mood-stabilization properties in addition to its acute anti-manic effects.For me, Depakote caused weight gain, hair loss, rash, and it seemed to make my depression worse. I’ve considered Zyprexa from time to time, but all AP’s scare me (e.g.; TD, etc).
> What is the Zone diet?"The Omega Rx Zone: The Miracle of the New High-Dose Fish Oil"
> > I’ve not been posting lately because I’m tied up with projects on my desk and projects around the house.> This is a good thing.
Yes indeed! I’m thankful.
> * What is the meaning of life?For me, the purpose of life is to love the Lord our God with all my heart and all my soul and to love my neighbor as myself.
-- Ron
Posted by SLS on December 10, 2003, at 9:00:22
In reply to Re: The Joys of Being Bipolar » SLS, posted by Ron Hill on December 9, 2003, at 13:55:27
Hi Ron.
Thanks for the info on l-theonine. Great bibliography.
To start Lamictal at a dosage of 200mg is silly. It violates the instructions printed on the package insert by the manufacturer. Almost anyone would react badly to that. There are plenty of examples of people titrating Lamictal too rapidly for whom discontinuation followed by reintroduction using the prescribed dosing schedule was successful. I would DEFINITELY consider adding it back to your regimen.
I haven't been able to come up with the citation I referred to in my previous post. It was very specific in its descripton of Lamictal increasing the time between depressive episodes and lithium extending the period between manic episodes. When used together, the time to relapse into any episode was extended significantly. Because of the nature of the statistics used to interpret such investigations, I imagine that the data pooled included people for whom there was no change in the course of their illness as well as people for whom an indefinite remission was achieved.
> For me, Depakote... seemed to make my depression worse.
Me too. What dosage did you work up to?
> I’ve considered Zyprexa from time to time, but all AP’s scare me (e.g.; TD, etc).
They don't scare me as much as they used to. Perhaps I've been brainwashed. :-)
- Scott
Posted by Ron Hill on December 10, 2003, at 12:00:13
In reply to Re: The Joys of Being Bipolar » Ron Hill, posted by SLS on December 10, 2003, at 9:00:22
My friend Scott,
> Thanks for the info on l-theonine. Great bibliography.
Please post your results if you decide to give it a trial. For me, the effects are subtle but very worthwhile (so far). Might help you, or might not, but probably worth a trial. For the benefit of others reading this post, the correct spelling is l-theanine.
> To start Lamictal at a dosage of 200mg is silly. It violates the instructions printed on the package insert by the manufacturer. Almost anyone would react badly to that.I totally agree with you. However, in defense of my initial pdoc, I think that much less was known about Lamictal dosing for BP patients back in 1997 when he prescribed it to me. I remember him telling me at the time that much higher doses of Lamictal have been used safely in the treatment of epilepsy.
> There are plenty of examples of people titrating Lamictal too rapidly for whom discontinuation followed by reintroduction using the prescribed dosing schedule was successful. I would DEFINITELY consider adding it back to your regimen.
Scott, thanks for giving me your opinion on this matter. I value your informed opinion. As a result, I’m going to bump this option up to a higher level on my “might-try” list. Having said that, however, I have three main reasons for my reluctance to adding Lamictal.
First and foremost, I’m reluctant to take any synthetic medication (I do not consider lithium to be a synthetic medication, but instead, I view it as a naturally occurring mineral). Given my history of leading a relatively normal productive life and then getting my brainchemistry so completely screwed up by allowing a pdoc to convince me to take Ritalin and Paxil (synthetic medications), it is little wonder that I am a little gun shy. Screw me up once, shame on you, Mr. pdoc. Screw me up twice, shame on me for not doing my homework. Further, we quite frankly do not know the long-term health consequences of these synthetic drugs.
Second, I don’t have health insurance, so I would have to pay for the Lamictal out of our family budget. Third, I truly doubt that I can avoid the rash, but only a properly conducted trial will answer this question.
Rigorous exercise served me well as an antidepressant for more than twenty years prior taking p-meds. Now that my brainchemistry has recovered from the insults of previous p-meds, I want to see if I can treat the depressive phase of my disorder using intense exercise (and vitamins/supplements). If I become convinced that a fully ramped up exercise program (in conjunction with a healthy diet, vitamins/supplements, and good lifestyle choices) is not enough to keep the enemy of depression at bay, then I’ll probably try some type of an add-on medication. And, Lamictal is high on the list.
> I haven't been able to come up with the citation I referred to in my previous post. It was very specific in its descripton of Lamictal increasing the time between depressive episodes and lithium extending the period between manic episodes. When used together, the time to relapse into any episode was extended significantly.If I recall correctly, Charles L. Bowden, MD mentioned something about this in his Grand Rounds presentation last spring (Maintenance Treatment of Bipolar Disorders):
http://psychiatry.uchicago.edu/grounds/030303/
> > For me, Depakote... seemed to make my depression worse.
>
> Me too. What dosage did you work up to?I think my initial pdoc made yet another mistake with regard to the methods he used when he switched me from Lamictal to Depakote. He made this switch after I repeatedly complained about the rash problems I was having with Lamictal. Without a wash out period, he switched me directly from 300 mg/day of Lamictal to 1000 mg/day of Depakote. I had rash problems with Depakote and I wonder if the Depakote rash could have been avoided with a Lamictal wash out period. Maybe not, I don’t know. At any rate, I reduced my Depakote dosage down to 500 mg/day to reduce (but not eliminate) the rash.
Scott, perhaps I’ve rambled a bit here. Sometimes typing (and/or talking) out my thoughts can help get things straight in my mind. “Over the lips and through the fingertips, thoughts disentangle themselves”.
I truly hope you find an answer to your treatment resistant depression. I send you my very best wishes my friend.
-- Ron
Posted by myclonic_jerk on December 10, 2003, at 12:20:42
In reply to Re: The Joys of Being Bipolar » SLS, posted by Ron Hill on December 9, 2003, at 13:55:27
Hi Ron,
>>> I bring all this up only to say that there is a possibility that the Lamictal rash might have been avoided if the pdoc had implemented a start low and go slow approach in the dosing. Therefore, I sometimes toy with the idea of trying Lamictal as an add-on to my Lithobid starting at about 5 mg/day and slowly titrating up trying to avoid the rash. However, my current pdoc (a good one) is of the opinion that Lamictal will cause a rash even if I go low and slow. But, I’m sure he would let me try it if I asked him to do so.
>>>I'm certain he's a good Pdoc, although in this particular instance he seems to be just erring on the side of caution.I take 350mg Lamictal, developed a (mild) rash initially on 12.5mg, but persevered with miniscule (2mg) increments.It was well worth the perseverance.Right now, if I'm feeling in a real slump, I can easily jump up by 100mg for a few days, wih no ill effects whatsoever.
If you're minded to go for a re-trial, the results can often be staggering.> > Lamictal is not a good anti manic agent per se, but is supposed to help stabilize rapid cyclicity. Lithium is a good antimanic agent, but is not usually of any value to prevent or mitigate depressive episodes, despite its occasional us as an augmentor of antidepressants. A combination of the two (Lamictal + lithium) has been shown to increase the time before relapse of both manic and depressive phases of bipolar disorder. Maybe I can dig up some of the material I came across that describes this observation.
>>>I often read of Lamictal not having mood stabilizing properties per se.All I can say is that for me at least, it most certainly does.
I was never able to tolerate any antidepressant whatsoever prior to starting Lamictal.Now I can get away with (at least)giving AD's a fair shot, for months at a time before deciding on a given med's efficacy.I'm not bipolar (although possibly type 111)if one wanted to apply a grandiose term to simple 'antidepressant intolerant')!
Lithium can complement Lamictal quite well for BP, or BP11- a very effective combo.+additional safety net with the lithium.
Its important not to stifle the Lamictal with too much lithium though, whilst maintaining just enough lith. to ensure stability.
> Yeah I hear ya, Scott. As I indicated above, I periodically toy with the idea of a trial of a Lamictal add-on to my Lithobid.>>>Go for it Ron ;)
The Jerk....
Posted by Ron Hill on December 10, 2003, at 18:11:37
In reply to Re: The Joys of Being Bipolar » Ron Hill, posted by myclonic_jerk on December 10, 2003, at 12:20:42
> I take 350mg Lamictal, developed a (mild) rash initially on 12.5mg, but persevered with miniscule (2mg) increments.It was well worth the perseverance.Right now, if I'm feeling in a real slump, I can easily jump up by 100mg for a few days, wih no ill effects whatsoever.
> Its important not to stifle the Lamictal with too much lithium though, whilst maintaining just enough lith. to ensure stability.
> The Jerk....
-----------------------Thank you for taking time to share your Lamictal experience.
You sound like a nice person and not at all like your signature name.
-- Ron
Posted by myclonic_jerk on December 11, 2003, at 8:12:00
In reply to Re: Lamictal add-on to Lithium » myclonic_jerk, posted by Ron Hill on December 10, 2003, at 18:11:37
> You sound like a nice person and not at all like your signature name.
>
> -- RonHey, what's wrong with my signiture name? I thought it was inspired?!!!
Best,
MJ.
This is the end of the thread.
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