Whenever the rainbow appears in the clouds, I will see it and remember the everlasting covenant between God and all living creatures of every kind on the earth." Genesis 9:13

Wednesday, January 02, 2008

How your treatment could hurt you

This seems to be my week of public service announcements--my how to find a doctor post has gotten more response than any previous post initially has. Since that was written in response to people posting elsewhere and this issue is from the same group of topics, maybe someone else can benefit.

This is another topic every bipolar patient should know. No matter what. And it's one of the reasons I'm against family doctors trying to treat bipolar; it is not something they often take into consideration. I don't think they often even know it.

It is very important that we all are aware that antidepressants can cause cycling. Further, if used for a long time without mood stabilizers or even with mood stabilizers that aren't working 100%, antidepressants can make you worse.

By the time I was diagnosed I had been on 11 antidepressants. With all but one I would take it for a few weeks, maybe get some response, have the response diminish and find myself even more depressed. I was on every dose of nearly all of those 11 antidepressants, plus routine ativan and lithium by the time I was diagnosed.

The day I was diagnosed the doctor closed his laptop and said "You've been on a lot of antidepressants. You don't have to do that anymore". By that point I had found out the reason for this, but it was one of the most comforting things I heard that day. (Although I actually wound up back on antidepressants eventually).

Antidepressants can trigger rapid cycling in susceptible people. The more rapid cycling you have the more it can increase your cycling, both in severity and frequency. I cycle so rapidly that it is often apparent that I go through 3-4 cycles in a therapy session (1 hour). This is probably because of the ridiculous expose to antidepressants. The rule of thumb is that if you have a patient who has had bad responses to 3 ADs, then they need to be evaluated for bipolar.

When you are beginning treatment it is ideal to be off all antidepressants. It is best to be stabilized with mood stabilizers first. Some are more useful for depression, some for mania. Lamictal is the best for depression; in some people it will act too much like an antidepressant and can cause some activation. That happened for me this spring when I was on it, although I was on an antidepressant as well. In my case I just lowered the antidepressant a bit. Lithium has a quality of being protective against suicide. It also has cognitive protectiveness. It is more for mania, but those 2 things fall on the depression side for me so I tend to think of it more as a "both sides" drug.

Over time you'll find the right mood stabilizers. I get so upset when I read how badly people are still hurting because they're still on the first drug combination tried, or something close to it. If you feel your drugs aren't working they probably aren't. There is nothing that says med changes can't be ongoing; mine are nearly monthly, sometimes sooner. As I've said I change some of my meds within parameters at will. The only reason for not trialing different things is a doctor who isn't doing their job.

I re-started antidepressants about 2 years into treatment because I'd had a severe depression and the med that saved me (Geodon) also gave me extrapyramidal syndrome, which is something you don't want if you've never had the pleasure. I had a history of doing very well on remeron for most of grad school, which were my early sympotatic years. So I took it for about 18 months until there was a side effect issue, then switched to imipramine. We trialed not using it since Seroquel is supposed to help depression; that was a no go. The funny thing for me was that I'd been on essentially all antidepressants available. The doctor hesitantly said "well, we could try imipramine but it's older and no more likely to work than all the others." Turns out imipramine has been magic for me, at tiny doses.

I take the antidepressant with a lot of care. It is definetely one that I must monitor. If I start getting manic for any reason the dose goes down. I take an absolutely bizarre dose that we've custom determined. To get the dose I feel best at I take 4 small pills rather than 1 big one because 10 mg matter to me. My dose goes up and down in a 30 mg range throughout the year (I have to be even more careful taking ADs come summer).

The point of all this is, if you are taking an AD and have never had a serious trial of coming off the AD and attempting stabilization with one or more mood stabilizers then you haven't had a treatment in line with what the bigwigs suggest. It's fully possible you're like me and need an AD. Emilja uses mood stabilizers to allow her to take higher dose ADs than she could without because of mania without the stabilizers. We're all so different.

But if you're on an AD and have never gotten the feeling that your bipolar is controlled, take control. Don't take yourself off; some of them are buggers to get off, but work with a doctor. As always, the best doctor you can find, even if it creates inconvience.


Angelissima said...

wow. your post is just what I needed to read. Ive been on every possible AD without good results. Lamectil works really well for mood stabilizing, but Im detoxing from cymbalta now after using it for a year, gaining 60 pounds, not being able to concentrate, extreme lethargy, worsening depression, suicidal thoughts, sexual problems, compulsive behavior...the list goes on and on. After doing some research, I realized the cymbalta was the problem. I thought I was detoxing slowly - 90mg to 60mg for a week, then down to 30mg for a week then cold turkey. IT IS HELL.
I can't get out of bed for the dizziness, brain zaps, extreme body aches. crying, no appetite, nausea, loose stools, anger. From what I read these symptoms can go on for 6 weeks or more. I was on the 90mg dose for over a year before my depression over took any manic or even happy moods.

Now Im stuck. Im taking pain meds late in the afternoon to be able to care for my children, cook, do laundry, etc. My husband is helping but there is only so much he can do.


Just Me said...

I don't know a ton about Cymbalta. I know it's popular and that it is a relative of Effexor which is famous for being hard to come off of. I seem to remember not enjoying that one.

There is something that can be tried (with a doctor obviously but I have to say that) to help. I haven't done this, will say why in a second I COULD never do this and don't know if I'd recommend it even, but it is existent.

Prozac is useful in weaning off ADs. It has an extremely long half-life, which makes it much more gentle. Drugs with a shorter half-life mean that you are hitting the effect of not having much med in early in the day and you feel it. If I remember right you take Prozac with what you are weaning and wean gradually, then wean the Prozac. Prozac's half-life is so big that it is still hanging around days after a dose.

HOWEVER (and that's in bold for a reason), Prozac is an activating med. It was the worst experience of my life. Nobody completely understands how that one didn't hospitalize me and it nearly did.

Another option would be asking for another mood stabilizer. I would think you could start that now. Like I said, use of Lamictal in combination (esp. with lithium or depakote) is pretty common. I personally like both of those meds. Anything that I take must be balanced with something to bring me down, plus I need stuff to bring me down beyond that 'cause I'm a really, really manicky lady.

Always remember no Cymbalta, no Effexor....:) (for me it's no SSRIs)