![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 101 to 125 of 129. Go back in thread:
Posted by Christ_empowered on February 20, 2012, at 17:34:51
In reply to re: Desperate - Part 2 - Please no anti-med posts, posted by Solstice on February 20, 2012, at 16:06:19
Do you think maybe the lithium+neuroleptic combination might be causing agitation? I don't know if it is or not, just throwing that one out there.
Posted by SLS on February 20, 2012, at 17:38:49
In reply to Re: Apology, posted by Solstice on February 20, 2012, at 15:58:16
> Okay.. first I want to apologize for perhaps making the issue more about Lou specifically than whats helpful.
Your apology is quite generous. However, I don't think you made an issue of someone any more than someone made an issue of themself.
- Scott
Posted by Solstice on February 20, 2012, at 18:21:01
In reply to re: Desperate - Part 2 - Please no anti-med posts, posted by Christ_empowered on February 20, 2012, at 17:34:51
> Do you think maybe the lithium+neuroleptic combination might be causing agitation? I don't know if it is or not, just throwing that one out there.
Good question, CE. But the agitation & irritability is a primary characteristic of her bipolar symptoms. The Geodon knocked it out of the ball park.. and when it shows back up and endures & escalates, her Geodon would be adjusted and we were stable again. So the agitation predates her starting on Latuda/lamictal/lithium. And it has been a real problem for about three months now, reaching crisis proportions before Christmas. The Latuda didn't seem to touch it. The Lamictal hasn't yet had time to build, so dr started lithium. It has gotten somewhat better than it was before, but it is still not stable enough for her to function as well as she needs to be able to function.
I'm really looking forward to our apt tomorrow to discuss some of the gifts of information I've gotten from my friends here :-)
Solstice
Posted by Solstice on February 20, 2012, at 18:24:23
In reply to Re: Apology » Solstice, posted by SLS on February 20, 2012, at 17:38:49
> > Okay.. first I want to apologize for perhaps making the issue more about Lou specifically than whats helpful.
>
> Your apology is quite generous. However, I don't think you made an issue of someone any more than someone made an issue of themself.
>
>
> - Scott
:-) That makes my heart smile.... felt like a big ole warm bear hug :-) I needed that.Solstice
Posted by Phillipa on February 20, 2012, at 18:24:51
In reply to re: Desperate - Part 2 - Please no anti-med posts » Christ_empowered, posted by Solstice on February 20, 2012, at 18:21:01
Best of luck tomorrow. I have an old poster friend also on latuda that just started it and is complaining of insomnia after a switch from zyprexa. Throwing it also out there Phillipa
Posted by SLS on February 20, 2012, at 18:32:48
In reply to re: Desperate - Part 2 - Please no anti-med posts, posted by Solstice on February 20, 2012, at 16:06:19
Well, anyway, Topamax is a drug that I have seen treat successfully bipolar II dysphoric hypomania in a 40 year old woman. She was first treated with 200 mg, but it was subsequently found that 100 mg was just as effective, and reduced the risk of developing kidney stones.
The clinical trials of Topamax to evaluate its efficacy in treating mania have not produced impressive results. I would not make Topamax my first choice as a treatment for pediatric bipolar disorder. However, there are anecdotes that report success with its use. Depakote would be a better choice if one is to explore anticonvulsant mood-stabilizers. My main concerns with Depakote are that the dosage of Lamictal must be reduced and that it might leave your daughter somewhat depressed with continued use.
In any event, I still feel that Topamax is a viable treatment that can yield improvements in mania in bipolar disorder.
- Scott
--------------------
Topiramate as add-on treatment for patients with bipolar mania.Chengappa KN, Rathore D, Levine J, Atzert R, Solai L, Parepally H, Levin H, Moffa N, Delaney J, Brar JS.
Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, PA 15215-2593, USA. chengappakn@msx.upmc.edu
Abstract
OBJECTIVE:
Anticonvulsant agents such as carbamazepine and valproate are alternatives to lithium in treating subjects with bipolar disorder. Topiramate (Topamax), a new antiepileptic agent, is a candidate drug for bipolar disorder. We evaluated topiramate as adjunctive treatment for bipolar patients.
METHODS:
Eighteen patients with DSM-IV bipolar I disorder [mania (n = 12), hypomania (n = 1), mixed episode (n = 5), and rapid cycling (n = 6)], and two subjects with schizoaffective disorder bipolar type, resistant to current mood-stabilizer treatment were initiated on topiramate, 25 mg/day, increasing by 25-50 mg every 3 7 days to a target dose between 100 and 300 mg/day, as other medications were held constant for 5 weeks. The Young Mania Rating Scale (Y-MRS), Hamilton Depression Rating Scale (Ham-D), and Clinical Global Impression-Bipolar Version Scale (CGI-BP) were used to rate subjects weekly.
RESULTS:
By 5 weeks, 12 (60%) subjects were responders, i.e., 50% reduction in the Y-MRS scores and a CGI of 'much' or 'very much improved'. Three subjects were 'minimally improved', four showed no change, and one was 'minimally worse'. Six subjects had parasthesia, three experienced fatigue, and two had 'word-finding' difficulties; in all cases, side effects were transient. All patients lost weight with a mean of 9.4 lb in 5 weeks, and a significant reduction in body mass index (BMI) occurred too.
CONCLUSIONS:
Topiramate appears to have efficacy for the manic and mixed phases of bipolar illness. Other preliminary data suggest antidepressant efficacy too. Among obese bipolar subjects, the weight loss potential of topiramate may be beneficial. If controlled trials confirm these initial results, topiramate may be a significant addition to the available treatments for bipolar disorder.
------------------------------------------
Posted by Solstice on February 20, 2012, at 18:54:53
In reply to re: Desperate - Part 2 - Please no anti-med posts » Solstice, posted by SLS on February 20, 2012, at 18:32:48
> Well, anyway, Topamax is a drug that I have seen treat successfully bipolar II dysphoric hypomania in a 40 year old woman. She was first treated with 200 mg, but it was subsequently found that 100 mg was just as effective, and reduced the risk of developing kidney stones.
>
> The clinical trials of Topamax to evaluate its efficacy in treating mania have not produced impressive results.I don't know.. but 60% of patients with a wide variety of diagnoses doesn't sound bad to me! Since the study specifically says it appears helpful for mania and hypomania, I'm wondering if the majority of the 60% responders had those two issues.
I would not make Topamax my first choice as a treatment for pediatric bipolar disorder. However, there are anecdotes that report success with its use.
Well.. the first choice was Abilify, which she had all the *bad* side effects. Second choice was Geodon - which was a miracle. The natural third choice was Latuda, which has seemed to fall flat. Lithium and/or Lamictal have reduced the frequency/intensity of the agitation, but not enough improvement to feel like we've found the right thing.
What concerns me is that I don't think we can tell which of these meds provoked the marginal improvement. I think sticking with Lamictal is a strong preference for me because it worked for her sister. However, I should probably note, her sister ironically had the same kind of reaction to Geodon that my younger one had to Abilify. My older one ended up on very low dose Abilify and very high dose Lamictal. It wasn't hard to see that it was the high dose Lamictal that was really hitting the sweet spot for her. She is now off Abilify.
Based on what you know about my daughter so far, what reservations would you have regarding Topamax? Would it be possible for Topamax to stand alone - maybe with Vyvanse - like Geodon did? What about Lamictal.. both Lamictal and Topamax are anti-convulsants. Do they work together, or are they redundant?
> Depakote would be a better choice if one is to explore anticonvulsant mood-stabilizers. My main concerns with Depakote are that the dosage of Lamictal must be reduced and that it might leave your daughter somewhat depressed with continued use.
I would have thought that depakote would be last choice simply because - doesn't it have the weight gain issue?
I wish I understood the varied 'faces' of bipolar depression in adolescents. I know she's got the hypomania - and it might be skating pretty close to mania at times. But that god-awful irritability.. it's so hard to know whether it's a feature of impatient hypomania - or whether it's what bipolar depression looks like in a teenager.
Whatcha think?
>
> In any event, I still feel that Topamax is a viable treatment that can yield improvements in mania in bipolar disorder.
>I've read a lot of the links you provided me.. and Topamax really does seem worth exploring.. especially since it really does look like she does the mixed state thing.
I'm interested in any additional thoughts you have, Scott
Solstice
Posted by Solstice on February 20, 2012, at 19:07:36
In reply to re: Desperate - Part 2 - Please no anti-med posts, posted by Solstice on February 20, 2012, at 18:54:53
Posted by Phillipa on February 20, 2012, at 20:09:31
In reply to re: Desperate - Part 2 - Please no anti-med posts, posted by Solstice on February 20, 2012, at 18:54:53
Are you saying you have another Daughter with same? If so don't they say what works for one could work well for another family member? Phillipa
Posted by Solstice on February 20, 2012, at 20:40:41
In reply to re: Desperate - Part 2 - Please no anti-med posts » Solstice, posted by Phillipa on February 20, 2012, at 20:09:31
> Are you saying you have another Daughter with same? If so don't they say what works for one could work well for another family member? Phillipa
No, it's not the same as with my oldest daughter. She has very complex issues and is legally disabled. Her mood instability is tied to life-long impaired cognition.
Solstice
Posted by SLS on February 21, 2012, at 5:14:42
In reply to re: Desperate - Part 2 - Please no anti-med posts » Phillipa, posted by Solstice on February 20, 2012, at 20:40:41
> > Are you saying you have another Daughter with same? If so don't they say what works for one could work well for another family member? Phillipa
>
> No, it's not the same as with my oldest daughter. She has very complex issues and is legally disabled. Her mood instability is tied to life-long impaired cognition.
>
> Solstice
God bless you for being the mother that you are. Incredible.
- Scott
Posted by SLS on February 21, 2012, at 9:19:25
In reply to re: Desperate - Part 2 - Please no anti-med posts, posted by Solstice on February 20, 2012, at 18:54:53
> I would have thought that depakote would be last choice simply because - doesn't it have the weight gain issue?
Not always. I had no problem with it at all.
> I wish I understood the varied 'faces' of bipolar depression in adolescents.
EXCELLENT!
Pediatric and adolescent depression does look different from depression seen in adults and is characterized by irritability.
Signs and symptoms of depression in teens:Sadness or hopelessness
Irritability, anger, or hostility
Rage
Tearfulness or frequent crying
Withdrawal from friends and family
Loss of interest in activities
Changes in eating and sleeping habits
Restlessness and agitation
Feelings of worthlessness and guilt
Lack of enthusiasm and motivation
Fatigue or lack of energy
Difficulty concentrating
Thoughts of death or suicide
Can you list all of the symptoms that your daughter is currently experiencing here? That might help us get a handle as to how much depression is going on to indicate whether we are looking at dysphoric hypomania (mixed-state) or depression only.
List:
- Scott
Posted by Solstice on February 21, 2012, at 11:27:23
In reply to re: Desperate - Part 2 - Please no anti-med posts » Solstice, posted by SLS on February 21, 2012, at 9:19:25
> > I wish I understood the varied 'faces' of bipolar depression in adolescents.
>
> EXCELLENT!
>
> Pediatric and adolescent depression does look different from depression seen in adults and is characterized by irritability.
>
>
> Signs and symptoms of depression in teens:
>
> Sadness or hopelessness
> Irritability, anger, or hostility ****CHECK****
> Rage ****CHECK****
> Tearfulness or frequent crying ****CHECK****
> Withdrawal from friends and family
> Loss of interest in activities
> Changes in eating and sleeping habits
> Restlessness and agitation ****CHECK****
> Feelings of worthlessness and guilt
> Lack of enthusiasm and motivation
> Fatigue or lack of energy
> Difficulty concentrating ****CHECK****
> Thoughts of death or suicide
>
>
> Can you list all of the symptoms that your daughter is currently experiencing here? That might help us get a handle as to how much depression is going on to indicate whether we are looking at dysphoric hypomania (mixed-state) or depression only.
>
>
List: I put ****CHECK**** by the ones that apply. Please let me know what you think.
Just got home from the PDoc.
THYROID; Dr. said there is no way that it's her thyroid, because the thyroid problems in the family are hypothyroid, and it would need to be hyperthyroid. That said, she said we need to check her thyroid anyway because of the lithium, so we'll do that in 2 weeks.
LATUDA: Dr. said it's falling flat. Daughter goes off of it tonight, and starts a Saphris trial.
LIHIUM Daughter's lithium level was .7 and dr. says it needs to be much higher. She wants to continue the lithium at the same level for now, while we see how things go with Saphris
ANTICONVULSANTS: I was just floored. I brought up Zonegran, Topomax, Trileptal, etc. She said 'absolutely not.' She said that there are no scientific studies proving that they work any better than placebo. She said she did use Topomax when it first came out, but doesn't think it was effective. She said Lamictal and Depakote are the only anticonvulsants she's willing to use. :-(
STIMULANT: She is certain the stimulant is NOT impacting her hypo/manic episodes. She said that in her practice (which is huge, includes lots of pediatric, and has been going 20 yrs), it has been extremely rare and has only happened in males that were diagnosed as young children. Interesting.
So... I'm hopeful that Saphris will work.. and somewhat discouraged by her unwillingness to consider other anticonvulsants.
Solstice
Posted by Beckett on February 21, 2012, at 12:20:45
In reply to Part 2 - Please no anti-med posts - and UPDATE » SLS, posted by Solstice on February 21, 2012, at 11:27:23
I'm hopeful, too. Saphris is reported to be good for agitated bipolar states. Your daughter's doc sounds good to me, Sol. Saphris could take care of any sleep difficulties, too. Best of luck tonight and going forward.
Posted by SLS on February 21, 2012, at 12:45:32
In reply to Part 2 - Please no anti-med posts - and UPDATE » SLS, posted by Solstice on February 21, 2012, at 11:27:23
> So... I'm hopeful that Saphris will work..
I would look forward to trying anything new. Saphris is a reasonable choice. I found it somewhat calming.
> and somewhat discouraged by her unwillingness to consider other anticonvulsants.
I'm surprised that the doctor disqualified Trileptal from consideration. It might not be appropriate for your daughter's case profile, but it helps a great many people where aggression and impulsiveness are present.
Looking at the big picture, I think your doctor is doing some good things, and I don't doubt that she can help your daughter.
- Scott
Posted by Solstice on February 21, 2012, at 17:41:19
In reply to Re: Part 2 - Please no anti-med posts - and UPDATE » Solstice, posted by SLS on February 21, 2012, at 12:45:32
For those who have tried Saphris - how has it done with respect to making you overly sleepy?
My daughter starts it tonight. She had two weeks of terrible sleepiness when she started Geodon, but it did eventually go away. I'm think I'll have her take it at 9pm.
Will that mitigate any sleepiness lasting throughout the school day?
Please describe for me how you experienced any sleepiness that it caused.. i.e. how long did it last, etc.
Thanks everybody!
Solstice
Posted by Phillipa on February 21, 2012, at 19:02:25
In reply to Re: Part 2 - question for SAPHRIS users, posted by Solstice on February 21, 2012, at 17:41:19
Solstice had to wish you and you Daughter the very best in her sapris trial. No personal experience. I'm hoping others weigh in and you keep us informed. I for one really care. And to second Scott you are one super Mom!!!! Phillipa
Posted by Beckett on February 21, 2012, at 19:50:49
In reply to Re: Part 2 - question for SAPHRIS users, posted by Solstice on February 21, 2012, at 17:41:19
Sol, I took it in bed, and it put me to sleep. That was the 5 mg dose. I woke 7:00 a.m. feeling rested and calm. That's from an adult with chronic insomnia. I don't know how it will effect an adolescent the following day.
Posted by Solstice on February 21, 2012, at 19:55:36
In reply to Re: Part 2 - question for SAPHRIS users » Solstice, posted by Beckett on February 21, 2012, at 19:50:49
> Sol, I took it in bed, and it put me to sleep. That was the 5 mg dose. I woke 7:00 a.m. feeling rested and calm. That's from an adult with chronic insomnia. I don't know how it will effect an adolescent the following day.
Thanks Beckett! My daughter does have terrible insomnia. When her bipolar is under control - she might get 6 hrs a night - but when she's in an extended episode like this she barely gets 2 hrs. Every week or so she crashes and sleeps a whole day and a half. She's got a 10mg starter pack. I'm hoping that if she takes it at 9pm, that she'll sleep good and her morning Vyvanse will stave off any residual sleepiness. It's just so hard on her since she's a jr in high school and really needs to be functioning well every day.
Solstice
Posted by Beckett on February 21, 2012, at 20:00:57
In reply to Re: Part 2 - question for SAPHRIS users » Beckett, posted by Solstice on February 21, 2012, at 19:55:36
Sol, I had restless legs during the first week. This can happen with Latuda or maybe even Geodon. I imagine her doctor has discussed possible start-up sides with you for different meds.
Posted by Solstice on February 21, 2012, at 20:12:46
In reply to Re: Part 2 - question for SAPHRIS users » Solstice, posted by Beckett on February 21, 2012, at 20:00:57
> Sol, I had restless legs during the first week. This can happen with Latuda or maybe even Geodon. I imagine her doctor has discussed possible start-up sides with you for different meds.
While she's been on Latuda, she's been physically agitated. Her muscles seem to bother her - feeling tense and tight. Constantly stretching things. She told me that at times she feels like even her eyelids need to be stretched. I looked all that up and saw that that kind of physical restlessness is a symptom of hypo/mania. She seems to have gotten some relief from it since her symptoms are slightly better, so it's hard to say whether it's the bipolar or the new meds.
She had her last Latuda last night and starts her first Saphris tonight.
keeping my fingers crossed!
Solstice
Posted by herpills on February 23, 2012, at 10:12:55
In reply to Re: Part 2 - question for SAPHRIS users, posted by Solstice on February 21, 2012, at 17:41:19
I could only tolerate Saphris at night, it is extremely sedating for me. I took it for about 9 months. I only took 5mg, right before bed. It has been the best med for sleep and also the best AP I have taken which actually helped mood.
I don't know if the drowsiness will lessen during the day. Could you talk to the doctor about taking it all at night? herpills
Posted by Solstice on February 23, 2012, at 10:26:10
In reply to Re: Part 2 - question for SAPHRIS users » Solstice, posted by herpills on February 23, 2012, at 10:12:55
> I could only tolerate Saphris at night, it is extremely sedating for me. I took it for about 9 months. I only took 5mg, right before bed. It has been the best med for sleep and also the best AP I have taken which actually helped mood.
>
> I don't know if the drowsiness will lessen during the day. Could you talk to the doctor about taking it all at night? herpills
>
>Thanks for the input, herpills!
She does take it at night. First night she took 10mg, and second night (last night), she took 5 mg. First day she felt somewhat sluggish.. said her brain would just stop and she couldn't 'think' - just blank. She complained about not being able to learn. This was happening at school, and from her description, it sounded like she felt her comprehension was compromised... had trouble following (or keeping up with?) new material. At home, though, no complaints about 'thinking,' and her ability to communicate and talk intelligently seemed normal to me.
Today is her second day. She got herself up and off to school. I'll find out how it went when she gets home.
let me know if you think of anything else!
Solstice
Posted by phidippus on February 23, 2012, at 17:21:36
In reply to Desperate, posted by Solstice on February 18, 2012, at 21:08:07
Latuda - 80 mg
Lithium - 90 mg
Intuniv - 3 mg
Vyvanse - 80 mg
Lamictal - 200 mgThat lithium dose is next to useless. Try 1200 mg and see if she improves.
Eric
Posted by Solstice on February 24, 2012, at 15:12:49
In reply to Re: Desperate » Solstice, posted by phidippus on February 23, 2012, at 17:21:36
> Latuda - 80 mg
> Lithium - 90 mg
> Intuniv - 3 mg
> Vyvanse - 80 mg
> Lamictal - 200 mg
>
> That lithium dose is next to useless. Try 1200 mg and see if she improves.
>
> EricHey Eric..
I put the wrong dose for lithium. She's taking 900 mg. Her lithium level is .7, which her PDoc says is too low. We're holding it at 900 for right now because of other med changes, but she is really complaining about her hands shaking - which I'm assuming is the Lithium.
But we took out the Latuda because it seemed to fall flat. Dr. added Saphris - 10mg at night. She took her third dose last night. Her chief complaint (other than the taste) is that she feels like her mind is 'blank' during the day at school.. like she can't 'think.'
When she had her initial manic episode a month ago, she spent the first week of it crying in the counselor's office all morning. She missed a lot of classes for the first couple of weeks. So I'm wondering if what she's experiencing is just that she's gotten behind and feels overwhelmed - can't follow along because of the missed instruction. She's very, very anxious because her grades are tanking. Her bipolar and ADHD make it real easy to 'check out.' I really wish I knew whether it was the Saphris causing this 'blank mind' feeling, or being lost and overwhelmed. She seems okay otherwise - in that she can have a conversation and stay with it. I don't think her mind seems impaired.I sure would appreciate hearing from anyone who has taken Saphris who could shed some light on this issue for me.
Go forward in 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.