Rapid-cycling Bipolar II–what to do . . . what to do

Jeff writes in with a common problem . . . feeling kind of crappy on the medicine:

Hey doctordan, I was in counseling for 11 months. Blah.  The same questions over and over. Point being, I dont need to talk . Honestly. I’m a smart cookie. Now, ONTO the LAMICTAL I have been diagnosed with Bipolar II disorder with rapid cycling and panic disorder and anxiety. I am off in lala land now, What is that ? Is it the Citalopram, or lamictal .  I have no energy and I just feel blah.   Its kind of like I went back in time. To a point before I was ever treated. The question is this, do you think decreasing the dosage will have any great impact or will cause it to be worse, the citalopram makes me sleepy but not enough to sleep. BTW 150 mg lamictal and 40 mg citalopram. This whole illness hit in nov 2005 and is realy consuming my life and its pissing me off. Any help would be appreciated. This is affecting my ability to work, communicate with others. Its just crap. I need that special pill that grows a new brain… If you have any extra send them my way. PLEASE.

OOOOooooooohhhhhhhhhHHHHHH . . . you want the SPECIAL pill!   I’ve been holding on to that for JUST such an occasion!!!  Don’t I wish . . . (not as much as you, I know).

A couple of things come to mind here.  Let’s talk about diagnosis.  If you truely have a rapid cycling Bipolar II disorder, then I wonder about the medication approach that is being used.  Conventional wisdom is that rapid cycling is best treated with Lithium.  Studies have shown that to be the most effective intervention for smoothing out the cycling pattern.  Not treating the depression, but just smoothing out the peaks and valleys.  Sometimes when we use Lithium, we end up with less of the ups and more of the downs in the mood cycle . . . leaving one to feel blah.  Sounds like you are already there.  Lamictal certainly has some mood stabilizing properties, but mostly for depressive symptoms and not for the hypomanic symptoms that are part of the definition of Bipolar II.  Can it work . . . sure.  But from your description, it doesn’t sound like it is.  Actually, your mood seems overly dampened down, like we can occasionally see with anti-manic mood stabilizers like Lithium.  Another area of concern is the high dose of the citalopram.  Again, conventional wisdom says antidepressants can promote mood instability.  In your vignette, all I hear is BLAH . . . depressed and flat.

Not knowing what you have been on in the past (clearly important information) I can only suggest generalities.  My guess is that the BLAH you have is from the Lamictal.  If I was your shrink, I would consider what my mood stabilizer options are and substitute.  Lithium, as mentioned above, is a good option if you have not been on it before.  Another option is Abilify . . . the overly expensive and highly advertized new-ish mood stabilizer.  Despite the hype . . . it actually is one of my favorites recently.  I have seen significant success in a good number of patients.  There is data showing it can enhance mood when given in combination with antidepressants (Prozac in the studies done) and will provide mood stability as well.  The process of switching you over to a new regimen should be slow . . . but not too slow if you are feeling crappy.  Perhaps adding the new mood stabilizer and lowering the Lamictal at the same time.  You will need to be re-assessed after a month or two to see how you are. 

Another point is the therapy.  No matter how smart you are, therapy can be helpful.  Must be with the right person and the right approach must be used.  The trick is finding that right combination.  Don’t discount therapy altogether . . . that would be like giving up on marriage after a string of bad dates!  I always recommend asking friends or family that may have had contact with the mental health system in your area.  Another excellent resource is your family doc (they know who is good).

 

–Dan Hartman, MD