If you have lithium-responsive bipolar disorder (a rare and coveted phenotype) then it could be disastrous to stop the lithium for no reason other than your doctor's limited availability -- a primary care doctor can renew the prescription -- student health service at your medical school?the course of illness can worsen if lithium gets stopped in a lithium-responsive phenotype. In fact, if lithium does do the job and you're in an area where psychiatry resources are limited, that's all the more reason to assure the lithium is maintained by some MD to minimize the risk for future trial-and-error exploration of other medicines.
Good luck with completion of your training!
Dr GView Thread
Dear An, There are ongoing research studies of ketamine in bipolar depression, as well as unipolar depression. It is still very much an experimental, non-mainstream possible treatment. One problem with ketamine is that its antidepressant effects often fade within a week (so one aspect of current research involves trying to come up with ways to prolong the effect -- repeated infusions? other medicines that might help to sustain a response?). To my knowledge, ketamine studies that are recruiting for treating the depressed phase of bipolar disorder (see www.clinicaltrials.gov) don't seem to exclude people who have had 4 or more episodes in the past 12 months from eligibility. (Though, if someone has very frequent episodes, it would make it that much harder to know if "improvement" from depression with ketamine was a result of the treatment or just the natural course of "cycling out" of a depression.)
I wouldn't especially expect any detectable differences in the effects you feel based on timing of the dose -- once the enzyme monoamine oxidase has been irreversibly inhibited, it stays inhibited for 2 weeks and specific, individual doses don't have much unique impact on that basic mechanism.
Consider talking with your doctor about withdrawing the Cymbalta, since in people who have 4 or more episodes per year, antidepressants -- especially SNRI's like Cymbalta -- have been associated with causing more episodes (of both mania and of depression) over time, and the mood stabilizers you're taking (lithium and Depakote) might work better for rapid cycling minus the antidepressant than with it.
Latuda, like all medicines, generally either helps or it doesn't. It has known antidepressant and antipsychotic properties and presumed
antimanic properties. I can't say that I've seen it cause hallucinations or other psychotic symptoms, nor can I think of a reason why an antipsychotic would cause psychosis -- though it could certainly fail to treat psychosis. In the manufacturer's studies for bipolar depression, 30 mg seemed to be plenty and it's not at all clear that there's a relationship between dose and response. I usually am in no rush to raise the dose above 20 mg/day when treating depression. Dose-response may actually be idiosyncratic for individual patients as determined on a case by case basis.
Latuda has a half life of 18 hours and it takes 5 half lives (about 4 days to reach steady state, or to be eliminated from the bloodstream).
Dr GView Thread
Insight literally refers to the ability to recognize the presence and nature of illness symptoms. In bipolar disorder, people can sometimes misidentify symptoms (eg, they could be manic but think they're depressed, or they could be paranoid but think they're just anxious) or not even recognize symptoms are present. Or they might minimize the severity and extent of their symptoms (think of someone having a heart attack who's in denial of it and so continues to work without realizing or acknowledging that something is very wrong). It's worth asking your doctor what he has meant by insight in relation to your case, since one goal of treatment typically is to try to help patients better recognize when they are having symptoms, and how to catch them and be aware of them before they get out of hand. Dr. G.View Thread
Latuda is better absorbed into your system -- about 3x as much -- if there's at least roughly 350 calories' worth of food in your stomach within a couple of hours of taking Latuda. If it's taken on an empty stomach, you'll only absorb about one third of the amount you'd otherwise get into your system. No harm, but potentially less potent.
The half-life of Nardil (meaning, how long it takes until half of the dose is eliminated from your system) is about 11-12 hours, so it's therefore usually a twice a day medicine in order to maintain steady blood levels. Chances are though it wouldn't have a gigantic impact on mood if someone took it all at once per day (or even three or more times a day) -- really just to keep a continuous level in your bloodstream, which doesn't necessarily translate to noticeable differences. Dr. G.View Thread
It is objectively upsetting when different doctors give different or conflicting recommendations. This is as true in psychiatry as in any other medical specialty. The best an "informed consumer" patient can do, I think, is to ask what the basis, or evidence base, is, for a given recommendation. Is the recommendation supported by formal research studies, or just one person's opinion. Often there is no single right or wrong answer to a medical question but there should always be a clear rationale and a scientific basis to support any assertion or recommendation.
Dr GView Thread
Ideally, an inpatient doctor confers with the outpatient doctor who knows and often refers their own patient for inpatient care. If and when the outpatient doctor has ideas and preferences about what (if any) medicines on a regimen should be changed, the inpatient team (who barely know the patient, and likely will know them only for a very short time, as compared to the outside doctor) usually follows that plan unless there is something very objectionable or some new crucial piece of information that becomes known only to the inpatient team (eg, drug abuse). Sometimes though the inpatient doctors may have their own ideas about what to do with respect to medicines and then, for better or worse, the outpatient doctor who then resumed the aftercare might end up changing things back, or making other changes, which can sometimes become confusing to the patient and everyone else if the different doctors flatly disagree about what the best course of treatment is. Hopefully that scenario isn't too common.
Dr GView Thread