Rule of thumb is to treat the patient, not the number, when it comes to things like valproate levels. Exact values can bounce around a bit so a 10 point difference doesn't mean much.
Dr GView Thread
There has to be a psychiatrist on call for emergencies covering the practice of your own doctor if he is not on call for himself over the weekend. You can always present to an ER for immediate evaluation (not necessary hospitalization) at any hour -- call ahead to make sure they have a psychiatrist on call to their ER.
Dr GView Thread
Dear Sarah, Sorry to hear of your ongoing difficulties. Again, I am cautious to "second guess" the treatment of someone I myself haven't evaluated or am treating....but, that said....just about every practice guideline written in the last 15 years strongly advises the elimination of antidepressants when even low-grade symptoms of mania are present, much less escalating mania symptoms. Stimulants also really have no role when agitation is present but, like Zoloft, can worsen existing mania symptoms. I think it would be reasonable to ask your doctor what his assessment of your DSM-IV mania symptoms is, and if there are at least 2 symptoms from the list of 7 that are present, let him know your concern that the continuation of any antidepressant dose with any stimulant is known to aggravate mania symptoms; and ask about his objection to initiating a standard antimanic drug (lithium, Depakote, Tegretol, any atypical antipsychotic) as the core treatment. Hospitalization decisions require face-to-face assessments and depend on many factors beyond just risk of self-harm, including, what the outpatient treatment is. Generally speaking, for serious symptoms that don't necessarily require an inpatient level of care, practice guidelines tend to advocate some higher level and frequency of care than visits 2 months apart. Partial hospital programs or intensive outpatient programs, depending on what part of the country you're in, typically are set up to provide closer monitoring (several days per week) and structure to assure a proper level of care. If you aren't satisfied with the level of care and standard of care you're receiving then, again, it's entirely reasonable to seek a second opinion. Good luck! Dr. G.View Thread
Latuda plus Lamictal very well might have some additive or synergistic benefit since they work differently and each address depression in unique ways. It is a logical pairing of medicines.
Tough for me to comment in an advice-giving way when I'm not the doctor who's evaluated you or is treating you (and webmd can't really provide specific treatment recommendations to anyone) but, that said, klonopin has some antimanic value and could be a step in the right direction. There is an extensive published medical literature by an expert scientific community advising against the use of antidepressants or stimulants when any mania symptoms are present because they can make those symptoms worse. Lamictal at any dose has no proven antimanic value -- this has been well-studied and the findings are in the public domain on the GlaxoSmithKline website. I think that you're in the very difficult position of being increasingly symptomatic and describing recommendations that are at variance with traditional treatment approaches to the management of mania.
A second opinion never hurts when you are getting confusing messages or are not getting better and wondering if a different approach warrants consideration.
Dr GView Thread
Dear monkeybee, Only your own doctor can advise you specifically what to do with regard to your treatment. If you are currently having manic symptoms (e.g., not sleeping, fast thoughts, overactivity) simultaneously with depression symptoms, then it would probably make sense to ask your doctor if he is concerned that the vyvanse could be aggravating the mania symptoms and perhaps therefore should be reconsidered, so long as there are any mania symptoms present. Dr. G.View Thread
Dear An, The musculoskeletal problems you're describing don't sound likely related to lithium. Your primary care doctor should be able to help diagnose the cause and recommend any appropriate treatment. Dr. G.View Thread
Dear Sarah, In my own practice I would optimize the dose of a medicine (400 mg of Lamictal is more than optimized) and judge its effect. If no effect, I tend to stop that medicine for lack of efficacy and move on to something else. Sometimes if there is a clear but incomplete improvement at an optimized dose one might push a little higher with dosing, but typically not unless it's to fine-tune an initial response. It is also customary to add together non-redundant medicines that have complementary mechanisms(e.g., lithium and lamotrigine) to further optimize an effect. If a patient has any mixed features (ie, mania symptoms co-occurring with depression symptoms) the experts tend to advise not giving an antidepressant (Zoloft) or stimulant (vyvanse) which could make the existing mania symptoms worse without helping the depressive symptoms. Trust and confidentiality/privacy are rather sacrosanct issues in any doctor-patient relationship and if you feel uncomfortable or have reason to think your doctor shared your personal information with someone else without your consent then that's a serious issue that should be openly and frankly addressed. Dr, G.View Thread
In the FDA studies of lamictal for relapse prevention in bipolar disorder, the manufacturer found that 200 mg was better than placebo to prevent highs or lows (but more potent against lows than highs) and 400 mg was no better than 200 mg. now and then one might go beyond 200-400 mg but that would be considered experimental rather than based on any studies. Lamictal and lithium do very different things -- lamictal mainly prevents lows while lithium mainly prevents highs, so usually we don't "replace" one with the other. Abilify may be a reasonable anti-manic drug but I think you'd want to know the rationale for stopping lithium given its fundamentally different purpose than lamictal.
Dr GView Thread