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    Treatment Frustration/ Dr. G
    casa222 posted:
    I have been seeing a psychiatrist for almost five years now to try and maintain my Bipolar I. I have been on several different combinations of meds to help "squash" my symptoms in hopes of stability. I have never been stable for more than a month at a time. Currently my psychiatrist and I are trying to optimize my current med combo which is Lithium, lamotrigine, and Quetiapine. We have maxed out both Lithium and Lamotrigine in the sense that I am at the maximum therapeutic levels to treat my disorder while also being on 800mg of Quetiapine. After all of that heavy medication I still have leak through symptoms. So I was wondering if it is unrealistic of me to expect ultimate stability or do I need to settle for second best? I wasn't sure if we were missing something in our treatment plan. I had a wild question of whether or not my body chemistry was affecting the effectiveness of my meds. I'm just not sure what I should be striving for and what to expect as a result. Your insights and personal experience on this subject are greatly appreciated. Thank you.
    lotus responded:
    I am not sure what you mean by ultimate stability. Is it that you no longer have any symptoms of bipolar? That the medication sort of "cures" you?
    lexismom11 responded:
    I don't know that it is possible to never have any symptoms. I would think stability means that for the most part you are not experiencing symptoms. At least that is my goal. I strive for those periods when I feel "normal". I wouldn't call it settling for second best as much as I would call it striving for the best that I can be. I don't think you are missing anything because you and your doc are trying to find the best med combo for you. It also depends on what symptoms you are experiencing when you feel you are not stable. Are they manageable symptoms?
    This is the question you have to answer.
    Joseph F Goldberg, MD responded:
    Dear casa222,

    You ask important and complex questions that all too many people struggle with. In the case of chronic conditions like bipolar disorder (or arthritis, or asthma, or emphysema, or diabetes, or migraine...), certainly the goal of treatment is to eliminate symptoms or least to make them as minimal as possible. Sometimes we are more successful than others; I don't think incomplete remissions means giving up hope for better remedies to come down the road, and one wants to be sure the treatments have been correct (eg, multiple antibiotics for chronic bronchitis may do nothing if the cause is a virus). A good clinician should be able to lay out for you all of the available treatments for your condition and discuss their appropriateness, risks and benefits, and possible outcomes. Besides lithium and quetiapine and lamotrigine, there are other anticonvulsants (Depakote, Tegretol), numerous other atypical antipsychotics (including Zyprexa and clozapine -- the latter often neglected in "refractory" cases), ECT, and a host of "novel" therapies with varying degrees of scientific support behind them (eg, thyroid hormone, calcium channel blockers, n-acetylcysteine, omega-3 fatty acids, riluzole, pramipexole, modafinil/armodafinil, tamoxifen...). The website lists ongoing research studies across the country that identify ongoing trials of treatments under development (for all conditions in medicine, including bipolar disorder) -- may be worth having a look by typing in relevant keywords (eg, bipolar disorder, your home state, etc.).

    At the same time, there is value in optimizing ways of living with a chronic condition -- something akin to radical acceptance in DBT language -- and having a reasonable grasp of what can and can't change, and how to make the best of things in the here-and-now without abandoning hope for the future.

    Dr. G.

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    Joseph F. Goldberg, MD, is a Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY. He also maintains a private prac...More

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