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Dr. G - Correct Dosages for Bipolar I?
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concerned_mother_in_law posted:
My son-in-law has recently/finally been diagnosed with Bipolar I. He' been suffering manic & depressive
episodes since late teens. He has every typical symptom of the mania (and depression) and has been in a
current manic episode for over 3 months. With this last episode all the symptoms became much worse, he has
developed extreme hostility/rage, and has been horribly verbally and emotionally abusive to my daughter and
grandchildren. He was never medically treated until recently when this last episode of mania got so destructive
he finally agreed to treatment. (His parents don't think mental illness is real, that medications shouldn't be
taken for mental illness, that their son couldn't possibly be afflicted with manic depression, and think any
problems he has can be solved through Christian marriage counseling and prayer. They have heavily
influenced his decisions/actions up to this point.) He lives in a small rural community with mental health care
limited to a county mental health facility. He is seeing a therapist once a week and a nurse practitioner
(NP) once every 3 weeks. Possibly because of his underlying fears/doubts of taking mental health medications
originating from his parents and now verbalized to the nurse practitioner, but it appears to me that the NP is not
prescribing the dosages needed to get out of this current manic episode and to stabilize his mood.

Current medication history: The NP originally prescribed 5mg Abilify 4.5 weeks ago. My daughter called after a
week and was told he could increase it to 10mg (and no more). The NP would not prescribe anything else until
the 2nd visit at 3 weeks. At the 2nd visit she prescribed Lamictal (25mg 1st week, 50mg 2nd week, 75mg 3rd
week, 100mg 4th week and then "we'll see from there").

Current situation: After a month on 10mg Abilify, I'd say my son-in-law is less manic but still manic
(still lots of talking, not sleeping much, grandiose thinking, making poor decisions). He has improved somewhat in that someone can 'get a work in edge-wise', he hasn't had a fit of uncontrollable rage for 2 weeks, and has stopped having delusions. But I'm questioning whether the improvement is the medication helping or if it isn't that he had already 'peaked' and has naturally started to come out of the most extreme mania on his own, which he started doing about a week prior to even starting any medications.

Question for Dr. G: I've read extensively about his medications online and based on that reading have some
concerns:
o First, for Abilify, everything I read says the average dose for bipolar is 15mg and up to 30mg. Does it sound correct the NP has him only on 10mg?
o What I've read says that it is important to stabilize the mania prior to and with something other than Lamictal; that Lamictal is for preventing future episodes of mania but is ineffective to treat current episodes. He is obviously still manic, so shouldn't she have stabilized the current episode first? She seems to be counting on the Lamictal to stabilize the current episode - said it takes longer for Lamictal to do that than Abilify (due to the ramp up period for Lamictal) so that was why she started him on Abilify rather than Lamictal.
o The nurse practioner seems to be building him up to only 100mg of Lamictal and then "see". Everything I've read says the average dose for Lamictal is 200mg if not on any other bipolar meds. She has said she intends to take him off of the Abilify after he works up to the 100mg of Lamictal. That doesn't sound right to me. He's still manic. 2nd, 100mg of Lamictal sounds too low. 3rd, several things I've read said for Bipolar 1, if taking only Lamictal, the patient can still eventually break through and have a manic episode. Should he take something with the Lamictal long term?

Thanks for any advice. Possibly I'm worrying for no reason, but really need to know if they should pursue these
questions with the nurse practitioner and/or get a 2nd opinion.

Thanks.
Reply
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Joseph F Goldberg, MD responded:
Dear Concerned,

You are correct in your statements. Lamictal is a preventative drug, mainly against recurrent depressions more so than manias, in bipolar disorder. It has no known value in acute mania (that is to say, it was studied extensively for that purpose and found to be no better than a placebo).

Abilify has somehow become the flavor of the month for treating anything and everything in the world of bipolar disorder, even though it has no antidepressant properties in bipolar disorder and has non-trivial side effects. While it is FDA-approved to treat hospitalized mania in bipolar I disorder at the 15-30 mg doses, many practitioners use it mainly as an add-on (not a solo treatment) to an antimanic drug -- most often Depakote and lithium. Depakote and lithium remains the gold standard, mainstay treatments for mania or preventions of relapses in bipolar I disorder. It may be worth asking the NP if there is a reason that she is avoiding the gold standard drugs and also why she is thinking that Lamictal has any value in acute mania given the negative published randomized trials.

Dr. G.
 
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An_249671 replied to Joseph F Goldberg, MD's response:
Thank you so much for the information! It will be very useful in addressing getting on the right medications. I suspect that the NP is staying away from the 'gold standards' because of my son-in-law's insistance that his body can't handle taking drugs and their side effects (like the weight gain). He seems to believe and stresses that drugs effect him significantly stronger than everyone else. I think this is more of a physchological issue (that he believes this based on what his parents have installed as a belief system) vs. a physical issue (that his body really can't handle drugs like the average person). So I suspect she's prescribing drugs that he has a higher chance of continuing to take vs. the ones best suited for the manic issues.
 
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An_249671 replied to An_249671's response:
Dr. G,
I am still encouraging my daughter to read what you've sent me & talk to the NP so that hasn't happened yet. Son-in-law isn't really capable of those kinds of conversations without her help (still manic and phobic about mental illness meds in general), and I think she's afraid to 'rock the boat' right now since he's finally taking any meds, not raging and in a more manageable form of mania right now.

As it stands right now, he's still on the 10mg of Abilify & now worked up to 75mg Lamictal. He seems to feel that the Lamictal is already helping. He says typically he'd start feeling depressed by now and isn't. And he says his usual feelings of negativity and aggitation (which happens apparently all the time...manic, stable, depressed) have lessened. He says he feels more clear in his head. So I think he's going to want to stay on the Lamictal and that's good for the depression. But as discussed previously, I don't think the 10mg of Abilify helped the mania at all, and once off of it (which if no one addresses any of this with the NP that's the course it's going) there is nothing helping him with the current mania and Lamictal isn't intended to prevent of future episodes of mania.

I like the idea of asking the NP about adding Depakote or lithium to address the mania. Are both of those meds compatible with Lamictal? If so, typically in what dose? (Since for the first 2 meds the NP low balled the recommended dosages, that info would be helpful going into the conversation with her.)

Thanks so much for your help.
 
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Joseph F Goldberg, MD replied to An_249671's response:
Dear An,

Lamictal does have some value in preventing (but not acutely treating) mania -- it is better than a placebo for that -- but it has a much more powerful effect in preventing depressions than manias.

Lithium or Depakote are each compatible with Lamictal but if one is going to add Depakote to Lamictal, the Lamictal dose must be halved because Depakote doubles the level of Lamictal -- so, if someone is already, say, taking 100 mg of Lamictal and Depakote is added, the Lamictal would be cut down to 50 mg/day. There is no dosing adjustment when adding lithium to Lamictal.

Dr. G.
 
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An_249671 replied to Joseph F Goldberg, MD's response:
Dr. G,

Thanks for the information. How will we know what the right amount of Lamictal is for him? (Assuming he isn't taking Depakote too), the NP had said they'd get him to 100mg and "then see". But everything I've read says the usual dose for bipolar is 200mg. Are some people OK with only 100mg? Or should we be asking/assuming he needs to work up to 200mg?
 
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Joseph F Goldberg, MD replied to An_249671's response:
Dear An,

Lamictal is a "preventative" drug rather than a drug used to treat here-and-now symptoms. With the usual target dose being 200 mg/day, then 100 mg/day would be the customary target dose when combined with Depakote to optimize against a relapse.

Dr. G.
 
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An_249671 replied to Joseph F Goldberg, MD's response:
Dr G.,

I am wondering your thoughts on genomic testing for bipolar disorder. In reading a book on another topic, I heard about Assurex Health's testing of 32 commonly prescribed antidepressant and antipsychotic medications and their reporting of the body's ability to metabolize medications. I contacted them and the 2 I am most interested in (Lamictal and Lithium) are not on the list of the 32 tested, but several other drugs used in the bipolar arena are. Do you feel this type of testing is valuable information for the bipolar patient to have? Are you aware of any other companies doing this type of testing that may be more specific to the medications used only for bipolar?

I had another question about therapy for bipolar. My son-in-law who is bipolar has not had much luck with therapy. He says it doesn't help him. He lives in a small rural town and his only option is the local county mental health facility. He says his therapist just talks with him about sports and general stuff. I can't tell that the therapist is really trying to help him develop any plans for coping or managing his illness. But in all fairness, I think my son-in-law only showed up for 3 visits and was very manic at the time, so the therapist may have been keeping the conversation very light. I've been reading about Interpersonal & Social Rhythm therapy and it seems like the type of help he needs. Are there any agencies that offer effective on-line or phone therapy specializing in bipolar? I am trying to figure out if there is a way to get him the help he needs even though he lives in a small town.

My son-in-law is currently taking 200mg Lamictal and I think still the Abilify. He hasn't gotten his Nurse Practictioner to add Lithium yet, which he needs to do. He is currently in a depressive cycle. He thinks the Lamictal has helped the depression. He at least gets out of bed every day compared to his previous depressive cycle. Zero initiative but seems to enjoy and go through the normal day to day. However, he stopped going to work regularly. After about 30 days of this he finally said he was feeling anxious more so than depressed and that was why he wasn't going to work. My daughter got him to go back to the Nurse Practioner and she prescribed BuSpar. I wanted your thoughts on this medication for the anxiety that is associated with bipolar, and the recommended dosage.

Thanks for all your input.
 
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Joseph F Goldberg, MD replied to An_249671's response:
Dear An,

Pharmacogenetic testing at present can tell us information about whether someone may metabolize certain medicines too quickly (meaning they'd need a higher dose) or too slowly (meaning they'd need a lower dose) to compensate for side effects. That's about as relevant as genetic testing is at present. I know of no science to show that these commercially available products can provide information about the efficacy of any psychiatric drug.

Lithium is a salt and is not metabolized, it is just excreted by the kidneys, so, there would be no rationale for claiming to study genes that metabolize it. Lamictal is metabolized by the liver, but not by the enzymes that AssureRX or Genomind (another company that does this) tests (ie, cytochrome P450 enzymes) -- it's by a metabolic process called glucuronidation, and I'm not aware of any known genetic variations in the enzymes that perform this function. These genetic tests say nothing about any diagnosis, bipolar or otherwise -- they just give information about how fast or slow the medicine is broken down by the body. I'm not sure that adds a whole lot of useful information, and it's pricey too.

Abilify has not been shown to treat bipolar depression (was the same as a placebo in the manufacturer's studies). Lamictal by itself also is more potent to prevent depression rather than treat it when it's present. The combination of lithium plus Lamictal has some research to support its value for acute bipolar depression. There are many other treatments though that are better established for bipolar depression, which are discussed in the videos I have links for under "Resources."

Interpersonal/social rhythm therapy (IPSRT) is useful when there is a lot of emotional overinvolvement in families (eg, critical communication styles, overinvolvement), developed largely by David Miklowitz PhD. I have no idea though how to find out if a given therapist is familiar with it, but my guess is it's a very small minority. There are ways of finding therapists trained in cognitive therapy, another form of psychotherapy specific to depression through the Association for Behavioral and Cognitive Therapists (http://www.abct.org/Members/?m=FindTherapist&fa=FT_Form&nolm=1 ).

Buspar is a mild medicine for generalized anxiety disorder. It wouldn't be expected to do much for mood symptoms, and hasn't specifically been studied for anxiety in people with bipolar disorder.

Dr. G.
 
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concerned_mother_in_law replied to Joseph F Goldberg, MD's response:
Thanks for the information. What GAD medications have been found to be effective with anxiety in people with bipolar disorder?
 
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Joseph F Goldberg, MD replied to concerned_mother_in_law's response:
Dear Concerned Mother,

No medicines have specifically been studied to treat GAD in people with bipolar disorder. There is some evidence that Seroquel can lower overall anxiety symptoms when using it to treat bipolar depression.

Dr.G.
 
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concerned_mother_in_law replied to Joseph F Goldberg, MD's response:
Thank you for the information. I watched your video on bipolar depression medications you recommended and it was very helpful. Thank you for all you do.
 
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concerned_mother_in_law replied to Joseph F Goldberg, MD's response:
My daughter finally went in to see the nurse practiioner with her bipolar I husband to help with the communication. She told the NP that after 7 months, none of the medicines perscribed seemed to be helping, and stated that she thinks he needs to be on one of the 'gold standards' for bipolar (as you suggested she ask about) and that she wanted to see him at a minimum on a baseline of mood stabilizers factually known to work. The NP agreed and took him off of Buspar and he is weaning off of Abilify. So that leaves him with 200mg Lamictal and the NP added Lithium. Here is my question. In looking up recommended starting doses for Lithium (I looked up because every time so far this mental health facility has perscribed lower than recommended dosages) it appears that the starting dose is 900mg for maintenance. He is not currently manic, in fact he is in a depressive episode. They only perscribed 600 mg ( 2-300mg pills one in AM and one in PM) for the first 30 days. Have they under dosed him again?
 
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Joseph F Goldberg, MD replied to concerned_mother_in_law's response:
Dear Concerned mother in law,

In my own patients, I often start lithium at 600 mg/day for a few days and then increase to 900 mg/day and then check a blood level after 5 days of stead-state dosing. The level should be between 0.6 and 1.2 mEq/L. If it is lower, I raise by 300 mg. If it is higher, I either recheck it or else lower back the dose. Thyroid tests also should be ordered at the start of giving lithium and kidney tests must be monitored periodically (I check every 6 months, or more if any concern about kidney function). Lamictal plus lithium is a very evidence-based combination for bipolar depression.

Dr. G.
 
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concerned_mother_in_law replied to Joseph F Goldberg, MD's response:
Hello again Dr. Goldberg. My son-in-law started taking and has been on 900mg of lithium since last summer up until two months ago. During that time his blood work tested at the lowest level of the range (0.6). Taking lithium and Lamictal seemed to help hold off a new episode of mania. Usually it is a year between episodes but this time he was manic free for 1.5 years. However, about 2 months ago he started having/showing manic symptoms. The nurse practitioner increased his lithium dosage to 1350 and then tested his blood a month later (end of June). He tested at 1.0. This is the first manic episode he has had since he has been taking correct bipolar meds. Unlike the previous episode (without meds) which was a full blown Bipolar I episode, it seems much less severe this time around....more like what is described for Bipolar II. He is talking a lot, gets agitated, and has increased energy levels. (But is not having trouble sleeping, spending large sums of money, making other bad choices, and acting out of his mind.) We know that something is wrong, but others who are unaware that he is bipolar are noticing something is a little off....ulinke last episode, where it was apparent to everyone he was acting crazy. I wanted some advice on his treatment and prognosis. How often should he be having his blood tested knowing he is in a manic state? What will likely happen with this episode? As long as he stays on his current level of lithium, will he probably stay at the same level of symptoms and eventually work out of the episode? Or is it likely he will get worse? He is definitely worse now than 2 months ago when the symptoms started, but as described, not totally out of control. It feels like waiting for 'the other shoe to fall'.


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