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Antidepressants or TMS for bipolar

H

HisWife

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My husband previously had a mixed episode triggered by Welbutrin. Before he became mixed, the Welbutrin worked really well on his depression.

His doctor is proposing trying Welbutrin again, combined with Olanzapine and Lamictal, to see if those keep him stable. He's nervous. Anyone have experience with this combo? Did the mood stabilzer keep working?

They are also considering TMS. Any experience there?

Are there other things that people have done for treatment resistant depression in someone with Bipolar?
 
Wishbone

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No experience with TMS from me but I have seen it mentioned on here before so just do a search and something should pop up.

Regarding those new meds mentioned, Lamictal will be the one that aims to keep his mood stable and also help to lift him a little and Olanzapine will be like the gatekeeper that keeps the others under control. Olanzapine is often paired with Fluoxetine, so a fairly similar combination. Just be sure to expect weight gain etc from them, Olanzapine is known for it.
And personally, if I know a medication has put me into a mixed state I wouldn't want it near me again. It's slightly different with the 'gatekeeper' introduction but he will have to stay 100% compliant with that otherwise the same could happen again.
 
H

HisWife

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No experience with TMS from me but I have seen it mentioned on here before so just do a search and something should pop up.

Regarding those new meds mentioned, Lamictal will be the one that aims to keep his mood stable and also help to lift him a little and Olanzapine will be like the gatekeeper that keeps the others under control. Olanzapine is often paired with Fluoxetine, so a fairly similar combination. Just be sure to expect weight gain etc from them, Olanzapine is known for it.
And personally, if I know a medication has put me into a mixed state I wouldn't want it near me again. It's slightly different with the 'gatekeeper' introduction but he will have to stay 100% compliant with that otherwise the same could happen again.
Have you found other things that work for depression and don't trigger mania/mixed episodes?
 
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BlueWater

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I am having some luck right now with Lexapro + Lamictal. I hope both work well together for me. No, I am not diagnosed with BP but no other forum suits my medication needs and symptoms as well as this one. My doc is trying me on Lexapro because it targets anxiety a bit more than depression. Weight gain on Lexapro ought to be minimal. If it doesn't work for me, then he wants to try Pristiq. If that doesn't work, then I assume an AP since we also have to treat OCD.

There are quite a few good reviews on drugs.com of Lexapro and Pristiq (also for weight loss) for bipolar. I'm sure others might have commentary about these meds. Seems like there's one guy on this forum who has bipolar and took Lexapro for many years with success but he now takes Depakote.

I have no idea if this answers any of your questions. These are the options I was offered because my doc said "I have a sensitive system" and these meds ought to be good entry-level ADs for me. Good luck.
 
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keith74

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They are also considering TMS. Any experience there?
TMS has a similar risk as antidepressants in potentially triggering mania in people with bipolar. If nothing else is working, then it is an option. If this route is chosen, a "gatekeeper" to prevent mania is recommended like Wishbone mentioned (an antipsychotic like Olanzapine).
 
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HisWife

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So, as I understand it they want to add either Wellbutrin or TMS to the Olanzapine/Lamictal/Klonipin combo, the argument seems to be that the other meds will prevent the mania?
 
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keith74

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So, as I understand it they want to add either Wellbutrin or TMS to the Olanzapine/Lamictal/Klonipin combo, the argument seems to be that the other meds will prevent the mania?
That is the hope... that the Olanzapine with protect against a manic relapse (the other two will not help as much for mania).
 
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BlueWater

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So, as I understand it they want to add either Wellbutrin or TMS to the Olanzapine/Lamictal/Klonipin combo, the argument seems to be that the other meds will prevent the mania?
Lamictal is definitely for mood (excellent for my rage) but also to give a bit of a lift from depression. I don't know if it can help his mania, but I do know it was horrible increasing this med while anxious. Bear in mind that Klonopin can contribute to depression, but it is superb for anxiety and rage, at least for me. So far Lexapro, which might not be good for your husband, is lifting the depression that Klonopin and OCD have been contributing to. If your husband can tolerate a beta blocker and is ok with adding something else to the mix and something that doesn't have to be taken daily (if he has the clarity to know when he needs it is important), then I've found Propranolol to be very good at controlling physical anxiety and slowing my mind down a bit. I'm taking it everyday because I like it so much. It mostly calms my sudden, explosive rage where something is suddenly happening that I can't tolerate which then leads to a sudden and very strong desire to harm both myself and others (oh so hard to write that down). Can't speak to Olanzapine but I hope it works.
 
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Are there other things that people have done for treatment resistant depression in someone with Bipolar?
Yes. I slid into a whopper depression ~3-4 years ago, but was pulled out with just a few Ketamine infusions. After 3 (expensive) IVs, my pdoc agreed to try compounded Ketamine nose spray 3 x day. My history says I should have had several depressive dips since I started it, but I haven't.

She says I am her best Ketamine responder. It poops out for most of her patients. Still, it could be worth a try since it works so fast.

A version of Ketamine nasal spray is now FDA approved (Spravato). It follows a different protocol than I do, but gets some good reports. I think insurance covers it.
 
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HisWife

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Clinically, not a lot. I see it of course, he’s super agitated and intermittently raging and delusional.

But the state he’s in now, while it’s better for me, doesn’t seem better for him. So, I don’t feel like I can say “don’t try anything, it’s too risky.”
 
Wishbone

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So he's back into depression now again? The problem you have with mixed episodes, and why I asked what you knew of them is that the very nature of them is to have elements of both depression and mania, so treating them is not at all easy. For mania you lower the mood, for depression you lift it - easy, right? What do you do when the person has both problems and there is a lot of aggression too? It should be about ensuring the mood doesn't go too high for sure as that's where the heightened raging really comes from. Irritability can come in depression but it's not the same energised, ferocious thing that a mixed episode can bring, for sure. At the same time, you don't want to be depressed because mixed states are one of the most dangerous states for the person to be in, you're a very high risk to yourself because of how intensely horrible it feels. So your mood needs to be kept from going too low, kept from going too high and hopefully kept bobbing along like a nice little boat on a lake, no problems. The bit that makes me uneasy here is the addition of an antidepressant because that is how you get lifted up in mood and potentially into choppier waters. If Olanzapine does its job he won't go too high, but the risk is there that it might not be at the right dosage yet etc. They're experts so they should get these things right but again, having had these episodes myself, antidepressants are no longer on my list of acceptable medications, both preferentially and officially, for the very reason they can trigger an episode.
I think it might be a good idea to get some rules out there right away so that he agrees that if you see anything untoward in him he'll call the doc right away just in case.
 
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HisWife

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Yes the way I understand it is he was depressed, then the mania got layered over that, so he was both, and now the Olanzapine got control of the mania and the delusions and he is back to “just” depressed with the added element of feeling crushing guilt about things that happened when he was mixed.

So, I get why antidepressants have the potential to be very bad. Although it sounds like other things like TMS and ketamine (not currently an option) also have the same risk. I don’t want the mania to come back, but how he is now also isn’t tolerable. He’s made multiple suicide attempts, so while I am no longer afraid of what he might do to me, he still is far from ready to come home. So, I am wondering what has worked for other people. What is OK to try?

Yes, I also think that we need to figure out some kind of plan for how we communicate about his symptoms so that we can get help fast when needed.
 
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keith74

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Yes the way I understand it is he was depressed, then the mania got layered over that, so he was both, and now the Olanzapine got control of the mania and the delusions and he is back to “just” depressed with the added element of feeling crushing guilt about things that happened when he was mixed.

So, I get why antidepressants have the potential to be very bad. Although it sounds like other things like TMS and ketamine (not currently an option) also have the same risk. I don’t want the mania to come back, but how he is now also isn’t tolerable. He’s made multiple suicide attempts, so while I am no longer afraid of what he might do to me, he still is far from ready to come home. So, I am wondering what has worked for other people. What is OK to try?

Yes, I also think that we need to figure out some kind of plan for how we communicate about his symptoms so that we can get help fast when needed.
ketamine is not a typical antidepressant, hence there should be no risk of triggering mania (though more research is needed). The antidepressants that are most risky are SSRI antidepressants:

Note while Wellbutrin is not an SSRI, there has been enough data that it carries the same risks. Again, everyone is different. And if nothing else is working, then there may be no choice but to use one as last resort. But also note that if your husband is rapid cycling (which he may), then using anidepressants is even more risky. Extreme vigilance and med compliance will be needed.

It's a tough situation and Wishbone and I are not saying that an antidepressant must be avoided at all cost. We are just being clear regarding the risks so that you can be vigilant about it.

Good luck!
 
Wishbone

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So, I am wondering what has worked for other people. What is OK to try?
I take Depakote (mood stabiliser) and Lurasidone (antipsychotic). One stops me from going to high or getting too riled up and the other is taking care of the lower end or getting too riled up. A good combination for me, and while we do sound potentially similar it might not be a combination that works for him. Docs get the say here really because he's in hospital. Olanzapine is a good drug and should be for depression too but it's very early days still. Maybe after a bit more time once things have settled some more it will show its worth. Is he getting any kind of therapy in there too? He sounds like the kind that would benefit from that quite a lot as well as the right meds.
And I'll stress again that meds need time to work. How long has he been out of the mixed episode?
 
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