Bipolar - what next?

[KurtCobainLover]

Hi, I've posted before about my bipolar and struggling with symptoms. I'm currently under the car of the mental health team again and have a call with my key worker tomorrow but not really sure what they can offer me.

I've been really down recently with intrusive thoughts of something happening to my children of being referred to social services. My anxiety is through the roof.

They tried giving me an antidepressant but that just made me high so I had to come off straight away which gave me awful withdrawals. I've been on other antidepressants before and they always send me high.

I'm just not sure where to go from here. I feel like I've tried all the medications and there's nowhere else to go (currently on 30mg aripiprazole, 250mg lamotragine and 800mg lithium). My key worker has mentioned psychological therapy but I've had lots of therapy in the past so not sure if it will help or not (plus I'm sure it has long waitlists).

I also have a review with the psychiatrist in 3 weeks and he always asks me what I want to try but this time I have no ideas.

What your blood lithium levrel? My Consultant is moving mine from 0.6 to st least 0.8, as I’m having active moderate depression episode. It’s an official approach in NICE guidelines.

Sedation options (approach of previous consultant) didn’t address my sleep issues. This consultant has started me on melatonin for circadian rhythm issues (increasingly believed to be a significant factor for a lot of people with bipolar). Briefly mentioned in NICE guidelines but blink and you miss it. It has made such a difference. I’m having proper sleep. I am so much more rested in the mornings. It’s been painful as my brain and body start to function again. It doesn’t work like sedation and I still have night wakings if I’m anxious about something at bedtime. But I can fall asleep and get back to sleep and my sleep is actually restorative.

You don’t mention if sleep is a factor for you but it often is do people with bipolar.

My last one was in Dec and was 0.66 so I guess there's room to go up again. I'm just a bit scared of going toxic but at this stage I'll do anything to feel better.

That's interesting about the melatonin, I'm sleeping too much at the moment but I'll ask.

Really appreciate the reply.

I was in the past too but I’m so keen to feel better, I will increase my dosage if they agree. I am careful to make sure I drink 2+ litres of water a day.

I don’t know if circadian rhythm treatment like melatonin helps with sleep quality even if you’re sleeping more rather than less but it’s worth asking. It’s made such a difference to my life. I’ve been struggling on for 2.5 years since my first episode of hypomania and diagnosis.

I’m afraid I don’t know of any other treatment options. I have heard of electrolysis of course but don’t know anything about it in practice.

All the best with your appointments.

Do you do any sort of regular exercise? I’ve been diagnosed for 30+ years (on Lithium) and it was when I introduced regular running/ cardio classes into my life that I started to feel properly on top of things.

It’s interesting you’ve found this. I have not been able to exercise after an op and I have felt sure it contributed to me getting a depressive episode.

Could I ask have you been on lithium for 30+ years? I dread not being able to stay on it at some point in the future. Did you find you settled with the diagnosis over time? I’m still struggling a bit 2 years in.

I’m trying to do a home workout everyday alongside walking the dog but my motivation has gone so I’m barely working up a sweat. Will keep trying it though.

Do you get much opportunity to socialise? I can’t exercise on my own, I never have the ability to motivate solo. I go to a CrossFit gym - I’m older, fatter and thy know I’m unwell but not the details - they scale the class for me and everyone works individually., it’s a key part of my staying well plan.

Optimise lithium level, switch out aripiprazole for quetiapine or maybe lurasidone?

Ultimate most effective treatment is ECT if you can get it. TMS also pretty good (proper evidence base not quackery) but unavailable on NHS in most areas and expensive privately

Leftfield suggestion Flow TDCS headset has some RCT evidence and people have found it helpful plus completely non harmful and not a prohibitive price to buy privately.

Just to comment, ECT has worked really well for me in the medium but not long term. Not risk free either. My memory had been moderately impacted for the last ten years

To whoever was interested. Yes I have been on lithium for 30 years. Except when pregnant.

I spent my 20’s trying to understand who I was but at 50+ I’m pretty sure that sleep, exercise, Lithium and the odd glass of wine work to keep me mostly sane.

Thank you. I’m also in my 50s. But only diagnosed a couple of years ago. That’s an approach I would be happy to work with,

Id second the idea of switching out the aripiprazole for a different antipsychotic, as it's known to cause anxiety and agitation. Definitely something to ask about.

Also low dose aripiprazole is better for depression. 30mg is a lot if you are also on lithium and not psychotic.

My psychiatrist told me that people with bipolar should never be given SSRIs as they cause a high. I am only on lamotrigine but can go up to 400mg - I am sure that he told me that is a therapeutic dose, although some people settle down on a lower dose. I am then 300 now but usually increase it in winter, and I didn’t feel a big difference until I got to 300. Is it an NHS psychiatrist? Mine was private - on a credit card at the time I was diagnosed, which isn’t ideal but was worth every penny in the end as I was able to work and function again.

I also know someone else with bipolar who saw the same psychiatrist and he had quetipine added in the evening. I also have olanzipine as a PRN med, I forgot about that as I only use it for a short time if something happens and I go off kilter.

I had a teams meeting with my key worker today who then went and spoke to the psychiatrist about meds and he said no changes until he sees me in a few weeks. She encouraged me to think about psychological input and said as I was under them I shouldn’t have to wait too long. I’ve agreed to think about it and will let her know when we meet next week.

I do have some diazepam that she said to take if my anxiety gets too bad (often goes hand in hand with a down for me).

My key worker is lovely and said she’ll be keeping a close eye on me until I see the psychiatrist and that there were no plans to discharge me until I’m stable which is good as previously I’ve been discharged with new meds and no follow up until it’s gone wrong (again).

Quetiapine has made the biggest impact to my mood. I am more prone to depressions than high moods but had issues with antidepressants before where a single dose of one sent me from suicidal to cartwheeling down the road! I have been on doses between 300 and 800mg but found the best for me is between 400-600mg

My worst depression with psychosis was after I had my daughter and I found I was able to tolerate antidepressants now. I was on quetiapine, mirtazapine and sertraline which didn't help. I then dropped the sertraline and added in lithium when i went into hospital. This helped the psychosis at around blood levels of 0.6-0.8 but didn't help the depression until I reached 0.9. I then ended up at 1.2 after the weather warmed up so they dropped the dose of the lithium to get me back to 0.8-0.9 and added in lamotrigine. I also had therapy with my daughter (vig through the infant parenting service) and over the next year I recovered. The lithium moved my depression from being severe and treatment resistant to moderate and semi functioning and time and the therapy got me back to "normal"

I'm struggling again after the birth of my son and I'm on quetiapine and venlafaxine and just started mirtazapine. It's not shifting the low mood but it has held it at moderate depression and I've not experienced any psychosis this time around.

Has the quetiapine made you put on weight?

Very little. I have been on it since 2012. In that time I have gained about half a stone when i turned 30 and then another half a stone after I stopped breastfeeding my daughter. I think this was probably the lithium I was on as I had lost 1.5 stone breastfeeding and became quite under weight. Within 3 months of being on lithium and stopping breastfeeding I was back at a normal weight. 6 months later I was back at my pre pregnancy weight and then over another year I gained another half a stone. I lost this trying for my second.

It sounds really heavy right now. Tell your key worker honestly about your anxiety and intrusive thoughts. You don’t need solutions just explain how you feel and let them help.

All ADs made me go high apart from Agomelatine. It’s been amazing. It works on circadian rhythms/melatonin so is a completely different type of antidepressant. It’s not used much as it’s viewed as not having much evidence of effectiveness but it saved me from horrific depression.

Other than that im on quetiapine (very good), prochlerperazine (very good). Lamotrigine (somewhat helpful) and carbamazepine (somewhat helpful).

I’ve just started on melatonin. My urologist (who is a bit of a prick at all times) totally sneered at it. However it’s been amazing. Only been a few week but I can finally sleep well and deeply -sedation options (tried many types) made me not awake but I didn’t wake up feeling restored. I’ve been in a depression for such a long time and I can finally feel it lifting.

I tried melatonin from the USA but it didn’t help much, although I was in a bad way so it’s difficult to know for sure.

I’m spiralling. I saw my key worker on Friday who spoke to the psychiatrist and they upped my lamotragine but I’m feeling worse. I’ve missed deadlines because I just can’t concentrate and want to curl up in a ball and ignore the world. I’ve been thinking of refining my dog because I’m letting her down and that the DC would be better off staying with their dad at the moment. He had them for three weeks last time I was this bad and I don’t think I’d get them back if they went again.

I’m due to leave for work soon and I just feel dread. I’m planning on going in and sending an email I need to send then waiting for my boss to come in at 1pm and going home and getting signed off for two weeks to give me chance to come back up again and for the increased meds to work but I’m scared I’ll lose my job which I can’t afford to do. Last time I was this ill I resigned after 3 months being off but they took me back after 18 months with reassurances that I was well enough. The trustees (I work for a charity) were already reluctant to take me back and I just feel like I’m screwing everything up.

I slept on the sofa last night because I couldn’t cope with going upstairs to bed. I slept in my clothes and can’t face showering or eating so I’ll be going to work in dirty clothes feeling like shit.

I don’t know what to do.

@KurtCobainLover how are you this afternoon?