Darkeyes - Now you know that I don't mind answering questions, especially for someone as nice as you .

I have a slightly different take on the refractoriness of lithium after stopping and restarting. The latest studies show that there is decrease in efficacy when one returns to lithium after stopping, in most cases. I'll try to explain why some people do not respond to lithium after stopping it.

I believe that one's response to lithium may be predicted by the onset of the bipolar disorder, the type of bipolar disorder one has, and the number of manic episodes one has experienced. A positive response to lithium can be correlated with an early onset (<25 years old), classic Type I bipolar disorder (full blown manic episodes, followed by depressive episodes), and fewer than 7 to 10 lifetime episodes.

I believe that many of the studies that reported refractoriness to lithium upon rechallenge may be explained in terms of the number of previous manic episodes the study participants had experienced. First, most of these studies used retrospective chart reviews of hospital records. The results of retrospective studies need to be understood within the limitations of such studies. Patterns that arise in such studies (eg. a number of patients did not respond to lithium upon rechallenge) can do so without there being clear causes and effects being evident (or controlled for).

A more likely explanation for the refractoriness to lithium upon rechallenge, which may not have been evident in all of the hospital records, is the exact number of previous manic episodes one has experienced. It is a well-studied fact that "kindling" more than likely occurs in bipolar disorder (and probably also occurs in unipolar depression); every manic episode kindles the next. This means that, with every episode experienced by an person with bipolar disorder, subsequent episodes will occur progressively closer together, be more severe, and last longer. In the days before mood stabilizing medication, some people would have episodes (both manic and depressive) lasting years, and causing total debilitation.

Mood stabilizing medication (lithium, valproate, carbamazepine, lamotrigine, topiramate, etc.) interferes with the kindling, and lengthens the time period between episodes. This decreases the total number of lifetime episodes one experiences, thus decreasing the potential for the eventual increased severity of the bipolar disorder.

Yeah, yeah, now I will answer the question .

People who have had more than 10 manic episodes do not seem to respond to lithium as well as those who have had fewer episodes. The studies that showed subsequent lithium refractoriness upon rechallenge were obviously done in acutely sick individuals (ie. they were hospitalized), who also had had bipolar disorder for a fairly long time. Hospital charts may not accurately reflect the number of episodes one has had. For instance, many people who are eventually diagnosed with bipolar disorder experience 2 or 3 (or more) manic or hypomanic episodes before they are formally diagnosed.

Not taken into account by most of these retrospective studies was the total number of episodes each participant had experienced, and more importantly, the number of episodes suffered between stopping the lithium and restarting it again. It is likely that many of the participants in these studies had become refractory to the lithium while taking it the previous time (or why did they quit taking it) and it is reasonable to assume that they had one or more episodes of mania before retrying the lithium, pushing them past that 7 to 10 lifetime episodes range. This could have resulted in them being more refractory to the effects of lithium in the current trial of the drug, than they had in the past.

Although I do not know the full story of your "freak-out" (eg. symptoms, extenuating circumstances, etc.), I would think that any amount of freaking-out is justifiable when finding out about spousal infidelity (but that is only in my opinion). As you know, cheating within a monogamous relationship is not something that I back, as a rule. I am surprized that your husband still has intact testicles.

Topamax™ (topiramate) is usually used only as an "add-on" (ie. adjunctive) mood stabilizer. It's use as a monotherapy is being debated. It is far more effective when used with lithium, valproate, or one of the so-called atypical antipsychotics. My suggestion would be to try adding it to the lithium, first. Ask your doc about this. You still have the potential of losing weight with the litium/Topamax combination.

Something that I am totally against is self-medication for psychiatric conditions (even by, or especially by, pharmacists and psychiatrists). There is no way that one can objectively assess (in a clinical manner) one's own change in mood &/or cognitive states. Self-medication can be, at least, very dangerous and, at most, crippling or deadly (even when you think you know what you are doing).

Yes, there are pharmacies in Europe and South America that will send you medication without a prescription. However, I have not heard of any that will send prescription diet pills (or other controlled drugs, or narcotics). Also, the FDA in your country (and Health Canada, in mine) have cracked down on this practice. They will (may) seize your medication at the border (especially meds like diet pills). I know that if you import medications into Canada, you better have a doctor's order (ie. prescription) for them, or Customs will not let you have them. They will also enter your name into a computer and anything that you import will be automatically flagged, resulting in every one of your packages being opened. Not that this would bother me; it is just that it slows down getting the order by a day or two.

I hope that this is of some help.
Lovingly yours - Cam


<font color=orange>"Sometimes you may be shown the light in the strangest of places, if you look at it right"
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