[FluffyDinosaur]

These past few months I've had a really bad mixed episode. In the end it became unmanageable. I couldn't function at all anymore and I was quite suicidal. The lack of help due to covid-19 made it worse. Luckily my Pdoc was there and gave me Seroquel in addition to my Lithium (which probably wasn't at the right dosage yet either but should be now).


The meds work to the extent that they make the situation less overwhelming, but I feel like they are only suppressing some of the symptoms and leaving others. The despair is mostly gone and I'm able to function, but I still have this constant sadness, anger, anxiety, and above all this sense of meaninglessness and emptiness. I'm unable to enjoy anything. It makes every day seem like forever. I often want to go to sleep just so I can take a break from existing. I feel trapped in life. Sometimes it still makes me think of suicide, though not to the extent I had before.


I'm unsure whether this means I need to up my Seroquel dosage or whether these symptoms could actually be side effects from the medication. In that case upping the dosage could only make things worse. Any advice?

[Blissfullyme]

I take both lithium and seroquel. I don't think it would be a side effect of either of these meds, the symptoms you describe. For me it was the case that the seroquel needed increasing. Then I found that eventually (after a couple of increases) pretty much all of my symptoms were in check. I still have intrusive thoughts although they are much less frequent than they were and the voices still bother me at times but again, much less frequent than before. I am able to function a lot better.

[FluffyDinosaur]

@Blissfullyme: Thank you, that makes me more certain that these are indeed residual symptoms and not side-effects of the meds. I suppose that means increasing the Seroquel dosage is the logical option if things don't improve.

[bpcyclist]

In my opinion, this is not optimally treated depression. Neither of those meds (both of which I have been on or am on) is especially effective in treating bipolar depression, in my experience.

Despite the concerns about mania, which are real for many, effective treatment of bipolar depression does not infrequently require some kind of antidepressant. My pdoc likes Wellbutrin for his bp 1 patients. He states that he has not seen it induce mania in over twenty years of use. There are, of course, others as well. It works great for me. I have gotten manic on others, though.


Have you ever tried a light? Some patients really respond to them, too. Do you exercise aerobically? It has been shown to be as effective as medication in major depression, which is different, but still... Walking regularly? A bicycle? Running a bit?

Sending you hope and strength. Don't give up. Take some action. You will get better.

Love and hugs.

[FluffyDinosaur]

@bpcyclist: Thank you, that's valuable input. And that was my feeling as well, that these meds have done more to suppress the manic side of my episode than the depressive side. I'm grateful that they've at least taken away the despair, but the anhedonia and emptiness are still driving me crazy. I will consider asking my Pdoc to add an anti-depressant to the mix, although I'm always hesitant to add new meds.

When the episode was at its worst I completely stopped exercising and all other coping strategies. I'm starting again now, so hopefully that will help a bit as well.

[Blissfullyme]

I can't have antidepressants as they have induced mania before. Seroquel actually is indicated for and licensed for use in treating bipolar depression and at the right dosage has been effective for me. To found reference to studies that showed it was more effective than placebo with absolutely no risk of induced mania. I wouldn't think there is any harm in trying a dosage increase first before potentially adding another medication into the mix. I REALLY WANTED to when I was unwell. They would NOT give me antidepressants because they said it would induce mania again or even worse mixed state so I trusted my team. And im glad I did as I've definitely improved massively.

[FluffyDinosaur]

@Blissfullyme: I see what you're saying, and I've also read that Seroquel is approved for use in treating bipolar depression. I see the logic in using it as a fast-acting med to treat a mixed episode, especially since it also helps with manic symptoms. And indeed it has made the situation more manageable for me. I also see bpcyclist's point that an anti-depressant may be needed if the Seroquel is not enough. Even though Seroquel helps a bit, it may turn out that it's not the ideal med.

Whether or not a higher dosage of Seroquel will benefit me more is a matter of trial and error I suppose. I do like the idea of first trying to up the dosage of Seroquel before seeing about adding an anti-depressant to the mix. As I said I'm hesitant to try new meds, and I feel like this way there's a lower chance of new side-effects. If that's not enough I will definitely consider trying Wellbutrin or another alternative. In part it also depends on how this covid-19 situation develops and how quickly I can go back to my therapy sessions. I am really missing those quite badly in this whole ordeal. I feel like if at least that part of life goes back to normal, I could get by with fewer meds.

Hi FluffyDinosaur. It definitely is a matter of trial to see what works. In my case, Seroquel XR has been helpful for me for both ends of the mood spectrum, including mixed states. Sometimes an increase does the trick, and sometimes a decrease. It's funny how that works for me. I will say that I do also take a small dose of Lamictal in addition to my Seroquel XR and my moodstabilizer (Tegretol XR). The Lamictal has always been activating for me. Like many, I have had bad luck with antidepressants (including Wellbutrin), so depend on moodstabilizers more geared towards lifting my mood (like Lamictal). I remember about 9 years ago feeling exactly as you describe. My psychiatrist decided to add on the Lamictal, since he knew it had been activating in the past. Since Lamictal must be added slowly, from small doses, it was surprising for me to see that when I reached only 75 mg, that a positive change was happening.My psychiatrist then upped it to 100 mg, and I started to become hypomanic. Instead of reducing my Lamictal, he decided to increase my antipsychotic, and that seemed to make things "just right", like Goldilocks experienced.

My medication mix has changed a bit over the years. Actually, when I was put back on the Lamictal back then, I was also on Lithium and an antipsychotic. My current mix has been in place for a long time now. For several years, the only medication adjustment I have had was the dosages of my Seroquel XR. Up and down. Up and up and up and down. Up and down. Up and up. It's worked out well!

I'd like to add another thing. I firmly believe that after a series of episodes, or a particularly severe episode, the brain needs time to heal. Sometimes medications alone cannot do the trick, or at least not for a while. It takes various strategies to heal the brain again. Therapeutic strategies help. Exercise. Healthy eating. Pushing oneself to slowly do more and more.

I don't really like the expression "Fake it Till You Make It", but there is something to that, in terms of building up endurance and "clearing the clouds away". A person that injures their legs cannot immediately run a marathon. It takes recovery exercises and effort, a little more at a time, to build back up to marathon abilities. No one debates that for physical injuries, but many don't see the same need for psychiatric injuries.

Hi FluffyDinosaur!

So sorry to hear you are feeling so bad.

As for meds, Wellbutrin and Celexa catalyzed hypomania for me. This is different from saying they induced it. What i mean is that i was ripe for an episode of hypomania being that it was Spring or Fall. Those are my regular times of year for hypomania. The anti-depressants just ignited the hypomania. Otherwise i might have skipped it. I didn't really mind. The risks associated with the depression were greater than the risks associated with hypomania.

Perhaps it would be helpful to weigh the risks?

It does make sense that you want to try something. It sounds like you're really suffering. Increased Seroquel only gives me akathisia. I'm only on 100mg. It makes me sleep soundly, tho it gives me crazy dreams. I feel it also prevents my hypomanias from escalating and improves my recovery-time.

Anyways, that's all about me. Sorry you are feeling so rotten. You seem very caring and considerate and don't deserve that. Did you say once that you have schizoid? If that was you, you sure are doing a good job of managing it. You're one of the most pleasant people here!

[FluffyDinosaur]

Originally Posted by BirdDancer

Hi FluffyDinosaur. It definitely is a matter of trial to see what works. In my case, Seroquel XR has been helpful for me for both ends of the mood spectrum, including mixed states. Sometimes an increase does the trick, and sometimes a decrease. It's funny how that works for me. I will say that I do also take a small dose of Lamictal in addition to my Seroquel XR and my moodstabilizer (Tegretol XR). The Lamictal has always been activating for me. Like many, I have had bad luck with antidepressants (including Wellbutrin), so depend on moodstabilizers more geared towards lifting my mood (like Lamictal). I remember about 9 years ago feeling exactly as you describe. My psychiatrist decided to add on the Lamictal, since he knew it had been activating in the past. Since Lamictal must be added slowly, from small doses, it was surprising for me to see that when I reached only 75 mg, that a positive change was happening.My psychiatrist then upped it to 100 mg, and I started to become hypomanic. Instead of reducing my Lamictal, he decided to increase my antipsychotic, and that seemed to make things "just right", like Goldilocks experienced.

Thank you, BirdDancer! It's very useful to hear all these experiences and get a better idea of all the options I have. Something activating does sound like it might be useful in countering these symptoms, so Lamictal is definitely something I will discuss with my Pdoc.

Originally Posted by BirdDancer

I'd like to add another thing. I firmly believe that after a series of episodes, or a particularly severe episode, the brain needs time to heal. Sometimes medications alone cannot do the trick, or at least not for a while. It takes various strategies to heal the brain again. Therapeutic strategies help. Exercise. Healthy eating. Pushing oneself to slowly do more and more.

I don't really like the expression "Fake it Till You Make It", but there is something to that, in terms of building up endurance and "clearing the clouds away". A person that injures their legs cannot immediately run a marathon. It takes recovery exercises and effort, a little more at a time, to build back up to marathon abilities. No one debates that for physical injuries, but many don't see the same need for psychiatric injuries.

I strongly agree about needing time to heal. The whole thing has been (and still is) exhausting. I'm trying to focus on some projects that I've wanted to do for a while now, hoping that it will make me feel more positive. But I'll keep that part about healing in mind when I get frustrated about lack of progress.

[FluffyDinosaur]

Originally Posted by whatever2013

Hi FluffyDinosaur!

So sorry to hear you are feeling so bad.

As for meds, Wellbutrin and Celexa catalyzed hypomania for me. This is different from saying they induced it. What i mean is that i was ripe for an episode of hypomania being that it was Spring or Fall. Those are my regular times of year for hypomania. The anti-depressants just ignited the hypomania. Otherwise i might have skipped it. I didn't really mind. The risks associated with the depression were greater than the risks associated with hypomania.

Perhaps it would be helpful to weigh the risks?

Thank you, and that's a very good point. To be honest I really like being hypomanic, so having that as a side-effect would not be a bad thing to me. My Pdoc would probably disagree with that, but I think he feels safe giving an anti-depressant a try as long as I'm on Lithium. The downside of adding another drug would be the risk of other side-effects.

Originally Posted by whatever2013

It does make sense that you want to try something. It sounds like you're really suffering. Increased Seroquel only gives me akathisia. I'm only on 100mg. It makes me sleep soundly, tho it gives me crazy dreams. I feel it also prevents my hypomanias from escalating and improves my recovery-time.

It sounds like your experiences with Seroquel are very similar to mine. I also sleep very soundly (much more soundly than I've ever slept) and get these weird dreams. I kind of feel like it's helping me think creatively in the period of time just before I go to bed. I had a bit of akathisia when I started, but that has since gone away. I definitely would not like for that to come back. I think there's a fair chance it will because I appear to get a lot of extrapyramidal symptoms from both the Lithium and Seroquel (tremors, clumsiness and such).

Originally Posted by whatever2013

Anyways, that's all about me. Sorry you are feeling so rotten. You seem very caring and considerate and don't deserve that. Did you say once that you have schizoid? If that was you, you sure are doing a good job of managing it. You're one of the most pleasant people here!

Thank you, I'm glad you think so! I do have schizoid features, but I still try to be friendly. I also find written communication to be easier than the spoken word.

[*Beth*]

Originally Posted by FluffyDinosaur

@bpcyclist: Thank you, that's valuable input. And that was my feeling as well, that these meds have done more to suppress the manic side of my episode than the depressive side. I'm grateful that they've at least taken away the despair, but the anhedonia and emptiness are still driving me crazy. I will consider asking my Pdoc to add an anti-depressant to the mix, although I'm always hesitant to add new meds.

When the episode was at its worst I completely stopped exercising and all other coping strategies. I'm starting again now, so hopefully that will help a bit as well.

I am prone to vicious mixed states. At one point 18 months ago I fell into the worst depression I've ever experienced. My pdoc prescribed Pristiq. I had very little faith in it, but along with Lamictal and and AP the Pristiq was a miracle. It pulled me out of the depression within a week or so.

I realize that some with BP cannot take antidepressants. For those of us with predominant mixed states, however, I believe an antidepressant is often helpful - as long as we are also taking the other meds. That feeling of being "half treated" (mania gone, but depression still hanging around) is the worst feeling, to me.

[FluffyDinosaur]

Originally Posted by BethRags

I am prone to vicious mixed states. At one point 18 months ago I fell into the worst depression I've ever experienced. My pdoc prescribed Pristiq. I had very little faith in it, but along with Lamictal and and AP the Pristiq was a miracle. It pulled me out of the depression within a week or so.

I realize that some with BP cannot take antidepressants. For those of us with predominant mixed states, however, I believe an antidepressant is often helpful - as long as we are also taking the other meds. That feeling of being "half treated" (mania gone, but depression still hanging around) is the worst feeling, to me.

Thank you for sharing your experience! I completely agree that the half-treated feeling is awful. I've had a lot of mixed states these past few years, so perhaps that means an anti-depressant would be good to try. The depression being over in a week sure does sound tempting. I've decided to first try upping the Seroquel, but if that doesn't work I'll definitely discuss these other options with my Pdoc.