switching meds

hello everyone. just had an appointment with my psych. he advises me to consistently take my current meds, lexapro and Abilify, and if I don't see improvement we'll switch. my options are Effexor, lithium, or lamictal which I've been on before. I don't know why but I keep thinking about going back on lamictal because it helped the rage when I was on it, and I know what it feels like, but it did make me kinda sad. I wasn't on an antidepressant with it so I don't know if that would help. Not sure what to do here. Part of me feels like getting off of everything but I don't think that's the best idea. thank you for reading

What are your symptoms mainly right now and how much does cycling and mania get in the way? I'm going to preface all this with stating everyone reacts to meds a little differently, but there are some general trends, and this is my experience and what I read from others.

Effexor is an antidepressant (like Lexapro) and they're not really supposed to be used for bipolar because of a significant risk of mania and rapid cycling. I took Effexor myself, and it worked really well to get me out of a depression, but then after a couple months I had another depressive episode, so they bumped up the dose and then I immediately went into some crazy mixed cycling stuff (over the five months I was on it, I had to get A LOT of medical treatment from self-harm, self-neglect, and a suicide attempt). It's also one of the hardest antidepressants to come off of for many (my IP doc wanted to put me in an Ativan coma for it).You're on Lexapro (an SSRI), and Effexor is an SNRI. SNRIs are thought to have a higher rate of causing elevated mood than SSRIs for people with bipolar, too. Just something to keep in mind. That being said, a lot of people with bipolar are on antidepressants and get some benefit from them, but it's important to have something that absolutely works for (hypo)mania.

Lithium was my favorite med I've been on. WAS. It worked so well but I wasn't compliant and got a three months supply and long story short my kidneys are wrecked now. It's gold standard for "classic" bipolar (euphoric manias, normal or hyperthymic temperament, longer periods of euthymia, not as many major comorbidities as "atypical" bipolar, later onset, etc.). A lot of docs aren't a huge fan of it though because of the lab monitoring and easy potential for toxicity if, say, you change your water, salt or caffeine intake.

Lamictal in my mind is an antidepressant that's somewhat safe for people with a history of mania. Less of a "mood stabilizer" (though that's what they consider it). When I was on it, my pdoc tried treating some hypomania by increasing the dose, and it didn't help at all. Definitely an underrated drug though if you're either one that it does work for the ups or if you have something else that covers that. Also titrating up is a bytch. A slow bytch.

You could try Lamictal again and see if it makes you sad this time. For me effexor and lithium were evil! Up to you though. Good luck!

@MuddyBoots I'm prone to depression and I usually run on the lower side but it mixes with rage and irritability in ways I can barely handle. If that makes sense. Lately I've been impulsive and self-destructive, keep going broke and giving into bad decisions like drinking. I have this feeling in my gut that Effexor will give me too much motivation and drive me wild lol. I experience hypomania but not mania so I feel like lithium may be too much for me. Also with my tendency to want to stop taking things I feel like I should be careful of that too. I feel like lamictal may be the best course of action for me if my current combination doesn't work. When I was on it I accidentally started on 100mg instead of the 25mg because of a pharmacy error, but thankfully I was fine. Thank you for your thoughts on this I appreciate your response.

@raspberrytorte Thank you for letting me know, I think that will be next my course of action

Nobody here can say, we’re not doctors. Plus we don’t know you or what your symptoms are. Or your history.

@Nammu I'm aware of that, looking for similar experiences or if anyone wanted to share

For some reason, while lithium isn't straight up considered first line treatment for depression, there is a lot of evidence for it lowering suicidal ideation if that's an issue for you.

I'm not at all a psychiatrist, but just for my $0.02 I'm gonna agree that lamictal would probably be your best bet, followed by lithium if we're just going for those three. I'd be afraid to put myself on an SNRI like Effexor if I were having increased impulsivity.

For curiosity's sake, have you ever been on antipsychotics other than Abilify?

Yeah. Effexor made me seriously homicidal. I had never been homicidal before and haven't been since. Had to get off that quick! I couldn't physically tolerate lithium. At just 300mg I could barely walk to the front door I was so weak and could hardly stand. Not good. Those were my experiences with the two. I've been on Lamictal for a long time (many years) and it's been nice to me.

They will no longer put me on lamictal because of non compliance, I got homicidal on effexor too.

@MuddyBoots I tried rexulti and vraylar briefly but not long enough and I didn't like how they felt. Vraylar gave me bad akesthesia. thank you again for your input, I am scared of Effexor and hearing everyone else's experiences on it makes me think twice because I really don't want something to give me more irritability.

@raspberrytorte I'm glad to hear that it has been working for you !! people respond different to all meds

@Victoria'smom thank you for sharing I'm thinking its best to steer clear of the Effexor and try others. did lamictal help you? I'm honestly glad my psych is still working with me due to how much I jump around from meds

I don't really know. I needed an AP with it and wasn't prescribed one.

Lamictal is part of my current med combo, and has been for over a year. This, combined with Wellbutrin, really helped me start moving towards stability. But, I also need an antipsychotic to help keep me stable. I'm really sensitive to ap meds. Risperidone is what I'm currently on, but it took a LONG time and a ton of trial and error with other meds before it.

I was probably my best, mentally, on lithium but my stomach couldn't handle it.

I am also prone to depression; Wellbutrin, at least for awhile, made a night and day difference. I don't think it's helping quite as much as it used to, but I am still very grateful for it. I think I'd be more depressed than I currently am, especially since I have some situational depression going on, without it. I can't take more than 150 mg though-a higher dose turned me into the hulk.

If you have trouble staying on meds lamictal might be an issue. If you miss 3 (?) doses in a row you have to start titrating up again and it takes weeks to go from the beginning to a therapeutic level. And as I understand it it's important not to just jump back on at a prior level it after a break because it can increase the risk of the rash. You'd need to talk to a dr about that as I only sort of know this but it would be something you'd need to commit to for best results.

I was told if I missed 2 days I had to call and start over

Good point. Although maybe that's a big reason to go for lamictal. At least for myself, stuff that is going to bite you in the asss if you're not compliant helps me be compliant.

thank you for all the additional insight. I do definitely need to be compliant. started taking Abilify in the morning instead of at night because of that. so now I'll actually be taking that and see how I do. feels like I have too many options in the air. I was on it before but went off because I was feeling too tired, low dose though

I'm bad. I've never titrated up on Lamictal. I always go straight up to 200mg. I was first put on it in the hospital and that's what they did, and I never developed the rash, so...

But don't be like me! I know I'm really not supposed to do that.

A guy friend on mine (more a penpal than a real friend: I have only seen him three times since I first met him over 15 years ago, but we are on email daily) with Bipolar II really needs Effexor to help with low mood, but he suffers from anhedonic ejaculation as a side effect. And that is a really bad side effect.

In women, I do not know if effexor causes sexual side effects. But apparently in men, it is known for that.

I think it can for women, but that was not my experience