Rapid-cycling Bipolar II–what to do . . . what to do

Jeff writes in with a common problem . . . feeling kind of crappy on the medicine:

Hey doctordan, I was in counseling for 11 months. Blah.  The same questions over and over. Point being, I dont need to talk . Honestly. I’m a smart cookie. Now, ONTO the LAMICTAL I have been diagnosed with Bipolar II disorder with rapid cycling and panic disorder and anxiety. I am off in lala land now, What is that ? Is it the Citalopram, or lamictal .  I have no energy and I just feel blah.   Its kind of like I went back in time. To a point before I was ever treated. The question is this, do you think decreasing the dosage will have any great impact or will cause it to be worse, the citalopram makes me sleepy but not enough to sleep. BTW 150 mg lamictal and 40 mg citalopram. This whole illness hit in nov 2005 and is realy consuming my life and its pissing me off. Any help would be appreciated. This is affecting my ability to work, communicate with others. Its just crap. I need that special pill that grows a new brain… If you have any extra send them my way. PLEASE.

OOOOooooooohhhhhhhhhHHHHHH . . . you want the SPECIAL pill!   I’ve been holding on to that for JUST such an occasion!!!  Don’t I wish . . . (not as much as you, I know).

A couple of things come to mind here.  Let’s talk about diagnosis.  If you truely have a rapid cycling Bipolar II disorder, then I wonder about the medication approach that is being used.  Conventional wisdom is that rapid cycling is best treated with Lithium. ******EDITORIAL ADJUSTMENT*********  Lithium is NOT the best for rapid cycling, Depakote is.  Please see comments below************EDITORIAL ADJUSTMENT**********  Studies have shown that to be the most effective intervention for smoothing out the cycling pattern.  Not treating the depression, but just smoothing out the peaks and valleys.  Sometimes when we use Lithium, we end up with less of the ups and more of the downs in the mood cycle . . . leaving one to feel blah.  Sounds like you are already there.  Lamictal certainly has some mood stabilizing properties, but mostly for depressive symptoms and not for the hypomanic symptoms that are part of the definition of Bipolar II.  Can it work . . . sure.  But from your description, it doesn’t sound like it is.  Actually, your mood seems overly dampened down, like we can occasionally see with anti-manic mood stabilizers like Lithium.  Another area of concern is the high dose of the citalopram.  Again, conventional wisdom says antidepressants can promote mood instability.  In your vignette, all I hear is BLAH . . . depressed and flat.

Not knowing what you have been on in the past (clearly important information) I can only suggest generalities.  My guess is that the BLAH you have is from the Lamictal.  If I was your shrink, I would consider what my mood stabilizer options are and substitute.  Lithium, as mentioned above, is a good option if you have not been on it before.  Another option is Abilify . . . the overly expensive and highly advertized new-ish mood stabilizer.  Despite the hype . . . it actually is one of my favorites recently.  I have seen significant success in a good number of patients.  There is data showing it can enhance mood when given in combination with antidepressants (Prozac in the studies done) and will provide mood stability as well.  The process of switching you over to a new regimen should be slow . . . but not too slow if you are feeling crappy.  Perhaps adding the new mood stabilizer and lowering the Lamictal at the same time.  You will need to be re-assessed after a month or two to see how you are.

Another point is the therapy.  No matter how smart you are, therapy can be helpful.  Must be with the right person and the right approach must be used.  The trick is finding that right combination.  Don’t discount therapy altogether . . . that would be like giving up on marriage after a string of bad dates!  I always recommend asking friends or family that may have had contact with the mental health system in your area.  Another excellent resource is your family doc (they know who is good).

–Dan Hartman, MD

5 comments to Rapid-cycling Bipolar II–what to do . . . what to do

  • Reading your article renminds me all too painfully of our struggles to find stability and the correct medications for an individual. What works really well for one can significantly aggravate for another. Recent research over rules the previously held beleif that Lithium was not suitable fir Raid Cycling and it is now beleived taht tis is becuae it was given in combination with antidepressants such as Prozac, effexor etc. It apperas all antide[ressants are likely to switch spomeone into hypomania and mania and generally incrase their cycling and mood instability over time. This was the case with my partner. However since he was taken off his Lithium, whic by the way was at too low a dose to be fully effeective we ghave since discovered, and put on Depakote, this had some effect but not entirely. Every time anti ds were added or worse still Lamictal , he has ben worse than ever. lamicatal seems to have the smae hypomanic or manic or mixed state precititating effeect that anti Ds did, so positively hate the drug. He has been worse than ever ever time it is recommenced he is manic within days, so I would not recommend Lamictal at all and have not witnessed it having any mood stabilising effect, only mood destbilising effects. It only appears to alleviate the depression by substituting it with Mania. I would rather he tried Lithium again any day as he was far more reasonable on that, and maybe adding in Seroquel which would help the mania prevention and assist with acute depression for which it has been found to be very erffective in doses above 300mg / 400mg or more, but not less. Certainly Epakote and lamictal do not seem a good combination.

  • Passerby

    You’re wrong about lithium, it’s actually known to be less effective for rapid cycling. Lamictal, on the other hand has been shown to address rapid cycling effectively in many Bipolar-II patients. It is more effective at treating depressive episodes than manic episodes for rapid-cyclers however. Granted, Depakote is better than Lamictal from what I’ve read.

    Here is some reading material so you can get informed:


    “Treatment Options for Rapid-Cycling Bipolar Affective Disorder” (in Drug Information Quarterly)

    David Taylor and Denise Duncan


    “Many of those that do not respond to lithium treatment are rapid cyclers; indeed lithium’s poor efficacy in RC has long been known (Dunner & Fieve, 1974) and average treatment failure rates in RC may be as high as around 80% (Calabrese & Woyshville, 1995).”


    “The efficacy of lamotrigine in rapid cycling and non–rapid cycling patients with bipolar disorder”

    Bowden et. al. in Biological Psychiatry


    “Lamotrigine was generally effective and well tolerated in this group of previously non–responsive, rapid cycling bipolar patients.”

    Rapid cycling bipolar disorder: A new treatment option

    Trisha Suppes

    in Current Psychiatry Reports


    “Lamotrigine provided significant prophylactic mood stabilization in a large cohort of patients with rapid cycling bipolar disorder. A striking significant difference
    between medication and placebo consistent with sustained clinical improvement was observed in bipolar II patients.”


    “Treatment Options for Rapid-Cycling Bipolar Affective Disorder” (in Drug Information Quarterly)

    From Taylor and Duncan


    “Like carbamazepine, valproate in its various forms (sodium valproate, valproic acid, divalproex sodium) has been shown to be a very useful agent in bipolar affective disorder (Balfour & Bryson, 1994).”

  • Passerby–Thanks for the catch! Even docs can have periodic brain farts. Absolutely agree that for rapid cycling Bipolar, Depakote has been shown to be consistently superior to Lithium. Thanks for catching the error!

    –DH MD

  • I was introduced to Bipolar II and its suggested meds by psycheducation.org (you may choose to omit this website and that is fine with me).

    A couple weeks ago I went to a nearby clinic in Colorado that specializes in depression and all forms of Bipolar illness. Diagnosed as Bipolar II…I am 62 years old. I am now on a combination of Lamictal and Trileptal. By looking at the table of meds on psycheducation.org, it appears that the Lamictal is the mood stabilizer and the Trileptal is to help with both depression and the cycling.

    Since the newer forms of Bipolar illness are just being discovered and researched, it appears that there are a lot of folks being diagnosed. My friend who recommended this clinic, plus two more of our friends who aren’t going to the clinic, have all been diagnosed. All four of us also suffer from binge eating disorder. However, the other two friends docs prescribed only the Lamictal.

    A problem with many of the meds for depression and Bipolar Illness is weight gain. If someone already has an eating disorder, and possibly is overweight, or not wanting to gain weight, some of the meds are inappropriate.

    Dr. Dan, do you have any comments? Thanks.

  • Emily–

    I will briefly comment on medicines for Bipolar II that are less likely to cause weight gain: The mood stabilizers that help stabilize mood and prevent hypomanic symptoms include trileptal (which I like) and Geodon (which I don’t). Abilify is great but sometimes increases carbo craving and weight. For depression, Lamictal (which can also help with mood stabiliation) and standard antidepressants. Standard antidepressants should only be used in the presence of a mood stabilizer or else you risk going bonkers from the antidepressant.

    –DH MD