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Robert Marietta, MD
Robert Marietta, MD, Psychiatrist
Category: Mental Health
Satisfied Customers: 40
Experience:  Board certified in general adult psychiatry, former military psychiatrist
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I have been diagnosed with bipolar 1 disorder. I have been

Customer Question

I have been diagnosed with bipolar 1 disorder. I have been put on lithium carbonate - the tablets are called Piradel 400mg prolonged released. I was inititated on Dec 20 2010. I had blood test taken to check levels but as I live in the UAE, tests have to be sent to Germany and I am still waiting the results. I was also given Rivortril 0.5mg and was not told how often to take them. I was also on Cipralex 20mg and no guidance was given on how to come off this medication but had started decreasing the frquency of dosing myself in November as I felt I might be entering a manic phase. I have not taken a Cipralex for about a week. After a few days on Rivotril and Priadel I was feeling suicidal and contacted my local psychiatrist. I was then given Seroquel 25mg and told to take it once a day. I still had the Rivotril and was not guided whether or not to stop taking it. I have become extremely frustrated with the lack of guidance. Yesterday was the first day in weeks I felt normal. I took 2 doses of Seroquel 25mg , one in the morning and one at midday. I took the lithium carbonate 400mg as usual at night but I also took a herbal sleeping tablet containing ginger, valerian, hops etc. I have been on Seroquel for about 3 days. Today I feel excessively sleepy, agitated, am sweating, have increased apeptite and am feeling aggressive. I am so confused as so little guidance has been given with dosage of these drugs etc as well as the frustration in having to wait for this extended period for the results of the lithium levels. I have lost approximately 12Kg in the past month. I weigh about 50kg and when I last did a check on one of those monitors my body fat was at 0.5% below normal. It is more likely at 1% below now as I have lost more weight since. I am 42 years of age, am about 5ft 3. My blood pressure is also 160 / 90 and has been for some time but the doctors think best to leave it. I have had my thyroid, kidney, adrenal and cortisol levels checked. Also tested for diabetes. All tests have come back normal. What do I do? By the way, the psychiatrist has not told us that I have Bipolar type 1, I have not been asked to complete any testing nor have questions been asked of me or my husband. The diagnosis has simply been based on a referral from my GP. A previous psychiatrist diagnosed me as being bipolar by scratching my forearm! I was the put on Abilify 10mg plus Cipralex 10mg with the hope of withdrawing Cipralex 10mg. The Abilify made me feel terrible so he discontinued the Abilify 10mg and told me to continue with the Cipralex 10mg. I am a pharmacist by training but have not practiced in this area and have been raising children for the past 12 years so am not up to date but even I am absolutely overwhelmed as to what to do and am getting increasingly frustrated by the lack of due attention been paid by the current psychiatrist I am under. My husband supports this view.
Submitted: 6 years ago.
Category: Mental Health
Expert:  Robert Marietta, MD replied 6 years ago.
Lithium is the gold standard treatment for bipolar I disorder. It treats both mania and depression associated with the disorder. Generally speaking, the starting dose of Lithium would be 300 twice per day. It could be raised to 300 three times per day and then 600 twice per day. Lithium can be toxic so it is important to check the blood levels of the medication. Around 1.0 is considered a therapeutic level. A psychiatrist might prescribe a lower dose of the medication in certain clinical situations.

Cipralex is an anti-depressant also known as escitalopram. It is in a class of medications called selective serotonin reuptake inhibitors. Psychiatrists would avoid prescribing anti-depressants in a patient with bipolar I disorder because they could cause agitation and mania.

Rivotril is a sedative medication also known as clonazepam. Both Seroquel and Abilify are atypical anti-psychotics. The anti-psychotics are used primarily to treat psychosis but are also used in bipolar disorder. The sedatives and anti-psychotic medications are generally used for acute mania. Rivotril, Seroquel and Abilify could all cause sedation.

The psychiatrist should be available to answer calls in a timely manner according to ethical and professional standards.

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Customer: replied 6 years ago.
Hi. Thank you so much for your reply. I have researched much of this information myself and as a pharmacist, understand much of the information.
I have finally received my blood test result and have been informed to raise the dose to 1 and 1/2 tablets once daily i.e. 600mg Lithium per day. At the moment the lithium levels are at o.53 and the physician wants to get them to 0.7.
I have been advised to take 25mg Seroquel at night only.
Why am I being prescribed a once daily dose of lithium when the normal method is twice daily dosing? Would 0.7 be considered a therapeutic level of lithium? Is it normal to gradually increase the serum concentrations of lithium?
What about counselling? Is it not considered best practice to provide counseling alongside stabilization on medications? I have been oscilating between extreme aggression, agitation with associated sleep disturbances and extreme morbidity. Although the physician says we can call at any time and a call will be answered but this has not been our experience to date.
I will do as advised. i.e. take 600mg lithium once daly and 25mg seroquel. However, my experience to date has been that I am not stabilized and it is like a living hell.
Expert:  Robert Marietta, MD replied 6 years ago.
For acute mania, 1.0 is considered a therapeutic dose. Sometimes a lower dose might be used for maintenance therapy.

Seroquel can be used for psychosis or acute mania. It is mainly an anti-psychotic but considered to have mood stabilizing properties. The starting dose for Seroquel is generally 100 to 200 mg. It tends to be a sedating medication at the lower doses so it is taken at night. Seroquel is gradually incremented up to a maximum dose of 800 mg. It is common for patients with bipolar disorder to be treated with both a mood stabilizer and an anti-psychotic.

Psychiatrists commonly prescribe psychotropic meds in incremental doses to improve their tolerability.

Counseling and psychotherapy when given in conjunction with meds improves outcomes. Counseling might be especially effective when there is a specific identifiable overwhelming life stress such as relationship or work conflicts. Sometimes psychiatrists do both the psychotherapy and med management by themselves or they use a team approach where a psychologist or social worker does the counseling.

I am unsure about the question regarding the Lithium. There are a number of different forms of Lithium. I would refer to the pharmaceutical companies instructions about the dosing.

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Customer: replied 6 years ago.
Thank you for your reply. The information was very helpful.
I am frustrated with my current care for the following reasons:
1) When I informed the doctor that I had strong suicidal feelings, I was changed from Rivotril to Seroquel with no counseling. I have been given Seroquel 25mg and not Seroquel XR. I was told to take one tab at night. What I am finding is that when the effects of the Seroquel wear off, I start feeling agitated and sometimes aggressive - this is verbal not physical. I do not know whether I can attribute these feelings to a side effect of the Seroquel or whether the dosage is incorrect or whether this is just the nature of the illness? This leaves me feeling overwhelmed, desperately sad and frustrated.
2) I don't know whether I am suffering effects from sudden withdrawal of Rivortril and Ciprolex and whether this too is contributing to my moods and feelings.
3) I am terrified of taking the Seroquel and terrified of drug interactions. Last night, within minutes of taking the Seroquel 25mg, I had a head splitting headache and was too terrified to take Asprin or Panadol as I feel my body is being so over loaded with chemicals with potentially very bad side effects.
4) Although I feel that my doctor is very competent and conservative with prescribing medication, last night when she phoned me to tell me my lithium levels, we ended up arguing because I said I felt overwhelmed at the number of drugs being prescribed and she told me that I had insulted her. The last person on earth I need to be arguing with is my primary carer. Again this leaves me wondering am I such an awful person that I have turned into this aggressive beast that I can't have a conversation even with my psychiatrist without it degenerating into a heated discussion?
5) I am frustrated that no counseling has been offered because I think, if I was better informed as what to expect from the medications and the journey to stabilization, I and my family, may be better equipped to deal with the situation.
There is a book I read, entitled "A million little pieces" about a man who goes through alcohol rehabilitation. I feel just like that. Confidence shattered, self esteem shattered, levels of paranoia increasing and a sense of helplessness and extreme frustration and distress.
Can you point me towards any good reading material on bipolar disorder as there is so much information out there it is overwhelming?
Many thanks for your reply.
Expert:  Robert Marietta, MD replied 6 years ago.
Seroquel XR is viewed by many psychiatrists as a "patent extender" drug that has little benefit over the original Seroquel.

Patients need to have proper informed consent about treatments including medications. They need to understand the risks and benefits of each drug. The physician ideally would spend an adequate amount of time discussing the treatment plan before initiating treatment.

Do a Google search about "A million little pieces". It turns out it is a work of fiction.

Are there NAMI meetings in your area? That might be a better source of support rather than a book.
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Customer: replied 6 years ago.
There are no local support networks that I am aware of - I did search extensively yesterday but will check with the physician.. In addition, although the physician wanted to hospitalize me last week, there are no facilities here. This combined with the fact that it takes a minimum of 5 days to obtain resuls on serum levels of lithium make for an extremely frustrating situation.
I pointed you towards "A Million Little Pieces" as a reference book of the feelings people / patients in my situation experience but I have no doubt that you have had a phethora of practical experience in this respect - something I am completely lacking.
I think a book in my situation is going to be the best resource given the current geographic location.