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Is Lithium safe to take for depression?

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Posted on Thu, 19 May 2016
Question: Dear Sir
As a student I used to be very studious,ambitious and hardworking with excellent memory and cheerful disposition along with excellent grades.My first Major Major Depressive episode occured 22 years back (i.e in the the year 1993) while doing my masters in engineering.
followed by recurrent depressive (unipolar) episodes(much milder than first one) at various points of time. I am on Flunil 40mg for most of this period.
The symptoms are as follows during first major depressive episode/attack and later period of time.
During First episode
severe numbness/blankness of brain, unsteady walking ( balance related) problems, anhedonia,complete lack of emotions/feelings(blankness),severe stiffness in neck region(tics),headaches, tremondus physical fatigue,severe fatigue,loss of erections,severe memory impairment(nothing used to get registered and retained in brain), slow thinking,reflexes,excessive sleepiness,lack of motivation etc.
My mood is always depressive, lot below the base line , I never had any manic episodes.
My current medications are as follows
Morning-B12- Methyl cobal amine -1000 mcg
After Breakfast-Flunil 60mg and Buspar 10mg
After Lunch-Amisulpride -50mg, Evion 400 (2 caps)
After Dinner-Lamictal 200 mg

The usage of Lamictal since last Four months helped me to some extent in slightly elevate/stabilising the mood and improved fatigue condition, but still lot need to be improved.
The current major problems are
1-Lack of normal or elevated mood,(dullness throughout the day) but better than earlier i.e before using Lamictal
2-Lack of motivation
3-Laziness
4-Anhedonia(No pleasure in activities I used to enjoy earlier),
5-cognition problems i.e Severe memory impairment (register, retention and recall)
6-Lack of normal erections and libido

Mild improvement in mood and fatigue levels are observed after introduction of Lamictal, but after some time, now no further improvement in mood , it is almost flat even though I am continuing with maintenance dose of Lamictal-200mg.

My doc advised me to add Lithium SR 400 twice daily (morning and evening) to current medication for further improvement in mood and depression levels.
I am very apprehensive about adding Lithium because of its severe side effect profile I read in several articles on net.
Considering my long duration (22 years) depression problem.

Kindly advise me whether go for addition of Lithium 400 as advised or anyother mood stabiliser or medicine (as Lamictal helped me more than flunil wrt to mood and fatigue symptoms) with less side effect profile along with Lamictal . Pls suggest any change in current medication also, if required.

Regards XXXXXXX XXXXXXX
doctor
Answered by Dr. Chintan Solanki (2 hours later)
Brief Answer:
lamictal can be increased or Desvenlafaxine or mirtatzapine can be added

Detailed Answer:
Hello Mr. XXXXXXX

Thanks for writing to me directly.

I read your query twice and understood your concern.

Considering overall history and improvement with lamictal, my first choice will be increasing dose of lamictal up to 300 mg.

Your doctor is also right as lithium us used in resistant depression and helps in cognition also. Lithium has side effects but it is not so serious what you read. Thousands of patients are stable on lithium since many years. Just one needs to consult doctor regularly and does the serum lithium level regularly. However I do not recommend lithium at this point.

Before that if I were your treating doctor, I would like to add Desvenlafaxine or Mirtazapine as they are antidepressant medicines with different mechanism of action from fluoxetine. These medicines do not cause sexual side effects and that is major advantage. In your case depression as well as fluoxetine are responsible foe sexual problems. For erection you can ask your doctor for sildenafil or tadalafil on required basis before sex.

In resistant depression Thyroid and vitamin B12 level should also be checked. Their deficiency may be responsible for memory and body symptoms. If you have not been tested for the same please go for thyroid hormone profile and serum Vitamin B12 level.

Instead of amisulpride I prefer quetiapine.

Other molecule which can later be added if no improvement and not used in past is imipramine.

I also prefer ECT in few patients to improve effects of medicines. It is very safe and specifically no side effects.

Simultaneously you should go for psychotherapy like CBT - Cognitive behavior therapy. CBT is specifically used to correct automatic thoughts and distorted cognition. In CBT psychiatrist/psychologist helps person to identify his/her automatic thoughts and faulty behavior which would ultimately be modified by person with active efforts and help of therapist. It also includes time management, daily sleep, meals and exercise timing.

You can discuss above aspect with your treating doctor and modify the treatment.

Hope I have answered your query, I will be happy to help further.
Regards,
Dr.Chintan Solanki.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Chintan Solanki (13 hours later)
Dear Sir

Thanks a lot for your detailed reply.Infact I contacted you directly because I read replies to some of your answered questions, which I felt very rational and scientific.

As you suggested I would like to increase my lamictal dosage to 300mg.
1-Pls let me know can I increase the dosage to 300 mg from my current 200 mg dosage (200 mg I am already using since last two months) or in multiples of 50mg required? Shall I add this 100 mg to already 200 mg currently taking at Night or as morning dosage? in divided doses

2-Regarding Mirtazapine pls let me know 1- what is the starting dose 2- on wards dosage and increase intervals,3- brand name of the tab to be bought from chemist shop, 4- At what time it is to be taken day or night etc.

3-Desvenlafaxine-Earlier I tried for 2 weeks without much success, thats why I want to go for Mirtazapine.

4-Amisulpride currently I am not finding much improvement even though it does nt have any side effect profile or sedation etc(i.e with least side effect profile)
So I want to switch to is quetiapine as advised.
Pls let me know 1- what is the starting dose 2- on wards dosage and increase intervals,3- brand name of the tab to be bought from chemist shop, 4- At what time it is to be taken day or night etc.

5- Initially I had Vitamin D and B12 deficiency thats why I am taking 1000 mcg , in my recent tests both are at normal range still I am continuing with B12 dosage of 1000 mcg. My thyroid profile is normal.

My intention is to have long term consultation with you online to update and monitor the progress in regular intervals as I trust your judgements.
Regards XXXXXXX XXXXXXX






doctor
Answered by Dr. Chintan Solanki (2 hours later)
Brief Answer:
increase lamictal stepwise

Detailed Answer:
Hi,

Thanks for follow up and positive feedback of my service.

Ans 1: If I were your treating doctor I would like to add 50 mg lamictal in morning and after 10 days more 50 mg. Overall 100 mg in morning and 200 mg at night.

Ans 2: Mirtazapine should be started with 7.5 mg. It may cause some sedation so it is given in night dose routinely. After 20 days it can be increased to 15 mg.
For brand names, you can ask your treating doctor for prescription.

Ans 3: It is ok. However with 2 weeks duration we cannot confirm that it is not working. I usually wait for 4 weeks.

Ans 4: Quetiapine should be started with 25 mg dose. Every 10 days according to response increase 25 mg up to 100 mg. Initial start with night dose. After 50 mg sustained release preparation is available which can be taken in daytime to prevent sedation. you can ask for brand name and prescription to your doctor.

Ans 5: Ok that is good. If you have sufficient vitamin B12 level no need to take it daily. Instead I recommend multivitamin like Felicita od, Nuhenz, Nervone forte or Rechamp gold daily once a day after meal for 20 days.

Feel free to discuss further.

Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Chintan Solanki (7 hours later)
Dear Sir

Thanks for the prompt and detailed reply

I would like to share the following points for more clarity
1- I never had any manic or aggressive symptoms it is always low mood since my first occurance of Major Depressive Episode in 1994 (22 years back) that persited all the time

2-All these years my Major problem is constant low mood and memory related (cognition) issues and severe body fatigue and pain in legs

3-After the start of Lamictal 4 months back it has helped me to a great extent in improving body fatigue symptoms and leg pains with marginal lift in mood (20% upwards)

Along with this I had anxiety symptoms (like biting nails ,licking lips, internal stress etc) un knowingly even though they are not effecting me personally .I am currently taking buspin 10mg.I prefer buspin because it is non sedating and non addictive unlike others. Do you think increase in dosage of Buspin or switching to any other medication does help?
Pls advise
Regards XXXXXXX


doctor
Answered by Dr. Chintan Solanki (5 hours later)
Brief Answer:
yes buspin can be increased or add  L-theanine

Detailed Answer:
Hi Mr. XXXXXXX

Sorry for delayed response.

1. Yes you made it clear that there is unipolar depression, not bipolar depression.

2. Depressive symptoms with somatic symptoms are there.

3. Lamotrigine helped you, that is why I recommended to increase the dose.

Other symptoms are anxiety symptoms. Yes you are right rather than using benzodiazepine buspin is good option. Increasing dose of buspin up to 20 mg by increasing 5 mg in two steps may help in these symptoms.

Recently one molecule cum supplement L-theanine (Thealife - 100 mg) has shown to improve stress and mild routine anxiety. You can add this to your current regimen. I have used in 2 patients until now. One is improved and other had stopped due to sedation.

You are welcome to clear your doubts if any.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Chintan Solanki (11 hours later)
Thanks for the reply sir.
1-I would like to know whether Thealife will be available in regular chemist shops
or is it to be separately ordered ? pls let me know

2-Today I hv taken 50mg Lamictal in the morning to start with rest i.e Mirtazapine and Quetiapine I may start gradually
Regards XXXXXXX
doctor
Answered by Dr. Chintan Solanki (2 hours later)
Brief Answer:
you should ask chemist to bring it for you

Detailed Answer:
Hi,

1. Thealife is product of sun pharma. You can ask your chemist to bring it for you.

2. We hope there will be further improvement after modification in treatment.

Let me know your progress.

Good luck and take care.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Chintan Solanki (17 days later)
Dear Sir

In continuation to my last interaction with you on 14 Feb 2016, I have upped Lamictal from 200mg to 300 mg .

Regarding Mirtazapine I took 7.5 mg for few days but it made me very very drowsy, so I could not continue the same.

1-So do you advise me to start -Desvenlafaxine or any other medication without much sedation effect in place of mirtazapine. If so in what medicine, what dosage and what time? pls advise.

2-Increase of Buspin to 20 mg from 10mg is helping me with anxiety

3-I kept the Quetiapine on hold as I got a doubt that can it be taken along with amisulpride 50mg currently I am taking or can I start this after abruptly stopping amisulpride as it is a minimum dosage. pls advise.

4-I have studied lot of side effects about quetiapine , and sedation effect I am very apprehensive.Both my parents are diabetic, even though I am not currently diabetic whether the use of quetiapine may trigger diabetes early as a side effect. Pls let me know and advice accordingly.
Regards XXXXXXX
doctor
Answered by Dr. Chintan Solanki (3 hours later)
Brief Answer:
armodafinil is good option

Detailed Answer:
Hello Mr. XXXXXXX

Thanks for writing back.

1. Bupropion is another medicine you can start instead of Mirtazapine. You can start in 150 mg dose and can increase up to 300. You have already tried desvenlafaxine though for less period. I would prefer it as second choice after bupropion to replace mirtazapine. In case no response to bupropion we can later on start desvenlafaxine.

2. Continue buspiron in 20 mg dose.

3 & 4. Considering side effect like sedation and your symptoms of sad mood I recommend starting armodafinil (waklert) for elevating mood instead of quetiapine. At 100 mg dose quetiapine is not causing much weight gain and diabetes like side effects and especially when proper precautions taken. If I were your treating doctor I would not like to start quetiapine at this stage.
Feel free to discuss further.

Above answer was peer-reviewed by : Dr. Naveen Kumar
doctor
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Follow up: Dr. Chintan Solanki (18 hours later)
Dear Sir
Thanks for the reply
1- Ok Sir, Pls let me know initially start with 150mg and after how many days I can increase the medicine to 300 mg and also what time I need to take the same.
2-Regarding armodafinil pls let me know the starting dose and increments upto what dosage can be allowed .Time interval in between starting dose and increasing dosage.
Whether to be taken day time or night time.
Regards XXXXXXX
doctor
Answered by Dr. Chintan Solanki (14 hours later)
Brief Answer:
armodafinil in morning

Detailed Answer:
Hi,

I am sorry for delayed response.

Bupropion in XL form 150 mg should be used.It can be taken at any time of the day. After 5 days if drug is tolerated we can increase the dose by taking it twice a day. Headache, dry mouth, agitation, dizziness are common side effects and can go away in 2-3 days if at they occur.

Armodafinil should be started in 75 mg dose in morning. And after 2 weeks depending upon response dose can be increased up to 150 mg and that is also single dose in morning.

Both are prescription drugs so your treating doctor can give more information while you take prescription.

Take care dear.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Chintan Solanki (3 days later)
Dear Sir

Thanks for the reply and I would like to to share this problem I m facing since long .
During night sleep I am having this problem of involuntary arm and leg movements and also shouting loudly and talking incoherantly in sleep etc.My partner complains me of this problem
when she wakes me up during that time I stop doing this ,again after some time I will continue this. This is particularly emberassing while sleeping among relatives at times.
Especially this is more sever and pronounced when I miss or change the dosage of fluexotine or anyother psychotic medication.

Kindly advise whether all this is due to Fluoxetine action on brain? What is the remedy for this?

Regards XXXXXXX
doctor
Answered by Dr. Chintan Solanki (4 hours later)
Brief Answer:
it may be side effect of fluoxetine,benzodiazepine will help

Detailed Answer:
Hi,

Thanks for asking your query.

Involuntary arm or leg movements can be part of restless leg syndrome (RLS).It is possible side effect of fluoxetine as well as other anti-depressant drugs. This is a part of parasomnia disorder category (disorders related with sleep). Talking in sleep is also part of parasomnia. It can happen normally, during stress or may be side effect of drug.

To confirm that this is drug induced we need to check for other common causes as well as to check the timing of occurrence is correlated with medicine initiation or not. Exact mechanism by which fluoxetine or other drug causes this side effect is not known, but most of the anti depressant medicines affect sleep pattern and sleep stages and that is why they are playing a role.


Brief description of RLS:
Restless leg syndrome (RLS) is a neurological/psychological disorder.
Treatment depends on finding out the cause. In few cases there is no specific abnormality and sometime patient does not respond to one drug and we need to give multiple medicines.
Following investigation should be done:
-     Iron levels, Ferritin, Transferrin saturation, Total iron binding capacity
-     CBC
-     Blood urea nitrogen (BUN)
-     Creatinine
-     Fasting blood glucose
-     Magnesium
-     Thyroid-stimulating hormone (TSH)
-     Vitamin B-12
-     Folate
-     Electromyography and nerve conduction studies
-     Polysomnography


Treatment of RLS include the following:
Medicines:
Dopaminergic agents
-     Benzodiazepines
-     Opioids
-     Anticonvulsants
-     Presynaptic alpha2-adrenergic agonists
-     Iron salt
Nonpharmacologic treatment
-     Sleep hygiene measures
-     Avoidance of caffeine, alcohol, and nicotine in patients with mild RLS who are sensitive to these substances
-     Discontinuation, when possible, of medications that cause or exacerbate RLS, such as selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinepherine reuptake inhibitors (SNRIs), diphenhydramine, and dopamine antagonists
-     Exercise
-     Physical modalities before bedtime, such as a hot or cold bath, whirlpool bath, limb massage, and vibratory or electrical stimulation of the feet and toes.

In your case I think we can add low dose clonazepam at night before sleep. Later on we can reduce the dose of fluoxetine if is sure culprit.

To clarify,

- You should undergo required investigations mentioned above.

- Are you aware about movements and do you feel discomfort in sleeping?

- Is this problem started after starting medications only?

- Is there any family history of such problem?

Take care.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Chintan Solanki (1 hour later)

Dear Sir

Thanks for the detailed reply

As advised, Pls let me know the dosage of clonazepam to be taken at Night before sleep.

1- Are you aware about movements and do you feel discomfort in sleeping?
Ans:
I am not aware of the movements but some times I realize when my wife wakes me up abruptly while I shout and talk some thing incoherently while in sleep. I don't find any discomfort in sleeping
but when I woke up in the morning I don't feel fresh and energetic, still I feel drowsy (may be because of quality of sleep is poor because of these sleep talking and movements )
2-- Is this problem started after starting medications only?
Ans: Yes, I am 100% definitely sure this problem started after initiating fluoxetine only but since I am dependent on flunil since last 20+years and could no taper I could hardly do anything about this.

My most predominant problem is sleep talking in coherently and loud shouting rather than body movements as they disturb everyone around.

3-- Is there any family history of such problem?
Ans: No such family history.

4-Six Months back I got almost all the tests mentioned
except Electromyography and nerve conduction studies and Polysomnography

and they are in normal range. If you want me to get it done those tests again I will get it done shortly.

5-I would also like to share the effect of lamictal in lifting the mood is slowly flattening out without further improvement in my depression levels unlike earlier when I started this medication. Pls advise
Regards XXXXXXX



doctor
Answered by Dr. Chintan Solanki (16 hours later)
Brief Answer:
no need to go for tests again, ECT is good option

Detailed Answer:
Hi,

Thanks for information. Sorry for delayed response.

You have narrated information well and there is no need to go for testing again. However polysomnography is useful investigation to diagnose sleep disorder. You can go for it to have better idea what exactly is going on.

Sleep talking in general is common parasomnia. It occurs during fever, stress or may be side effect of medicines due to disturbed sleep patterns.
It is not serious side effect. Only problem is it affects sleep of partner or others who are sleeping around.
Clonazepam in dose range of 0.5 mg to 2 mg or zolpidem 10 mg can help to treat this symptom. Ask your treating doctor to write suitable option for you as these are prescription drugs.


Considering your overall history I recommend ECT - electro convulsive therapy at this stage rather than giving more medicines. It is very safe and specifically no side effects like those of drugs. It helps medicines to be effective and lift your mood. You can discuss this suggestion with your doctor and go ahead.

Take care dear.
Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Chintan Solanki (3 days later)
Dear Sir

Thanks for the advise.
I started with 0.5mg Clonazepam at night for parasomina as advised.

Before trying for ECT I would like to share the following
Initially during Major Depressive episode I was on Flunil and Demolox for sometime. I felt Demolox worked well during that time but later I had to discontinue that as I moved out from that place and was not in contact with that doctor. Is there any equivalent medication with least side effects.

Initially you mentioned Imipramine is one molecule that can be added later if regular medicines does not work. Do you think adding imipramine or Demolox(equivalent molecule) will help at this stage? One more molecule that I read recently was Moclobemide
(Reversible MOAI. I would like to try any of these options if you think they are safe and can be tried. Pls advise.

Regards XXXXXXX
doctor
Answered by Dr. Chintan Solanki (16 hours later)
Brief Answer:
yes imipramine or amoxapine can help

Detailed Answer:
Hi XXXXXXX

Welcome back and sorry for late reply.

Demolox contains amoxapine and it is tetracyclic antidepressant drug. Imipramine is tricyclic anti-depressant drug. Action of both is more or less same. Constipation, dry mouth, sedation and postural hypo tension are common side effects but tolerated well. Imipramine is time tasted drug. We often got the results when SSRI and other newer molecules don't work.
You had good response with demolox in past so I recommend demolox in your case.

MAOI drugs are almost outdated as they can cause significant side effects as well as possibility of major drug interaction. I have never used in any of the patients till date.

Hope this answer will help. Welcome for further queries.

Have a great day.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Chintan Solanki (3 hours later)
Dear Sir

Thanks for the advise. Pls let me know whether to go for imipramine or demolox
and also the start dosage and upward titration dosage intervals as I dont remember dosage etc as it is more than 20 years.Waht time of day is preferable to take etc.Hope I can continue taking my current medication like Flunil and Lamictal along with this medication
Regards XXXXXXX
doctor
Answered by Dr. Chintan Solanki (2 hours later)
Brief Answer:
start amoxapine after baseline ECG

Detailed Answer:
Hi,

Thanks for follow up. I want to clarify that though I am providing treatment details it is always better to take the prescription from local doctor. Any side effect occurs by chance, doctor can provide immediate help.

If I were your treating doctor I would go for Amoxapine (demolox). It should be started in 25 mg dose at night. After 2 days dose should be 50 mg at night. I usually wait for 15 days at this dose and then if required increase the dose up to 100 mg. Highest recommended dose is 300 mg however I used to get results in 200 mg.
As such there is no significant drug interaction between demolox, flunil and lamictal. Only concern is amoxapine and fluoxetine both increase QTc interval. So better to have baseline ECG(elcectrocardiogram) done before you start demolox and periodically do ECG as per doctor's advice.

Regards.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Is Lithium safe to take for depression?

Brief Answer: lamictal can be increased or Desvenlafaxine or mirtatzapine can be added Detailed Answer: Hello Mr. XXXXXXX Thanks for writing to me directly. I read your query twice and understood your concern. Considering overall history and improvement with lamictal, my first choice will be increasing dose of lamictal up to 300 mg. Your doctor is also right as lithium us used in resistant depression and helps in cognition also. Lithium has side effects but it is not so serious what you read. Thousands of patients are stable on lithium since many years. Just one needs to consult doctor regularly and does the serum lithium level regularly. However I do not recommend lithium at this point. Before that if I were your treating doctor, I would like to add Desvenlafaxine or Mirtazapine as they are antidepressant medicines with different mechanism of action from fluoxetine. These medicines do not cause sexual side effects and that is major advantage. In your case depression as well as fluoxetine are responsible foe sexual problems. For erection you can ask your doctor for sildenafil or tadalafil on required basis before sex. In resistant depression Thyroid and vitamin B12 level should also be checked. Their deficiency may be responsible for memory and body symptoms. If you have not been tested for the same please go for thyroid hormone profile and serum Vitamin B12 level. Instead of amisulpride I prefer quetiapine. Other molecule which can later be added if no improvement and not used in past is imipramine. I also prefer ECT in few patients to improve effects of medicines. It is very safe and specifically no side effects. Simultaneously you should go for psychotherapy like CBT - Cognitive behavior therapy. CBT is specifically used to correct automatic thoughts and distorted cognition. In CBT psychiatrist/psychologist helps person to identify his/her automatic thoughts and faulty behavior which would ultimately be modified by person with active efforts and help of therapist. It also includes time management, daily sleep, meals and exercise timing. You can discuss above aspect with your treating doctor and modify the treatment. Hope I have answered your query, I will be happy to help further. Regards, Dr.Chintan Solanki.