Lamictal and fatigue

I was treated for unipolar depression back in 2020 with SSRI lexapro + amisulpride 50mg and was in remission until 2023 with it.
Then in 2023 I blew a small stressor TOTALLY out of proportion(I think hypomania had already begun then) and got into a really bad or probably even mixed episode (my first one if it was actually mixed). I'd get so restless I'd want to tear off my clothes, attempt to run away, suicidal, get so irritative that I'd say the most wicked shit to my loved ones who were really just trying to help me, lay in bed and cry and shout so loud ALL the time. It was so bad I felt like I was going to die and family members were so worried, I was admitted.
Doctors totally ruled out mania/bipolar disorder because I wasn't impulsively buying stuff, didn't lose control etc bullshit and kept treating me for unipolar depression but they did add lamictal with the 20mg Lexapro to address the aggression etc it was titrate to 200mg and put me in remission for a whole year.
But now in 2024 January I relapsed again and this time it was so bad that doctors were continuosly suggesting ECT. I was admitted for over 3 weeks. Same symptoms- agitation, restlessness etc being treated for MDD and borderline personality disorder Bullshit.
Finally, I saw this miracle doc who said I might actually be bipolar and experiencing mixed episodes. Both the combination of hypomania and depression were making me restless. He said he often sees his patients who're hypomanic get so restless they wanted to crawl out of their skin.
SSRI lexapro would only fuel both so it must be stopped immediately and suggested me to try ketamine (because my symptoms were mostly depressive) and started lithium 600mg/day. They worked like a CHARM. I loved ketamine so much and it put me in remission for 3 months.
But then I relapsed again 3 months later and doc now said it is now time to try the big guns aka antipsychotics and continue ketamine. He said he's willing to prescribe either Vraylar or Latuda which work great for mixed episodes.
TLDR : So, do you have any of my symptoms especially the restlessness during your depressive/hypomanic episodes and which antipsychotic of the two worked the best for you without fueling the restlessness. Personally leaning more towards Vraylar (it has amazing reviews and doesn't cause weight gain)
Symptoms list optionally if anyone wants to read that my son made :
What's your go to treatment plan for mixed states? Is this a mixed state rather than unipolar

• Agitation/Inner restlessness: Unable to remain calm/sit still. Blaming all of her symptoms on this restlessness. When this comes the other symptoms which I'll mention come along too:
  
• Crying and shouting loudly (simply can not control this to sorta escape)
  
• Excessive anger and snapping at/blaming others for no reason: Involuntarily blame people for the most random and petty things who've been the most helpful and kind.
  
• Very Irritable.
  
• Suicidality (to escape the restlessness). Suicidal attempts in aggression where she had to be stopped with a lot of physical force.
  
• Racing negative thoughts leading to Guilt and worthlessness
  
• Irrational/Questionable decisions and behaviors were almost always noted by my family members during these periods accompanied with extreme impatience.
  
• Energy: Being fatigued and unmotivated that she can't even move or do stuff. But at the same time having so much Energy to shout so loud and rip her chest open to escape the "agitation".
  
• Pupils get dilated.
  

I was treated for unipolar depression back in 2020 with SSRI lexapro + amisulpride 50mg and was in remission until 2023 with it.
Then in 2023 I blew a small stressor TOTALLY out of proportion(I think hypomania had already begun then) and got into a really bad or probably even mixed episode (my first one if it was actually mixed). I'd get so restless I'd want to tear off my clothes, attempt to run away, suicidal, get so irritative that I'd say the most wicked shit to my loved ones who were really just trying to help me, lay in bed and cry and shout so loud ALL the time. It was so bad I felt like I was going to die and family members were so worried, I was admitted.
Doctors totally ruled out mania/bipolar disorder because I wasn't impulsively buying stuff, didn't lose control etc bullshit and kept treating me for unipolar depression but they did add lamictal with the 20mg Lexapro to address the aggression etc it was titrate to 200mg and put me in remission for a whole year.
But now in 2024 January I relapsed again and this time it was so bad that doctors were continuosly suggesting ECT. I was admitted for over 3 weeks. Same symptoms- agitation, restlessness etc being treated for MDD and borderline personality disorder Bullshit.
Finally, I saw this miracle doc who said I might actually be bipolar and experiencing mixed episodes. Both the combination of hypomania and depression were making me restless. He said he often sees his patients who're hypomanic get so restless they wanted to crawl out of their skin.
SSRI lexapro would only fuel both so it must be stopped immediately and suggested me to try ketamine (because my symptoms were mostly depressive) and started lithium 600mg/day. They worked like a CHARM. I loved ketamine so much and it put me in remission for 3 months.
But then I relapsed again 3 months later and doc now said it is now time to try the big guns aka antipsychotics and continue ketamine. He said he's willing to prescribe either Vraylar or Latuda which work great for mixed episodes.
TLDR : So, do you have any of my symptoms especially the restlessness during your depressive/hypomanic episodes and which antipsychotic of the two worked the best for you without fueling the restlessness. Personally leaning more towards Vraylar (it has amazing reviews and doesn't cause weight gain)
Symptoms list optionally if anyone wants to read that my son made :
What's your go to treatment plan for mixed states? Is this a mixed state rather than unipolar

• Agitation/Inner restlessness: Unable to remain calm/sit still. Blaming all of her symptoms on this restlessness. When this comes the other symptoms which I'll mention come along too:
  
• Crying and shouting loudly (simply can not control this to sorta escape)
  
• Excessive anger and snapping at/blaming others for no reason: Involuntarily blame people for the most random and petty things who've been the most helpful and kind.
  
• Very Irritable.
  
• Suicidality (to escape the restlessness). Suicidal attempts in aggression where she had to be stopped with a lot of physical force.
  
• Racing negative thoughts leading to Guilt and worthlessness
  
• Irrational/Questionable decisions and behaviors were almost always noted by my family members during these periods accompanied with extreme impatience.
  
• Energy: Being fatigued and unmotivated that she can't even move or do stuff. But at the same time having so much Energy to shout so loud and rip her chest open to escape the "agitation".
  
• Pupils get dilated.
  

Dizziness started in mid November 2021, went to Canberra on the 10th of December and I had my first near faint experience followed by high heart beat and palpitation.
Dizziness and lightheaded was followed till the 28th of December when I nearly fainted again and had really high heart rate: went to hospital. They did blood work and ecg couldn’t find a probable cause. Went to hospital again 3 days later and no findings were evident. Upon my 3rd visit to hospital X-ray was done off my chest and nothing was found. I was bedridden for 6 weeks, everyday was a battle for life, I felt like I was in septic shock everyday. I had to get iv fluids about 10 times because of dehydration, I sweated constantly with no appetite for water or food.
Symptoms
Lightheaded Dizziness Heart gets tired quickly Sometimes my arms and hands become a little numb. My head feels tension. heat in my abdomen, back and my ears get hot. Feels like a pulsating feeling through my body during a bad episode Sometimes left shoulder feels warm My eyes sometimes drop tears randomly Unable to concentrate at times Shortness of breath during episode There’s always a tense feeling in my chest and around my heart area. Sometimes hits my lower abdomen and I feel nausea makes my stomach make noises. I have difficulty sleeping my head spins more when I close my eyes. I wake up between 1-3am with a weird feeling as if I’m scared or something. Vision sometimes becomes blurry. Fatigue and tiredness. Little sudden Noises scare me. Whenever I have a episode that peaks, my hands and feet get sweaty and I feel heat. My hands and feet sometimes get cold. The feeling in my mid left chest area I can’t explain but it’s as if my muscles are vibrating. When I stand up it’s seems my head and chest symptoms get worse for about a minute and then settle down. Same thing happens when I lay down. It gets worse for a minute till it goes back to how it was. Sometimes I can feel it hitting my front part of my head and my sinus feels tense as well. As well as my ears feel the pressure. Lying down seems to reduce some tension in my head. I feel bad 80% of the day really bad 15% of the day and alright 5% of the day.
Let’s go back to my childhood, my earliest memory is probably when I was around 10. If I would focus on my breathing it felt like I couldn’t breath anymore. I also had these unexplained spinning and dizziness at a young age during sleep time. Doctors couldn’t find anything. I was always a scared kid thinking about the worse case scenario that might kill me but in reality it was overthinking. In highschool a few times I nearly fainted out of the blue. Sometimes during sports I’ll hit a point where out of no where my heart would start racing and my breathing would become laboured. Sometimes over excitement caused this as well.
Now medications
Lexapro 40mg for 6 months, no benefits. Made me really bad during the first 2 weeks and kinda of settled after that, dumbed the depressive symptoms but that’s about it. Felt much better after coming off, it definitely made my condition worse. Derealisation, fatigue, tiredness, forgetfulness. All of it.
Zoloft 50mg for 18 days and 100mg for 3 days, had a panic attack on day 3 I thought it was Zoloft but found it to be thc later on. Discontinued Zoloft then. No benefits during the 18 days on 50mg and made my condition way worse.
Paxil 20mg for 2 months, probably one of the strongest reactions to any ssri, daily panic attacks losing my mind, as if there’s a laughter in my head but it’s my internal monologue creating it but still I was losing it. Pushed on for 2 months and it just made me worse as the days went on.
Agomelatine 20mg no benefits, daily panic attacks, took it for about 36 days.
Pristiq, I’m on day 54 and I’ve stopped taking it, my last dose was on Wednesday not sure how to stop. It’s making me worse, mood is swinging, brain fog and all other symptoms are reappearing on this medication.
Clonidine didn’t do much except relax my body alittle
Lyrica, knocked me out at 25mg and made me tired. No benefits.
Valium 5mg, very small relief, short benefits 3-5 hours, more of a muscle relaxant, addictive in nature.
Clonezapam 1mg, small amount of relief, short relief 3-5 hours.
Xanax 2mg, haven’t tried
Ativan 1mg only have tried 0.5mg and it didn’t do much.
Seroquel 25mg, good for sleep, couldn’t sleep for more then 4 hours for the last 5 years or so, now I get a solid 8 hours, it’s not a 100% good quality sleep but it gets the job done, I don’t feel tired through the day as before I got sick.
Epilim haven’t tried chickenend out
Lamictal discontinued on day 3 after developing rash
Lithium 500mg, 37 days. Left like losing my mind not sure if adverse reaction to the lithium or it was some kind of discontinuation I was getting from the lexapro.
Prozac 4 days to bridge off lexapro
Thc/cbd oil, made me go full panic mode for 4 hours each time I tried it. Very similar to what I was feeling with the Paxil minus the laughter side effect.
Symptoms
Dizziness Burning tongue Headache Nausea Metallic taste in mouth Hot flushes Muscle pain and tension Fatigue Numbness in hands Pins and needles Brain fog Startled easily Blood pressure problems Heart feeling heavy Fast heart beat Feel like I’m dying Losing my mind Losing control Very negative thoughts Intrusive thoughts Hyper reactive Blurry vision Cold palms and feet Sweaty palms and feet Hot flushes Feeling sick / flu like Weak limbs Digestion problems Numbness Nightmares
Currently my biggest challenges are
I think I’m developing schizophrenia all the time, and I’m going to lose my mind.
I’m hyper vigilant and see things in the corners of my eye.
My physical symptoms cycle throughout the weeks and I’m never symptomsless. Physical or cognitive I always feel something.
My mind always feels like as if something is off,
As my overall condition gets worse my brain fogs becomes really bad and my hands and feet become so cold to the touch,
I become very forgetful
I can never stop thinking about my condition, my mind is occupied by it 24/7
When I go into crowded areas my physical symptoms become much worse, such as brain fog heart rate and jelly legs.
My internal monologue never shuts up and it’s always active.
Racing thoughts
When I’m on medications l as ssri’s I get irrational fears such as being allergic to nuts or something crazy. But seems to go away after a month when discontinuing the medication,
Lightheaded, feel like my neck muscles are so tense that my brain isn’t getting enough blood.
I’m hyper focused on all bodily functions physical or Cognitive, if I suspect something that is schizophrenic or damaging I get a mini panic attack. But panic attack do occur for no reason as well most of the times.
I’m in this state constantly let’s say chronically,
When my condition worsens and it’s at full flip, no amount of logic can override my thought process, I just believe I’m dying because the physical sensations are just toooo strong that I want to jump out of my skin. I don’t know how to explain it but it’s a weird feeling. Agitated state, dizzy, wobbly, can’t focus etc.
Something else is weird sometime when I’m having a super bad panic attack, such as my heart racing at 180bpm, my cognitive focus will be on my heart and my condition will disappear? I’ll actually feel normalised, mentally and physically. Something happed with the thc, my nausea and cognitive and physical symptoms had been relived but then panic set in. It’s like it suppressed the anxiety symptoms but aggravated the panic if that is possible. Sometimes if I truely focus on something, a lot of it all goes away for a few milliseconds. Kind of same feeling after a massive panic attack, when the panic subsides before it’s next hit I’ll feel my condition/anxiety problems actually settle to better then base levels before priming back up.
Mental illness problems are prevalent in my family,
I’ve done all the physical body checkups before the anxiety diagnosis. Everything check out well physically.

Hello. I talked with my doctor that I am in depression and have no motivation to do anything. We increased lamotrigine to 100. For the seroquel part and fatigue well I tried to reduce from 200 to 150 and felt anxious every day. So I am back to 200. But i just cannot feel any different even with more lamictal. Yesterday I had an hour in the afternoon when I really felt good like normal. But it faded away. Idk why and Idk why today I am back to that totally depressed state. I am so tired I need Something for relief. We also added amisulpride which is supposed to act on dopamine and help with depression pretty fast. But it doesn't. Wish I knew how and what to do next.

25M here,
I've been taking Lamictal (Lamotrigine) for the last 17 years and Briviact for the last 2 years. Everything was going smoothly, apart from side effects like fatigue and restlessness. But in the last couple of weeks, my sleep got messed up. I used to sleep more than 8 hours before.
My cognition is heavily affected, as is loss of appetite and extreme fatigue, drowsiness and irratability, agitation, and a small focal seizure today. Before 2 weeks, everything was fine.
My blood work is fine and optimal, and I've been taking supplements for the last 4 years. They include multivitamins, vitamin D3+K2, magnesium, and B-complex.
What went wrong suddenly? Why a drastic decline in my health within a couple of weeks?

Has anyone taken more advanced hormone tests like the DUTCH test or done gut microbiome testing?
If so were you able to alter lifestyle, take supplements, change eating habits to help with either BP symptoms or med side effects?
I have BP 2 and am currently only on Lamictal and some supplements. I'm still really struggling with depression, fatigue, and apathy.
I do not tolerate ssris or welbutrin, and don't want to just keep taking more and more medications.
My symptoms do seem somewhat related to menstrual cycle, and though I have a clean diet I wonder if there is something I could do to get my body sort of working a little better so I could fight this apathy and lethargy.
Any experience appreciated. Oh I'm not trying to get off my meds or anything, just additional information/treatment interest.

I was wondering if anyone out there can share their experience coming off this medication after taking it for MANY years.
I didn't have any negative experiences with this med - I've just had multiple psychiatrists (and a therapist) tell me within the last 2 years that I'm not bi polar 2 after all, and that I don't need the med.
Plus I have fibromyalgia, have had for seven years, and in an effort to just be on less medication/put fewer things into my body (let alone "things" I don't need), my doc has be going off lamictal and one other psych med (quetiapine aka Seroquel). I have been off lamictal for just over a week after being on it since it came out in 2010 and had been tapering down from 200 for about 2 months. I am down to 25mg seroquell down from 100. About a year ago I started to take trazodone bc I was having really bad sleep. Now it has replaced quetiapine.
Because I gradually tapered off lamictal and quetiapine at the same time, it's hard if not impossible to tell what's causing what. My symptoms? The most insane fatigue I have ever felt in my life. Barely able to function. Yes, chronic fatigue is a stymtom of fibromyalgia, but this is on another level. I did have some pretty bad separation anxiety when my boyfriend went on a a trip. But other than that, the process has not been dramatic (obviously the fatigue is dramatic, but nothing emotional is happening to me).
Everything I've read online is basically like once the med is out of your system you're done/good. But this medication has been in my system for 14 years. This has to be a huge shock to my system (doctor doesn't agree). Is it fair to assume that I'm not going to feel normal for a while?? 14 years is a long time!!

Feels like I see nothing but praise for lamictal on here. It was the first bipolar medication I tried and it was 2 months of fatigue, trouble waking up, and the worst part - body aches and joint pain. These side effects never went away, so I stopped taking it.
Fast forward 2 years and I'm a week into Trileptal, an anticonvulsant like Lamictal, and those exact symptoms have returned.
It seems my body hates these seizure meds and that they will NOT work as a mood stabilizer if I feel like shit every single day, which of course makes me more depressed and hopeless and less functional.
Has anyone else had a terrible time on anticonvulsants?

So I’m at a very low dose (20 mg) and all I’ve felt is fatigue. The first 2 days were nice, I felt elated and sedated right after I took it. I titrate up this week and I’m giving it the benefit of the doubt. I know it’s too early to say anything but my psych was very adamant about this being fast acting. I was on lamictal for about a month before I got a rash indicating I was having an allergic reaction. I miss the stability from the mood stabilizers but not the numbness to my emotions. On Latuda, I still feel things but I can sort of get over them, and I feel exhausted. Also standing up too fast is no joke, almost passed out at work yesterday LMAO

Demographics: 31M. 5’11” 220lbs
Dx: depression, ADHD, OCD(much worse in childhood, well managed now)
Meds: Prozac 20mg daily, Adderall 5mg BID, Lamictal 50mg daily (titrating up, problems started before this med)
Hi. I’ve had problems with fatigue and depression for quite a while but they have recently gotten worse. I saw my PCP to run some labs, but everything looked more or less alright and no explanation for the way I’m feeling.
I had a sore throat and a swollen lymph node in my neck with debilitating fatigue that put me down for days. I was negative for Covid, flu, strep, and mono (and maybe other viruses on a panel). They gave me augmentin and said follow up with PCP if swelling doesn’t go away.
So I’m about a month post that appointment. My lymph node is still palpably swollen but not very tender anymore. No sore throat. Still very fatigued. I’m scheduling with my PCP.
The fatigue has been something I’ve been treating as depression/ADHD for years now and it feels like I’ve thrown everything and the kitchen sink at it, and still hardly any relief besides some momentary improvement when starting a new med that eventually doesn’t work anymore.
I feel like something is really wrong with me and this is really touching every aspect of my life. Any insight or advice?

A new patient(F45) mildly obese was brought in who was planned for ECT in a week. Though she might actually be bipolar (atleast on the spectrum). She was terrified of ECT.
She had severe depression including suicidality and severe agitation.
She was on Lithium 600mg/day (Started recently), Lamotrigine 200mg, Lexapro 20mg and clonazepam 1mg with quietiapine 50mg for sleep.
Since 2023 she'd been experiencing strange episodes according to her family.
Here's all the history and symptoms provided about these episodes since 2023 :

• Agitation/Inner restlessness: Unable to remain calm/sit still. Blaming all of her symptoms on this restlessness. When this comes the other symptoms which I'll mention come along too:
  
• Crying and shouting loudly (simply can not control this to sorta escape)
  
• Excessive anger and snapping at/blaming others for no reason: Involuntarily blame people for the most random and petty things who've been the most helpful and kind.
  
• Very Irritable.
  
• Suicidality (to escape the restlessness). Suicidal attempts in aggression where she had to be stopped with a lot of physical force.
  
• Guilt and worthlessness
  
• Irrational/Questionable decisions and behaviors were almost always noted by family members during these periods accompanied with extreme impatience.
  
• Energy: Being fatigued and unmotivated that she can't even move or do stuff. But at the same time having so much Energy to shout so loud and rip her chest open to escape the "agitation".
  
• Pupils were dilated when I saw her.
  

After her lexapro was increased to 20MG her symptoms have been just worsening and worsening including suicidality.
Benzos would do nothing even injectable ones for the agitation.
Then today when she came to me during the severe agitation I immediately thought of a mixed state. Gave her zyprexa and asked to taper down the lexapro.
After she took the zyprexa (sublingual) in about 2 hours experienced tremendous relief - felt calm, brain went silent and took a long nap quite refreshing. She wasn't bothered by people talking. She wasn't irritated. She just felt normal. The relief seemed never-ending.
It makes sense now how being put on lamictal back in 2023 put her into remission and it kept masking Lexapro's rebound effect(in bipolar)
I'm honestly unsure why high dose Lexapro was continued over a year (even though there was a clear worsening of symptoms with dosage increase) and why high dose benzodiazepines were constantly being used to control the agitation despite having little to no effect. Even effexor was started in cross-titration with Lexapro which further worsened her suicidality etc?
Sorta leaning towards ECT and later on adjusting the medications because it does seem to be severe and ECT it is quite effective though the patient wants to try the no-ssri approach.
If we do go with the latter approach, I plan on : - Switch to Vraylar for its good evidence in mixed states. Cariprazine is dirt cheap here.

• Stick to Lamotrigine and increase Lithium/ Switch to Valproate(Good evidence in mixed features).
  
• Wellbutrin for depression if it does not or only partially responds to psychotherapy.
  
• Gabapentin.
  
• Low dose Trazodone for insomnia.
  

Perhaps the increased energy from the (hypo)mania and the activation from the SSRI is resulting in the restlessness which explains the relief from Olanzapine. I've seen many hypomanic patients who'd get so restless that they wanted to crawl out of their own skin.
What's your go to treatment for mixed states? What about the efficacy of Lithium in mixed bipolarity? Which mood stabilizers seem to work best?

A new patient was brought in who was planned for ECT in a week. Though she might actually be bipolar (atleast on the spectrum). She was terrified of ECT.
She had severe depression including suicidality and severe agitation.
She was on Lithium 600mg/day (Started recently), Lamotrigine 200mg, Lexapro 20mg and clonazepam 1mg with quietiapine 50mg for sleep.
Since 2023 she'd been experiencing strange episodes according to her family.
Here's all the history and symptoms provided about these episodes since 2023 :

• Inner restlessness:Getting EXTREMELY restless (CAN NOT sit still). Inner restlessness that makes her want to slap /kill herself just to escape it. She'd beg her family to kill her so she can escape this.This comes and goes daily during these episodes and is the main symptom. When this comes the other symptoms which I'll mention come along too:
  
• Crying and shouting loudly (simply can not control this to sorta escape)
  
• Excessive anger and snapping at/blaming others for no reason: Involuntarily blame people for the most random and petty things who've been the most helpful and kind.
  
• Very Irritable.
  
• Suicidality (to escape the restlessness)
  
• Guilt and worthlessness
  
• Irrational/Questionable decisions were almost always noted by family members during these periods accompanied with extreme impatience.
  
• Energy: Being fatigued and unmotivated that she can't even move or do stuff. But at the same time having so much Energy to shout so loud and rip her chest open to escape the "agitation".
  

After her lexapro was increased to 20MG her symptoms have been just worsening and worsening including suicidality.
Benzos would do nothing even injectable ones for the agitation.
Then today when she came to me during the severe agitation I immediately thought of a mixed state. Gave her zyprexa and asked to taper down the lexapro.
After she took the zyprexa (sublingual) experienced tremendous relief - felt calm, brain went silent and took a long nap quite refreshing. She wasn't bothered by people talking. She wasn't irritated. She just felt normal. The relief was long lasting.
It makes sense now how being put on lamictal back in 2023 put her into remission and it kept masking Lexapro's rebound effect(in bipolar)
I'm honestly unsure why high dose Lexapro was continued over a year and why high dose benzodiazepines were being used to control the agitation despite having little to no effect.
Sorta leaning towards ECT and later on adjusting the medications because it does seem to be severe and ECT it is quite effective though the patient wants to try the no-ssri approach.
If we do go with the latter approach, I plan on : - Using either VraylaLatuda for their good results in mixed states. Cariprazine is dirt cheap here.

• Stick to Lamotrigine and increase Lithium.
  
• Wellbutrin for depression if it does not or only partially responds to psychotherapy.
  
• Gabapentin.
  

What's your go to treatment plan for mixed states? Is this a mixed state rather than unipolar depression?
A new patient was brought in who was planned for ECT in a week. Though she might actually be bipolar (atleast on the spectrum). She was terrified of ECT.
She had severe depression including suicidality and severe agitation.
She was on Lithium 600mg/day (Started recently), Lamotrigine 200mg, Lexapro 20mg and clonazepam 1mg with quietiapine 50mg for sleep.
Since 2023 she'd been experiencing strange episodes according to her family.
Here's all the history and symptoms provided about these episodes since 2023 :

• Inner restlessness:Getting EXTREMELY restless (CAN NOT sit still). Inner restlessness that makes her want to slap /kill herself just to escape it. She'd beg her family to kill her so she can escape this.This comes and goes daily during these episodes and is the main symptom. When this comes the other symptoms which I'll mention come along too:
  
• Crying and shouting loudly (simply can not control this to sorta escape)
  
• Excessive anger and snapping at/blaming others for no reason: Involuntarily blame people for the most random and petty things who've been the most helpful and kind.
  
• Very Irritable.
  
• Suicidality (to escape the restlessness)
  
• Guilt and worthlessness
  
• Irrational/Questionable decisions were almost always noted by family members during these periods accompanied with extreme impatience.
  
• Energy: Being fatigued and unmotivated that she can't even move or do stuff. But at the same time having so much Energy to shout so loud and rip her chest open to escape the "agitation".
  

After her lexapro was increased to 20MG her symptoms have been just worsening and worsening including suicidality.
Benzos would do nothing even injectable ones for the agitation.
Then today when she came to me during the severe agitation I immediately thought of a mixed state. Gave her zyprexa and asked to taper down the lexapro.
After she took the zyprexa (sublingual) in about 2 hours experienced tremendous relief - felt calm, brain went silent and took a long nap quite refreshing. She wasn't bothered by people talking. She wasn't irritated. She just felt normal. The relief seemed never-ending.
It makes sense now how being put on lamictal back in 2023 put her into remission and it kept masking Lexapro's rebound effect(in bipolar)
I'm honestly unsure why high dose Lexapro was continued over a year and why high dose benzodiazepines were constantly being used to control the agitation despite having little to no effect. Even effexor was started in cross-titration with Lexapro which further worsened her suicidality etc?
Sorta leaning towards ECT and later on adjusting the medications because it does seem to be severe and ECT it is quite effective though the patient wants to try the no-ssri approach.
If we do go with the latter approach, I plan on : - Switch to Vraylar for its good evidence in mixed states. Cariprazine is dirt cheap here.

• Stick to Lamotrigine and increase Lithium.
  
• Wellbutrin for depression if it does not or only partially responds to psychotherapy.
  
• Gabapentin.
  
• Low dose Trazodone for insomnia.
  

What's your go to treatment for mixed states? What about the efficacy of Lithium in mixed bipolarity? Which mood stabilizers seem to work best?

I'm a 27 year old female, 5'4", 175lbs, I take lamictal 200mg, and seroquel 100mg, I also vape nicotine
My last period (4/19-4/27) was extremely debilitating. I was in a lot of pain from cramps and extremely fatigued. Since then I've still felt extremely fatigued, bloated, and painful cramps. I went to the doctor 5/7. The doctor palpated my stomach and his impression was my pain was from constipation. He ordered blood tests and an intravaginal ultrasound.
The ultrasound results came back normal but said "pelvic free fluid: trace physiological fluid" (before I could get the imaging done I experienced such bad pelvic pain I collapsed on the ground...could an ovarian cyst have ruptured?).
Blood tests that came back normal: testosterone, CBC w/ differential, and hemoglobin A1c. Not sure if it matters but basophil % was right at high end of normal and absolute early granulocyte count was right at low end of normal.
DHEA-sulfate came back high. It said normal is 35-430ug/dL. Mine was 547.
I'm wondering what this could mean and what, if any, additional testing would make sense to do. Thank you for any advice and I can provide more health information/history if needed to bring more clarity.

So I started Lamictal 25mg about 15 days ago, and within a couple days I noticed my mood dropping considerably and some mild suicidal ideation, along with tearfulness. I was doing pretty solid on Latuda beforehand so this shook me up.
I decided to continue along anyway, and it hasn’t really gotten any better. I’m fatigued all the time and my nightmares have come back. I’m due to go up to 50 mg tonight but I’m scared.
I always see everyone praising this med so it’s hard to find anyone who decided it wasn’t for them. Did anyone else experience this, and if so did it get better?

I already messaged my dr. but figured it couldn’t hurt to get other opinions lol.
So I’m nonbinary and have been on low dose testosterone since November or so, 2 pumps of gel a day. I typically a pump an arm in the morning (and am a night showerer), but every once in a while I’ll switch up time or location if I forget.
I just did bloodwork yesterday and learned my T levels were 2.88 ngl/mL, whereas they were 3.82 ng/mL in December and 0.245 in October.
My estradiol results were 66.2 pg/mL, but in December they were 28.6 pg/mL. Besides starting Lamictal about a month and a half ago, I haven’t made any changes to my medicine or anything.
Could this be due to poor T gel absorption? I’ve seen some gradual changes (a little more facial and body hair, voice dropping, some bottom growth) but it definitely seemed to have hit a plateau earlier this year — and now I see why lol. I’ve also been more fatigued than usual lately, but it could just be PMS. I may try to switch to shots if the gel seems to be absorbing poorly, but my one minor concern is it’ll be a major change in pace from gel, which has been pretty gradual. If that’s the case, couldn’t I just stop once I’ve reached the changes I want?
Thanks in advance for reading and your input 🤍

Hi All-- I posted most of the symptoms improvements in a reply but wanted to share in its own post. It's therapeutic for me to reflect on the progress, especially since I'm having a worse day today--those are fewer and farther between lately--and maybe others can benefit.
I've been on keto for about 4 months now. I've been doing a 2:1 modified Adkins, though its often more like 3:1 depending on the day, with <20 g net carbs. I've aimed for blood ketones above 2.0 mmol/l taken in the late afternoon and also maintaining above 1.0 upon waking. I took me about a month to figure out how to get to those levels consistently. Content of diet beyond the macros has been pretty normal though I've experimented with limiting dairy to goat cheese and butter recently. That restriction seems to help with some of the symptoms. I've done keto in the past with some benefit but not as strict with macros and was typically in lower levels of ketosis. I've been working with Nicole Laurent this round who has been great in helping me learn to do the diet consistent with known keto for mental health best practices and navigate anything unexpected that comes up. She's also been a great support in encouraging patience and recognizing the progress when it comes, plus healing isn't always easy as "waking up is hard to do." I've also found a supportive Psychiatric Nurse Practitioner who is relatively new to assisting with keto but has done Georgia Ede's clinician training. My therapist has become a convert as she's seen my significant progress the last few months.
Symptoms/illness-wise, I'm coming at this from a pretty complex place. Bipolar diagnosis after Zoloft induced manic episode at 18, treated with lithium other mood stabilizers, always paired with still an SSRI, usually celexa. Improved a lot in my late 20s/early 30s on just lithium and Adderall until doc thought Prozac to address anxiety would be a good idea. Cold turkeyed lithium, then the Prozac a year later and had a terrible Prozac withdrawal syndrome that maybe morphed into a bipolar mixed episode. I tried going back on lithium other drugs and the additions and changes just made things worse. I was left with long term effects from multiple drugs and symptoms of complex PTSD from the dysphoric states I endured. My cognitive functioning was about 50% of baseline based on a neuropsych exam, and I had to take 4 months off work in desperate hope of getting better with the time off. The recent years have been bad but even during the better stretches on lithium I never felt well and always like a part of me was missing--I don't know what of that was bipolar and what the dulling effects of lithium.
I started keto 3 months into the time off and have seen significant improvement with all my symptoms-- though I'll have clearer periods and then worsening.
Symptoms I've seen improve:
derealization -- this had been pretty bad, just lacking the crispness of life. While on keto, I've had the feeling of like watching a TV and it suddenly going from standard definition to HD...and then it would happen again. Gradually but at times I'd notice the difference and then kind of get used to it only to notice it again down the road.
tinnitus - I had developed terrible tinnitus after taking lamictal. It's improved significantly, again gradually and is probably 80% less frequent and 50% less intense when it occurs.
anxiety -- I had terrible anxiety and couldn't cope with most things in life. I often felt helpless and that if I confronted anymore adversity I couldn't respond. I]m handling a lot of adversity now.
Fatigue - I was really just dragging myself through every day and could barely get through them. This has gradually gotten better, and I now have energy to do things like clean up the kitchen at the end of the day. When you're not exhausted all the time, it's easier to enjoy life.
cognitive impairment -- this is a biggie as it was disabling and I couldn't perform my work as an attorney. I've noticed various brain functions gradually come back online. I went back to work in early February and have just gotten better and better. I'm able to think and reason again, and my memory's tremendously better. In some ways it's going back to before the Prozac misfortune but also back to my premorbid functioning, before the manic episode. This can be overwhelming at times as I have to process how I got by all those years and the brain reshaping itself creates some feeling of instability.
Sleep - I developed chronic sleep issues during the med changes/withdrawal mess and was too sensitive to take any drug or supplement that might help. I was waking up a lot before keto and usually couldn't go back to sleep, sometimes couldn't go to sleep at all. About 2-3 months in to keto, my sleep started improving a lot. I'm now reliably sleeping through the night most nights and get 6-7 hours. A few times I've been able to sleep in which had become foreign to me.
Executive functioning - I've gotten better at managing myself and my life. I can juggle a lot more and keep up with things. I'm more motivated and can make myself exercise consistently.
Feeling unsafe - this is one of my big PTSD symptoms. I just couldn't relax, ever, always self monitoring and monitoring my situation. Waiting for something to go wrong. This will take time to fully heal, but it's so much better now.
Revisiting -- another PTSD symptom. I was very much stuck in the past reliving certain events around my worsening. I couldn't step out the front door or take out the trash without thinking about things that happened in those settings. As with some other symptoms, it's not perfect, but I'm having more and longer periods where I'm just in the here and now. I can just walk outside and can just take the trash out.
Social anxiety -- At my worst I pretty much totally isolated, and was very withdrawn when around my immediate family that I couldn't isolate from. Each of these have gotten better, again gradually, and I can carry on normal conversations, joke and laugh again. I feel a desire to connect with people and am repairing the relationships I still have, including with my wife and kids.
I'm not fully healed and some days the symptoms come back or worsen. I've been through hell but really feel keto is laying the groundwork for long-term and complete healing. I've even started tapering lithium, under the supervision of a provider, down to 750 mg from 900 mg and feeling more stable than ever. I'm incredibly hopeful and can see the possibility of a full life again.

after 4 years i’ve decided to find a new psychiatrist and get on new medications. when i was 16 i was given prozac that didn’t do shit, and later tried lamictal (got allergic rash reaction to it) and then a cocktail of lithium, seroquel, topirimate, and metformin bc the side effects. i hated taking all those stupid big ass pills and when i did i felt like half a person watching my life through a screen with constant hunger and fatigue , i felt as if i couldn’t speak and that my mouth would lag behind my brain so i’d skip words it was AWFUL ugh. what medications worked for you guys ?? and what were the side effects?

About a year ago I told my therapist I think I have avpd, after she looked into it she said we’ll work based off that diagnosis. I work in a social occupation. My job is basically to talk and make connections with people. It makes me wonder if I’m malingering.
I’m on lexapro, lamictal, and adderall. When I’m off my meds I’m a mess. I’m suicidal, I isolate, and I can’t function.
I’ve been consistent with my meds lately and I have more energy (though I’m still fairly exhausted and fatigued but I am getting tested for autoimmune issues).
Does anyone feel that they can function well but internally feel different? I feel like I am wrong most of the time and I’m somehow messing things up. I also feel like I’m on the opposite end of that, like I feel that I can do better than others. It shifts from egotistical to self deprecating.
I don’t know if it’s a avpd thing or a depression thing or anxiety. Or if I’m unconsciously making things up to feel sorry for myself? I don’t know, I just want to be a good person.

I have been dealing with depression and anxiety for years since a breakup from my first boyfriend. I took celexa for 12 years and I was stable until I decided to try another antidepressant to help me with fatigue from celexa. I reacted pretty bad to Prozac, Wellbutrin, Nortriptyline Zoloft and even lamictal ( Felt better for a week then way way worse with suicidal ideation). I saw a psychiatrist and she immediately diagnosed me with bipolar 2. I read her reviews and all her patients said she diagnoses everyone with bipolar disorder. I am now terrified of meds. I think ever since this idea of bipolar started I got worse and worse everyday because I’m too terrified of meds and going through changing them. I am losing my mind because I now don’t trust the doctor but I have researched and I feel like I have some signs of bipolar spectrum I feel like I can’t find the answer l. I don’t know what is wrong with me. I am working 2 full time jobs. My husband was laid off. Our mortgage rate has been doubled and with this issue I am just feeling my life is over. How do I know if these antipsychotics and antidepressant combos won’t make me worse?! How do I trust my diagnosis ? The more I read about it the more I try to find out if I am hypomanic or depressed or if I should trust my judgement … I am so confused and scared.

I have been dealing with depression and anxiety for years since a breakup from my first boyfriend. I took celexa for 12 years and I was stable until I decided to try another antidepressant to help me with fatigue from celexa. I reacted pretty bad to Prozac, Wellbutrin, Nortriptyline Zoloft and even lamictal ( Felt better for a week then way way worse with suicidal ideation). I saw a psychiatrist and she immediately diagnosed me with bipolar 2. I read her reviews and all her patients said she diagnoses everyone with bipolar disorder. I am now terrified of meds. I think ever since this idea of bipolar started I got worse and worse everyday because I’m too terrified of meds and going through changing them. I am losing my mind because I now don’t trust the doctor but I have researched and I feel like I have some signs of bipolar spectrum I feel like I can’t find the answer l. I don’t know what is wrong with me. I am working 2 full time jobs. My husband was laid off. Our mortgage rate has been doubled and with this issue I am just feeling my life is over. How do I know if these antipsychotics and antidepressant combos won’t make me worse?! How do I trust my diagnosis ? The more I read about it the more I try to find out if I am hypomanic or depressed or if I should trust my judgement … I am so confused and scared.

I do not smoke cigarettes or drink, but I do smoke marijuana.
When I was 13 I was put on Lithium and it caused thyroid issues, so I've been on levothyroxine for years. This year I was taken off of Lithium and put on Lamictal, so I asked the dr for a thyroid test to see if the change in medication had caused any changes in my thyroid. She ordered a TSH. The TSH came back and I was concerned by the results, but because its technically in the MyChart normal range, all she commented was "Thyroid is normal" and nothing else. I went from consistently being in the 2.00 to 3.00 range to suddenly this test being a .53. I'm extremely concerned by this and am thinking I should ask for a referral to an endocrinologist, because theres no way this is normal with the side effects I've been having recently (I've gained 10lbs despite no change in diet or exercise in two weeks, I've been sleeping a lot more than I should due to fatigue, and I've been experiencing muscle soreness/pain.)
I guess what I'm wondering is if I'm overreacting to be concerned, or if I really should pursue a second opinion. I'm on the spectrum and advocating for myself is very hard because I'm a perpetual people pleaser due to my inability to read social situations and the need to be liked, even by professionals, so an opinion by someone who knows what they're talking about would make me feel better asking for this. This may be common sense, but I wouldn't know. I only started going to appointments without my mother recently, I have no scope of these kinds of situations. Sorry if I'm overexplaining.
For context of medications I currently take just in case it effects this:
Levothyroxine 50mg every morning (on an empty stomach before all my other pills by about an hour)
Abilify 5mg every morning
Hydroxyzine as needed for anxiety 50mg (haven't been taking in the past month because new med Lamictal has helped my anxiety a lot)
Buspar 10mg every morning
Lamictal 300mg every morning
I appreciate your help.

Why do I burn out so easily? I am 19 years old and recently got diagnosed with bipolar 1. I am a full time college student and regularly hop jobs. Whenever something significant changes in my life, such as starting school or a new job, it always sends me into a manic episode. I am super motivated for the first couple of months and then I crash and burn out. I can't keep a job no matter how hard I try. I always end up in such a depressive state that I cant get out of bed or even take care of my personal hygiene. I am currently medicated with Latuda and Remeron and my psychiatrist said the Remeron is causing breakthrough episodes. I am on the verge of dropping out of college and I'm only finished with the second semester. I failed 2 classes this semester because my depressive episode hit so hard. My boyfriend moved in with me for a year and I was hypomanic the whole time and then I finally crashed in January.
This has been a constant pattern basically my whole life since 4th grade, even though I'm medicated now. I'm looking into mood stabilizers but I havent found the right one yet. I tried lamictal and it made me feel very fatigued and sick. What can I do to break this pattern? I just want to be able to keep a job for longer than 3 months. I want to be able to make it through one semester without completely burning out. After the crash in january I got into stimulants a little bit to help me get through school because i felt like it was my only option and now I'm rapid cycling. I've had 2 manic episodes this year already and one full blown depressive episode. I got sober and now I'm stuck in hypomania and I feel like I'm about to crash again any day now. But summer is coming up and I end up in mania every single summer and then i crash around october when im getting into the school semester.