instruction: hello doctor I have bipolar disorder I and diagnosed with social and generalized anxiety disorders currently my medication fails to uplift my depression I take lithium 3x450 my olanzapine my escitalopram 20 my previously I tried valproic acid carbamazepine topiramate zoloft prozac clonazepam tranxene rudotel and lexotanil I experience more depressive episodes than hypomanic and I cannot take lithium anymore due to kidney damage done what are my treatment options we are considering changing to lamictal and a small dose of wellbutrin what do you think about this
output: hello welcome to icliniq com yes bipolar depression is difficult to treat and it can be persistent many people do respond to a combination of lamotrigine and quetiapine popularly called as lami quel it takes time to act but it is highly effective currently I would suggest that instead of lithium you use lamotrigine 25 my then 50 my and finally 100 my dose titration is every two to three weeks instead of olanzapine I would replace it with quetiapine 50 to 100 my for start and raise if needed based on the sedation also continue escitalopram if needed or replace it with a tea tricyclic antidepressant class of antidepressants and yes do add bupropion wellbutrin also you can consider doing a few sessions of rims repetitive transcranial magnetic stimulation if possible