Depressed after manic phase
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Depressed after manic phase (Ernesto)

Q: I got a friend with the following characteristics She's been controloed since she began with the disiease, with Lithium 300 mg by day. She's been detected with the disease 8 months ago. When she began with it, she's been treated with a medicine called here in Mexico as Tegretol(Capacetine) 200 mg by day and other called Siprexa 15 mg. by day. Also she's been treated with Conduct Therapy and Psicoanalysis 3 time a week. Her mania is recently controled, also the psicotic phases. But she's fully depresed. The doctor has tried Prosac, Welbutrin, and recently Tofranil(Imperamine) with better results, but with the full losse of sexual desire. Since 2 week from now this treatment has been removed and she's been treated only with 900 Mg of Lithium, with the consequence of a total depresion. Any help on any association, phisician, drugs or anything that you could submit will be wonderful. Thanks in advance. Ernesto

Dear Ernesto
Her situation is one of the hardest to treat in bipolar disorder.  Some psychiatrists use antidepressants in this situation, as hers did.  One cannot really argue with that.  The alternative sometimes does not work very well:  that is to emphasize "more mood stabilizers", particularly those with some antidepressant effect.  Eventually many people have to get away from the antidepressants because they keep making the whole thing cycle up and down, as she may have done recently.

So one alternative here would be to increase her lithium until the blood level is near 1.0 ng/dl.  That is trying to get the maximum effect from lithium, including especially its antidepressant effect, which can be strong.  If that isn't possible because of side effects, which is common; or if it doesn't work, which is also unfortunately common, the choice is even trickier.  Some psychiatrists would add an antidepressant again.  Others, me among them, would look for any evidence that she is still having some degree of "manic" symptoms (for example, is she sleeping excessively?  most people with "pure" bipolar depression will sleep 10, 12, even 14 hours/day; if she is only sleeping 4-6 hours, and waking a lot, then she may have "mixed state" (a combination of manic and depressed symptoms) that will respond much better to adding another mood stabilizer than to adding any more, or any at all, antidepressant medication.

In the U.S., the "mood stabilizers" include the medications she took before: Tegretol and "Zyprexa", as well as "Depakote" (divalproex sodium) and the newer "Topomax" (topiramate) which can sometimes block the appetite increase associated with Depakote and Zyprexa.

So, there are a lot of choices and a lot of decisions, you can see.  Best of luck.

Dr. Phelps
 

Published October, 2000
 

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