Dr Phelps:
My therapist and psychiatrist think "maybe" I have bipolar 2. My doctor said he does not want to "label" me quite yet. Now I am on tryptan. I can take 750 mg. up to four times (2 at bedtime and 2 if I wake up during the night). If this does not work they are thinking of putting me on Epival. What do you think of this medication? If I do have bipolar 2 (and from reading your bipolar site - I think I just might have it) what mood stabilizer would be good to start with? My psychiatrist is very open to my ideas and if I do go on a mood stabilizer, we will talk pros and cons. Right now I am on l50 mg. of Bupropian and 3 l0 mg. of Buspar.  I have been on this medication since last June (200l) and frankly now that I am going thru my "cycle" again, I dont think it is working. I think my Dr. is hoping the tryptan will enhance the antidepressant and help me to sleep.Four years ago I was on Paxil. It did not work. Then he put me on Nardil and that was a nightmare. I was sleeping fantastic but I had so much engergy. Too much energy. Then he wanted to put me on Bupropion and I read about it on the internet and got scared. I tried it alone for a year. So no antidepressant has really worked. Am I maybe "treatment resistant"and in depression or am I maybe bipolar? This has been going on for so long - I am sick of this. I am glad my psychiatrist does not want to "label" me, but I am so confused.

Thanking you in advance,
Dianne


Dear Dianne - 
Well, you and your doctor are asking the right question all right.   And now you're on the verge of trying a treatment for what you might have had all along.  I confess it always surprises me that people are willing to try 3 or 4 different antidepressants but seem to hold back when it comes to trying a mood stabilizer, even though there is evidence that antidepressants can make bipolar disorder worse, and no evidence so far (in over 10 years) that mood stabilizers can make depression worse.  Granted, mood stabilizers can indeed make a depressive phase worse, but if that was monitored for from the outset, and the medication was stopped as soon as that was clearly recognized, then -- the point -- there is no evidence for a lasting negative effect from having tried the mood stabilizer.  By contrast, there is suggestive evidence (e.g Winsberg et al, but nothing definitive yet) that taking even a single antidepressant can make bipolar disorder worse in a way people don't get to "go back" from.  That scares the heck out of me, that we could be making folks worse in some way when we're trying to help.  

So again, I confess that I don't understand why there would be the hope that we could keep treating you as though you don't have bipolar disorder, hoping you don't.  Instead, we could treat you as though you do, and hope we're wrong.  Granted, bipolar disorder is basically a good deal more complicated than unipolar disorder, in symptoms and treatment.  Okay, so maybe we're wrong: another failed medication trial, but we're not making you worse in the process.  If it turns out to be true that you really do have something more like bipolar disorder (you've learned from my site, I hope, about how this question is not really a yes-or-no matter?) then, oh well, we were treating you with the right medication approach, too bad.  I'd rather have a more severe diagnosis but a correct one than a less severe diagnosis that was wrong, wouldn't you? 

So I turn to the possibility of a bipolar diagnosis right from the beginning of treating depression, rather than turning to consider it after several trials of antidepressants.  Mind you, I'm one of the only psychiatrists I've heard talk this way, so this is just my own personal point of view (I hope that's what you were asking for).  There are plenty of psychiatrists who would continue to hold back and treat you with some different set of antidepressants.  They may understand something I don't.  Time is going to help sort this out for us professionals, i.e. where the right balance point is on this diagnostic issue.  But I'm glad to hear that the "bipolar issue" is so strongly being considered for you, right now.  I hope one way or another you find something that really helps a lot, and soon. 

Dr. Phelps