Q:  Are These Meds Working Against Each Other

Dr. Phelps,

My doctor recently prescribed Risperdal for suspicous thoughts. I am also taking Wellbutrin and Trileptal. I am aware paranoia is a side effect of Wellbutrin. Every time I take an AD I get psychotic symptoms and then I am prescribed an antipschotic.My question is: does the anti pscyhotic work against the antidepressent? I understand Wellbutrin stimulates dopamine while psychotics block it. I'm sure it is more complicated than that but I still wonder if these medications antagonize each other. I may be better off finding alternature treatments for depression.

Dear Ms. S'  --
Your doctor probably wants to avoid tapering back the Wellbutrin for some specific reason, but as you've figured out, yes the Wellbutrin might be triggering the paranoia and thus the Risperidone and the Wellbutrin would be "working against one another".  You're also right that although these have somewhat opposite effects on dopamine that the whole story is a great deal more complicated, far more complicated than we doc's understand yet.  You could try asking your doc' why she/he is choosing not to try lowering (and eventually perhaps stopping, as this is fairly routine in many cases of bipolar disorder) the Wellbutrin -- but don't start down on your own!  Ask first; if she's got a good reason, and there could definitely be one, then you could mess up something badly if you go on your own.  On the other hand, if your doc' is not too terribly pressed for time (and some definitely are), she might be able to help you understand the logic of these choices a bit more.  

Remember, in the "old days" before we had lots of mood stabilizer options, a standard bipolar regimen was an antipsychotic plus an antidepressant, each continued long term.  Now we tend to emphasize multiple mood stabilizers and avoiding antidepressants (and thus avoiding, in many cases, the antipsychotic too), but this all has to tailored to you pretty closely.  To my knowledge, no one in alternative medicine has come up with evidence of a good response to any other class of agents (the data on omega-3 fatty acids just got a little better recently, but that's about it to my knowledge).  

Dr. Phelps