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Q: Depressed & Already on a Mood Stabilizer
Dear Dr. Phelps,
I was diagosed with bipolar disorder when I was 16 years old. I started off
severly depressed, not knowing I was bipolar they put me on a trycyclic
antidepressant-tofranil. I then spun into a severe manic eposide, and was
hospitalized. I was started on lithium, which did not seem to effect me at
all. The doctors added tegretol, and I stabilized out. I weaned off lithium
about 7 years ago, and I remained completely stable. I have been completely
stable for the last 16 years-absolutely no problems. My husband and I wanted to
conceive, so my doctor encouraged me to wean off my medicine completely. After
about 4 months of no medicine in my system, I quickly relapsed into depression
with severe insomnia! I got back on my tegretol, but it is not pulling me out
of the depression-it is not working like it used to. What would be your
recommendation of my next step? I went to two different psychiatrists to help
guide me in my next step & I am getting conflicting information. Please let me
know what you would reccommend. Please help. (one stats add lexapro to the
tegretol, the other stats to add topomax to the tegretol- I am currently
taking 1000mg of tegretol & trying diff. meds to help with sleep)
Dear Ms. E' --
I just finished preparing a report to my local colleagues on this issue, i.e.
what to do when your patient has bipolar disorder and is depressed and is
already on a mood stabilizer. Should one add an antidepressant? This is an
area of great controversy in psychiatry. However, I was struck by a recent
essay on this topic by Dr. Ghaemi from Harvard, who reported that whereas
community psychiatrists have 80% of their bipolar patients on antidepressants,
and university-based mood clinics 50% of bipolar patients; his bipolar specialty
clinic has only 20% of their patients on antidepressants. He specifically
recommends having only about that percentage of patients in one's practice on
antidepressants (patients with bipolar disorder). And he may be the world's
authority on this issue: he was the chief editor for a special issue of the
journal Bipolar Disorder that was devoted entirely to this issue. In
other words, the world's authority on this issue, though he clearly recognizes
that not all psychiatrists agree with him in theory or in their practice,
recommends great caution in the use of antidepressants. If you've looked over
my website on bipolar II, in the treatment section you've seen that I strongly
agree with him. So, coming from that place, which means admitting that there
are other psychiatrists who'd recommend otherwise... (long caveat, huh?)
My inclination in situations like this is to
specifically avoid adding an antidepressant if I can avoid it. That certainly
applies to Lexapro. It might apply to Topomax also, because that agent is kind
of weird: it's not a mood stabilizer (tested in randomized trials, it's no more
likely to stabilize mood than a placebo), but it definitely has mood effects,
and occasionally, people do really well on it (of course, there's the 1.5%
chance of a kidney stone, the new concern about a metabolic shift called "acidosis;
and the potential for getting kind of batty ("cognitive changes") that's as high
as 1 person in 3 -- you can tell I am not a big fan of this medication in this
context; great for binge eating that doesn't respond to other treatments,
though...).
So, how to "avoid the antidepressant"? I rely on mood
stabilizers with antidepressant potential. First there's lithium, but that
didn't work well for you, at least for the manic-side symptoms, though it might
be a candidate in this circumstance (many psychiatrists particularly in Europe
and Australia would probably start there). Then there's
lamotrigine, which some people even think might be safe in pregnancy (only
about 300 cases so far are known, but the rate of fetal abnormalities in those
cases was the same as the base rate in the population, says the manufacturer,
GlaxoSmithKline; here's their
registry). It
has very clear antidepressant effects in many people without a risk of
destabilizing mood. Finally, there's
fish oil,
which is now regarded as safe in pregnancy (e.g. this
report
from the University of Sheffield) and possibly of additional benefit to the
baby (University
of Kansas report), and seems to possibly have antidepressant effects --
though that may require either high doses or a long period of time before you
know if it's working, or both. See that link above on fish oil for more info'.
Thus there may be some options that would even be
compatible with the original pregnancy idea; at least lamotrigine has been shown
to have the kind of mood stabilizer power that might allow it to be a single
medication for you. However, this is very tricky territory as you've learned
from experience already. I'm trying to just make sure you're aware of some
options, not to make a specific recommendation for you. That has to be worked
out with your doc's. Good luck with the process, including
talking to your
doc's about your ideas.
Dr. Phelps
Published April, 2004
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