Depressed & Already on a Mood Stabilizer
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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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