Mood is Good Yet Feels Lethargic
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Q:  Mood is Good Yet Feels Lethargic

Dear Dr. Phelps,

I've been diagnosed bipolair II in the end of 2003. In the six years before I  experienced 2 episode of true mania, retrospectively induced by antidepressants, a few periodes of hypomania, and quit a few more episodes of depression.

I'am using lithium 1200 mg and moclobemide 450 mg right now. I used venlafaxine, fluoxetine and paroxetine before, but the sexual problems I experienced with the SSRI and SNRI category were bothersome. The combination is doing just fine, as far as my mood is concurned. I was amazed that a mood stabilizer could extually prevent the (hypo)mania ... for the first time in 5 years my mood was good and ... reactive to the (emotional) stimuli around me. Great!

So what's the problem then? Well, I have to say that although the mood part is doing great, I still feel the need to sleep so much. It is not that I'am tired, it's more sleepiness, the same thing I experience during a depression in a very sever manner  (the term "letheragy" would be more applicabele then. I can litterally sleep for days). So in other words, there is some kind of "remnent" of the "physical" component of depression, it seems too me.

What could be the cause/what could be done about that? I noticed that moclobemide is more of an "energizer" than the other AD's ... is something even more energizing? I'm very content with it actually, so few side-effects as it has.

PS lab findings are normal. TSH = 2.60 (before lithium 1.01), free T4 = 15.9 (European Units prob. mmol/l)

Thanks for your time

Dear Matthew -- 
That was smart of you to include the thyroid numbers:  that was my first thought ("I wonder what his TSH is").  As you may see discussed in another letter of this date, there is very good reason to think that thyroid hormone is a safe thing to try, as long as you don't take so much you become hyperthyroid.  Getting your TSH back down around 1.0, where it used to be; which you probably have learned is an inverse marker for your total thyroid situation (it goes down when thyroid goes up, as explained in this essay on
Thyroid and Bipolar disorder); not only is a very safe thing to try but has also implicated in one study to be related to depression response in bipolar disorder.  (Cole and colleagues).  

When considering thyroid hormone, some psychiatrists would also consider using the T3 version as well as the T4 version, as you'll see discussed in my essay linked above, and some might consider using just T3 alone though that's based mostly on some old work by Bob Joffe (here's his review) (and here are his studies, 1 and 2).  

As for other explanations, basically I'm not sure.  As you imply, usually when someone's bipolar depression improves, so does their energy.  To have this little energy after your mood has substantially improved is puzzling and so you're right to wonder if it's really coming from bipolar disorder.  

And finally, as you've probably also been told or considered, when all else fails (re: trying to effectively explain it), there's always just trying to treat it.  And one tool to keep in mind there is modafinil (Provigil), which I've now seen have a remarkable positive effect (not at 100 mg, but at 200 mg; haven't gone higher yet) in one patient with no side effect problems.  However, since it's new, who knows what will turn up down the road (i.e. there aren't that many folks ahead of you finding out the long-term problems); and you and your doc' would have to check very carefully to see if there's any problem using it with an MAOI.  

Dr. Phelps

Published October, 2004


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