Bulimia, Binge Eating & Topomax
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Q:  Bulimia, Binge Eating & Topomax

HI- I am 22 bipolar, formally bulimic, and now feel that i am a binge eater.  I have been researching topomax- ive been on lamictal & wellbutrin for a while and it just seems ok. i am depressed still, overweight and have rapid mood cycling.  I would like to try topomax but wonder what i could take with it for depression? i also use adderall sometimes- is that safe with topomax? thanks a lot for any suggestions you can offer!

Dear M' -- 
As you may have seen, Dr. McElroy's group at the University of Cincinnatti has been studying topiramate (Topomax) for bulimia and binge eating.  They are reporting good responses (the problem is dealing with the side effects, especially the fairly common effects on thinking and memory).  Some people seem to get an antidepressant effect from it also; but yet, it can also cause depression (that's listed as a side effect in the product information, and I had one patient who definitely had that happen to her).  Likewise it seems to sometimes help treat anxiety symptoms, particularly those that seem related to PTSD (post-traumatic stress disorder); and yet, sometimes it seems to make anxiety worse.  So, it's like a wild card:  I've come to expect nearly anything to happen when people go on it, from very good to pretty bad. 

I mention all that because you can imagine what this means for combining it with other medications:  if you don't know what's going to happen with topiramate alone, imagine how hard it is to figure out what's going on when it's combined with other medications. 

A last thought:  most mood experts agree that antidepressants can cause rapid cycling.  You have rapid cycling, and you're on an antidepressant.  Now,  DO NOT take this as a recommendation to stop your antidepressant; but you might want to talk with your doc' and ask about whether some of your cycling might be associated with the Wellbutrin.  If you had a good response to the topiramate for suppressing binging, you might get lucky and get the antidepressant-like effect too -- but seems to me that it might make sense to taper the Wellbutrin first before you have your try.  

Everybody always wonders at that point:  hey doc', I'm already having problems with depression, and you're talking about taking away my antidepressant?  My answer usually is:  you're having problems with cycling, right?  Could the cycling be causing the depressions?  In other words, could you be having depression because you're cycling?  If that was so, we could "treat" your depression by treating the cycling, and that means: 1) using medications known to be able to stop cycling, generally "mood stabilizers"; and 2) tapering off, not just stopping, the antidepressant, since it could be that the antidepressant is causing the cycling (and ironically, thus "causing" the depressions to some extent, perhaps).  

In the meantime, there are mood stabilizers with antidepressant effects also: lamotrigine (Lamictal) is one.  Sometimes you can get more antidepressant effect from it by pushing up the dose (DON'T do that on your own either; your doc' has to know what you're doing and participate in that planning with you).  Sometimes a little bit of lithium can help, short of doses that produce any side effects.  Some evidence suggests that fish oil might help some in this way also; check that out and discuss it too with your doctor.  

A lot of work to do there, eh?  I hope you get to combinations that are even more helpful than what you're on now. 

Dr. Phelps

Published January, 2005


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