Q:  Depression or BP after Chemotherapy

I have been diagnosed with "mild" bipolar disorder.  After trying many mood stabilizers I have settled on Ativan and Prozac for depression.  I've been taking Prozac for 6 yrs.  My question is...I have been diagnosed with ovarian cancer, had surgery and underwent chemotherapy.  I just finished my last treatment.  Depression has been slowly creeping up on me and I've tried raising my Prozac (with Dr. approval), but it doesn't seem to be helping.  Do you have any advice regarding depression or bipolar after chemotherapy.

Thanks,


Dear Ms. B. --

Complicated situation.  Sorry to hear that you face this. First of all, we can ask, as you are probably asking here, whether chemotherapy somehow changes one's physiology such that treatment must be changed accordingly. To my knowledge, we have no data on that. I've never seen anything suggesting that this was necessary. However, you can imagine how competition it would be to try to figure that out, given all the variables which could be affecting mood after chemotherapy.

Beyond that, there are numerous options for "augmentation" of an antidepressant strategy that is no longer working well enough. Most of the data come from the study of "unipolar" Major Depression, and we apply them to bipolar disorder only by extrapolation. Some recent rather strong data suggest that antidepressants do not have lasting value in patients with bipolar depression, but obviously your experience has been quite the opposite. As you explained, your "mild" bipolar disorder may not need to be treated from a point of view emphasizing cycling as the target (the usual approach and bipolar disorder management) but rather just the depression itself, making the challenge more like what we face in Major Depression. Therefore the augmentation agents for this purpose may be just those which you now need to consider.

Perhaps at the top of the list should be psychotherapy, although you may already have some form of this underway. As you may know, there are at least two studies showing better cancerous survivorship in those who had a group-model psychotherapy in addition to the rest of their cancer treatment. However, finding such treatment, which in one of these studies was conducted by some of the world's experts in group psychotherapy, at Stanford, would be difficult. We cannot be certain that more "generic" psychotherapy we carry this benefit. Nonetheless, psychotherapy clearly has been shown to be a good augmentation agent and so deserves to be high on your list of options.

As for medication approaches (assuming that you have a good exercise program underway, as exercise also has good data showing efficacy in depression), there are at least three common tools to consider. Lithium, bupropion (formerly Wellbutrin, now generic), and Cytomel (a form of thyroid hormone,tri-iodothyronine) have all been shown to be of benefit as add-on medications when an antidepressant is not working well enough. Lithium has the advantage of providing an anti-cycling protection, whereas bupropion could increase the risk thereof, and perhaps Cytomel as well although this is less well understood (another form of thyroid hormone, levothyroxine, may have more of a mood stabilizer effect, at least that high doses, but its role in your circumstances would be much less clear).

Hope that gives you some raw material for discussion with your providers.  Good luck with all that.

Dr. Phelps