This Combo for Me? (Anxiety & Depression are the Factors)
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Q:  This Combo for Me? (Anxiety & Depression are the Factors)

Dear Dr. Phelps

I live in the UK and was given a diagnosis of Bipolar Affective Disorder in May 2006, hypomania with mixed episodes.  I guess this is what you call BP II in the US? 

I am on Epilum (sodium valproate) 1000mg slow release per day and 100mg Sertraline (Zoloft) per day.  Since my doctor upped my dose of Sertraline a month ago to 100mg due to anxiety I have felt worse.  The anxiety doesn't seem to be going away, almost kind of like a manic episode but not quite.

Could you please clarify for me if this medication combination is the right choice for me as my biggest problem is the anxiety/depression factor?  With many thanks and I look forward to hearing from you.

Dear Ms. W. --                   

Yes, you are correct, in the official language of the Diagnostic and Statistical Manual (DSM-IV), which is the approach used in the United States and elsewhere, hypomania with depression defines Bipolar II. However, "mixed episodes", in which depression and hypomanic symptoms occur together, is not officially recognized in the DSM and so your doctor is actually being more precise than the DSM. This may be a statement about her or him more than the country in which you reside.

As for the effect of having increased the sertraline: I certainly cannot tell you if this medication combination is the right choice for you. I try to avoid giving specific advice like that. It is not actually legally acceptable for me to do so. At the same time, what I try to do here is provide information. In that respect, I can respond to your implied question about whether the increase in sertraline could account for an increase in anxiety, "kind of like a manic episode but not quite", that is not going away.

Antidepressants are widely recognized to have the potential to induce manic symptoms, even when someone is already taking a "mood stabilizer" like valproate. In patients with Bipolar I, antidepressants can induce "mania", i.e. the full experience of accelerated thought and action (which sometimes can be a euphoric experience, but unfortunately, and unfortunately little known to many, about half the time it can be a dysphoric experience, agitation and anxiety and accelerated negative thinking).

But in Bipolar II, antidepressants can instead induce a dysphoric hypomania (as well as a euphoric hypomania, but that is obviously less relevant to your question). So one would have to ask if that might account for what you are describing. Ask your provider about that possibility. 

Interestingly, here is where the geographic difference might be relevant: in my understanding, and to a lesser extent in my experience talking with overseas colleagues, there is a tendency for American psychiatrists to be really worried about antidepressants for patients with bipolar disorder (at least some of the more prominent mood experts here), versus a tendency amongst the psychiatrists in the UK to be much less worried about this potential problem -- to the point where they look at us on this side of the pond and wonder what we are so worried about. I asked a very well-known, highly experienced, and very intelligent UK mood expert (Dr. Guy Goodwin) what might account for this transatlantic difference. His response: "you have a couple of very vocal anti--antidepressant thought leaders". I doubt that this accounts for the difference. One of those vocal thought leaders over here thinks it is a continuation of US-British antagonism dating back to the War of Independence. That is not much more useful either, is it?

In any case, you may need to be prepared for some resistance on the part of your prescriber to considering that the antidepressant might be the basis for this reaction. And, of course, she or he could be right in that respect. Or, in this case, us Yankees might have something worth considering. For an extensive presentation of the concerns about antidepressants and bipolar disorder, should you wish to or need to refer to your doctor to it, see my page on
Antidepressant Controversies. Good luck with all that.

Dr. Phelps

Published September, 2007


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