Dear Dr. Phelps,
I have been diagnosed with a NOS mood disorder and PTSD. After reading your website and book, I think I am soft bipolar. (BTW your insights and information is awesome! thanks for all your hard work.) I am 55 years old and I have been depressed most of my life, but never manic. In the past I have become suicidal taking anti-depressants so I have just toughed it out over the years. My current depression is so bad I gave in and went to a new psychiatrist. I have slowly titrated Lamictal to 50 mg, (after getting swollen glands, sore throat and freaking out when first trying Lamictal. Then I tried Geodon (for about 2 weeks before feeling suicidal and then Trileptal (for about 3 days before getting REALLY suicidal), so I went back to the Lamictal. So far I am tolerating it but like I said going up very slowly. However, the depression just hasn't gone away or gotten tolerable, so my Pdoc put me on Wellbutrin XL 150 this week. I have taken it for 5 days now, and although I am feeling a   LOT less depressed, I am saying things I have always suppressed and being mean to my SO. I feel terrible about this as he is trying (but I feel he is controlling and domineering) and we are going to counseling. I am wondering if the Wellbutrin is such a good thing? but at the same time I am so tired of this awful depression.


Dear K.' --

If you are really sure that there is a "causal connection" between the two -- i.e. that Wellbutrin is really the basis for this "saying things I have always suppressed", and being mean to your significant other -- then I think you do have at least a little reason to be concerned about the long-term outcomes of using Wellbutrin in this way. On the other hand, you are properly comparing and weighing the downside of the two options you seem to have at present. Hopefully your significant other can be similarly aware of the difficulty you face in weighing these two options.

Meanwhile, as I'm sure you are aware, you might get more benefit against depression from the lamotrigine (Lamictal) as the dose goes up, so that perhaps even relatively soon you might be able to take the Wellbutrin back out (only after discussion with your psychiatrist, of course, not on your own).

As you have learned, antidepressant effects that push you toward the manic side of the balance between mania and depression -- even if only manifest in terms of irritability or suicidality -- are recognized as statistically associated with a bipolar component to one's depression. In other words, even if you could not find any evidence of hypomania or mania at all, just this reaction that you keep having is suggestive of a degree of bipolarity that may warrant treating your depressions as though they were "bipolar depression". (I know that you have already read about that in my book, the part about bipolarity without hypomania or mania). By the way, Geodon is thought to have significant antidepressant-like effects, particularly at low doses, which also would be consistent with this pattern of yours in which antidepressants seem to make things worse, even if at the same time they might be making the depression side of things better, as with Wellbutrin.

So far, if I understand you correctly, I have not told you anything you did not already know. I think you're really asking about how much risk Wellbutrin might pose beyond the current irritability. Unfortunately, we have almost no data to go on there. There is some evidence suggesting that when antidepressants produce this reaction, you might be more prone to cycling, i.e. having more episodes of depression despite the antidepressant, as well as more prominent symptoms of hypomania (more than just the irritability). This evidence is summarized on my webpage about antidepressant controversies, in the section about promoting cycling. The next section thereafter, about "kindling", I hope you will understand is a theoretical risk about which I am concerned by the end for which the evidence is so difficult to gather the it will likely remain hypothetical for quite a while. Therefore it is entirely unclear at this point how much you should factor in concerns about this "kindling" risk. My working guess is that this is more of an issue for people who have substantial mood instability already; versus people who do not really cycle (into both mania/hypomania and depression). The latter group, such as people like you who only have episodes of depression, may be at less risk. Finally, I hope you recognize that that last sentence represents speculation on top of speculation, so how much weight you should place upon it is not clear -- probably not very much at all.

I hope that is somewhat useful in addressing your question.

Dr. Phelps



Published November, 2007