Is This Combo of Meds Reasonable?
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Q:  Is This Combo of Meds Reasonable?


My husband is being treated for Bipolar disorder with many medications and it is becoming an extreme concern for me.  His current medication list is as follows:  Lithium 300mg am, Prozac 60mg am, Lithium 450mg HS, Seroquel XR 300mg HS,  Clonaxepam .25mg HS,  Nexium 40mg, Toprol 50mg, Lipitor 40mg.  He is currently at risk for diabetes.  His current weight is 332pounds.  He wore a size 36 7 years ago and now wears a 46.  My question is, is this combination of medications reasonable?  He's becoming more and more angry and agitated unreasonably so and because his doctor is prescribing these he becomes upset with me when I question it.  He has a history of drug and alcohol abuse.  He is now has 20 months sobriety.  I'm trying not to make this too lengthy.  I hope that I have given you enough information.  I'm at a loss for what to do. 

Thank you, 
 

Dear Ms. E --
Three issues stand out to my eye from your paragraph.  First, your question -- "is this combination of medications reasonable?"  Unfortunately, the answer there is yes.  Unfortunate, in the sense that all too often, successful treatment of bipolar disorder can require multiple medications, not just one or two. Your husband is on five (lithium through clonazapam in your list above).  In a research study from the mood disorders clinic at Harvard, the average number of medications for patients in their program was 4.  That was just the average.

Secondly, there is the very controversial issue of the role of antidepressants in the treatment of bipolar disorder.  Indeed, there are several controversies, and your husband's situation raises at least three of them.  First, there is the question as to whether antidepressants actually help at all in the treatment of bipolar depression.  Secondly, mood experts disagree on just how much risk antidepressants pose in terms of sometimes making bipolar disorder worse, by inducing manic symptoms (which can combine with depression symptoms to cause something called "mixed state" -- which can include angry and agitated and unreasonable behavior.  So you can see that this question is relevant).  Third, controversy also surrounds the question of whether to continue antidepressants when a patient has responded to them, or try to routinely take them back out as soon as possible.

I've summarized these three issues (and one more, about whether antidepressants carry other risks) on my website page entitled Antidepressant Controversies.  Although somewhat technical, because I have written it for primary care colleagues and psychiatry colleagues, you may be able to get through some of it.  What you'll discover is that available evidence does not clearly answer any of these questions.

However, as you will also see, it is certainly possible to interpret the available evidence as suggesting that antidepressants carry more risk than generally recognized.  If your husband was doing well, the role of Prozac in the mixture of medications is taking might not be such an issue.  (I would still think so, but many of my college would disagree.)  However, because he is clearly not doing well, I think most mood experts would look at the presence of Prozac as an important question (not necessarily assuming that it is contributing to the poor outcome right now, but certainly placing it high up on the list of potential explanations). 

Of course, what are you going to do with that information?  It is going to be tricky, it appears, from the account you provided (thank you for trying to be brief).  If you cannot get your husband to listen, you can take the risk of calling the psychiatrist directly and leaving a message.  This is risky because you may be perceived as meddling (let alone questioning the psychiatrist's judgment).  Some thoughts on how you might phrase your comments can be found in my essay on talking with doctors, although you will have to adapt them as spouse (not patient, in this case).

Finally (remember there were three different issues I wanted to address? This is the last one), what about the weight gain?  Unfortunately, this is a very common side effect from medication treatment of bipolar disorder.  Even more unfortunate, it can also be caused by the illness itself.  Probably most commonly, it comes from both.  That means that switching to medication approaches which do not cause weight gain is not necessarily guaranteed to lead to weight loss.  This is another big mess.  You'll find yet another essay on weight gain in bipolar disorder on my website, but unfortunately it does not contain any magic solutions, as you'll see.

A last thought along those lines: at his body weight, "sleep apnea" is a common problem.  This leads to difficulty sleeping which makes symptom control more difficult as well.  Sometimes treating the sleep apnea if it is found to be present, can have a dramatic impact on getting better symptom control.  Indeed, substantial evidence suggests that poor sleep can contribute directly to weight gain; and successful treatment of sleep apnea can promote weight loss.  So that is obviously worth checking out.  Your husband could ask his primary care doctor about that.

I hope something in all that proves to be of use to you and your husband --/

Dr. Phelps

 

Published October, 2008
 

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