Feeling Down Again, Asks if Another Med Could be Added
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Q:  Feeling Down Again, Asks if Another Med Could be Added

I have been diagnosed as having bipolar and am currently on zyprexia 20mg and lithium 800mg. I am starting to feel very down again and was wondering if there is another medication that could be added to this to control it. My Doctor is reluctant to prescribe an anti-depressant because of the risk of mania. As a short term measure he has prescribed valium. I have previously been on depakote with minimum effect so this was stopped

Dear Julie
In these circumstances I usually turn to my mental list of
nine antidepressants that aren't antidepressants (the link goes to a page on my website that walks you through them all).  If you are already on two out of nine.  Although Depakote is not officially on the list, there is one small randomized trial showing that it too can have antidepressant effects, more than a placebo.  So that makes 10 options total, leaving 8 for you to examine.  You may well have been on several of those, but I'll bet a few would be new to you.

The point is, like your psychiatrist, I am generally reluctant to use an antidepressant (one of the medications we usually think of when using that term, such as citalopram (Celexa), or fluoxetine (Prozac), or venlafaxine (Effexor)). So I made the list of nine options to present when my patient and his or her family might otherwise be thinking it is time to add an antidepressant medication.

After all that, when my patient has tried everything on that list that she or he is willing to consider (some of them are not options for everyone, for varying reasons), then I might consider adding an antidepressant.  At that point, I think many mood experts are starting to think that the best option is bupropion (formerly Wellbutrin, now generic even in the once-a-day XL version).  It appears to be less likely to destabilize things than venlafaxine, for example, and perhaps even less than all of the other alternatives.  Some data suggest that it may not be very destabilizing at all, and many people.  What I have definitely seen it trigger a swing toward manic symptoms, within several days.  For example, I recently predicted to myself on a Thursday that "by Monday, he'll be much better, something dramatic will have happened"; and the patient came back indicating that on Saturday, he had a really "great day", but by Monday, though still better than he was (just about ready to be put in the hospital, he was so depressed), things were getting complicated, more "mixed" between manic-like symptoms and depression.  In other words, at least in a few people, even bupropion can have too strong an antidepressant effect, leading to fluctuation and mixed states.

I hope you'll find something useful in all this.  Good luck --

Dr. Phelps

Published January, 2009

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