|Q: Mixed States and Antidepressants
Dear Dr. Phelps,
My 17 yo son was diagnosed bipolar last September (2000; he was
originally diagnosed with severe depression that August after a
suiciced attempt. However, after a manic episode caused by Paxil, the
pdoc went with the BP diagnosis. He is currently on 1500mg Deakote,
600mg seroquel, and 20mg paxil daily.
My son recently went into a severe depression and made a major suicide
attempt. He is currently in a residential treatment center and the
working diagnosis is bipolar mixed (don't know if this is I or II or
My question regards the medicatioins. He has had sever side effects -
notably weight gain. But, I;m very concerned about the paxil, and
whether this could be causing the depression and/or the cycling? Also,
should I push the pdoc for a different "cocktail" now that he is in a
safe and secure place?
Dear Kurt --
You can imagine how I can get myself in trouble urging you to push
your doc' for anything. I will second your concern that Paxil
can have a destabilizing effect and potentially played a role in the
recurrence; that's just a known statistic . It doesn't mean everybody
in his circumstance should come off the Paxil, so there I can't help
you further as his doc' knows a great deal more about his circumstance
It has been my practice for several years to
avoid antidepressants unless I'm really pushed into it, in bipolar
disorder (doesn't make much difference if it's BPI or BPII). (If it's
BPIII, it should be even more a knee-jerk reaction to stop the AD,
obviously). I learned from Gary Sachs at Harvard to go slow with that
process unless "pushed" by severe symptoms; so your son may well be
out by the time the AD was finally being tapered to zero, and thus the
timing issue may be somewhat moot.
I still believe very strongly in two general
principles that have guided me for years, and seem rarely to fail:
a) rely on mood stabilizers (i.e. not
particularly on antipsychotics unless overwhelming psychosis is
present; they just don't work as well as mood stabilizers); and
b) avoid antidepressants unless no "manic"
symptoms are present (i.e. don't use 'em in mixed states).
Published April, 2001