Q:  Still Have Mood Swings

Dr Phelps,
I have been diag since 1985 and have slowly increased my meds to the point that I now take 7 diff meds for b.p.

My current dr says I should be reduced to mood stabilizers. Here is what I take:
Eskalith, Lithium,Wellbutrin, Tegretol, Zoloft, Lamictol(new),and ativan.

I would appreciate your professional opinion. I still have mood swings and times of
short term anxiety (seperation anxiety w/ new wife)... Any ideas. I will f/u with my
dr.

Thanks,
Buck

 

Dear Buck -- 
In general, when a person "still has mood swings", two principles have worked well for me: 

1. Slowly taper anything that causes cycling; and

2. If that's not working, or working fast enough, add an additional mood stabilizer (if none of the mood stabilizers already in place can be increased any further because of side effects). 

So, what in your current mix might cause cycling?  Well, it's very clear that in many people, especially those with "rapid cycling" (technically more than 4 mood episodes per year, but in practice, we see folks who shift every few days or weeks, most commonly; and some who shift within a day), antidepressants can contribute in a major way to cycling.  Most mood experts agree that if someone has rapid cycling and is on an antidepressant, that medication should be tapered off. 

Tapered off means very slowly lowering the dose.  One expert recommends taking four months to stop, decreasing by 25% per month.  So your doctor may be looking at the Wellbutrin and Zoloft as candidates for tapering. 

There are clear reports of lamotrigine causing manic symptoms.  In that respect it seems to have the capacity to act too much like an antidepressant, and not enough like a mood stabilizer, at least in some people.  The role for lamotrigine in bipolar disorder is still being figured out. It seems pretty clearly to have  more antidepressant property than Tegretol, for example. 

But, overall, the name of the game is "stop cycling", which is much more important in the long run than treating any existing depression.  If you stop the cycling, many people will "land in the middle".  For those who stop cycling but are still depressed, that's where lamotrigine may have some value (allowing you to avoid antidepressants and their risk of causing the cycling to resume).  

And finally, there is one antidepressant that doesn't cause cycling.  It improves your cholesterol.  It lowers heart disease risk.  It lowers blood pressure.  It often seems to help with sleep.  It definitely helps prevent osteoporosis.  It appears to decrease or prevent PMS symptoms, and may help with perimenopausal mood swings.  It is clearly a miracle drug, and if it just came in a pill, everyone would want to take it.  Unfortunately, it causes sweating, shortness of breath, muscle pain, and it takes 30 minutes at least 3 days a week.  Got it?

Dr. Phelps