Q: Depression & Other Med Options
Dear Dr. Phelps,
I lowered my dose of Wellbutrin on my own after a really bad mixed episode. AT
the time I was also taking Trileptal. I had to be taken off the Trileptal due
to a sodiom problem; otherwise it worked very well. After I graduated, I went
off Depakote ER and continued taking a low doss of Wellbutrin with no problems.
I even did okay managing time zone changes. Now I find myself slipping into a
deeper and deeper depression. My new pdoc wanted to put me on Depakote and
Wellbutrin. I don't think the Depakote will help my depression. I'm wondering
whether or not Lamictal would be a good option. I would like to consider it if
it doesn't cause mania. What are some other options? Have you had any
experience with Keppra?
Dear Jane --
You've done well educating yourself on this stuff. Unfortunately your
experience is all too common. We see this "prozac poop-out"
commonly as a manifestation of bipolar disorder (I'll assume that's your
diagnosis and that there's not too much question about that, for now).
People switch to a different antidepressant and do well for a while, commonly,
then the depression comes again even while taking a medication that seemed to be
So, then what do you do? Well, if your symptoms
have been predominantly depression, lamotrigine is indeed something we're
using for that situation. I don't trust it yet as a "pure mood
stabilizer" for people who have both clear manic or hypomanic symptoms, and
depression. I also don't trust it not to induce manic symptoms; in fact, I
see that fairly commonly, so generally, for now at least, use it with another
mood stabilizer -- unless the person just has had recurrent depression, with
only a slight hint if any of manic side symptoms (sounds like, with your bad
mixed state episode, this doesn't describe you so well).
Depakote and lamotrigine have a well-known interaction
you've probably already learned about, increasing each other's levels
substantially; but otherwise, this is not a problematic interaction and some
mood experts think this is a particularly good combination. So, if your
pdoc's first move here, which is also a smart one, doesn't work, you could
switch Wellbutrin to lamotrigine as long has she/he is careful about this
interaction. See my
guidelines for an example of how differently one proceeds with lamotrigine
when Depakote is already on board.
However, this first move of adding Depakote -- it could
indeed help with the depression. For one thing, fairly often Depakote will
have some antidepressant oomph itself. Skeptics on that should check out
the article by
and Ketter, for example; if you look at the article itself (as opposed to
the abstract I linked) you'll find a stunning antidepressant response in this
particular group of patients.
But here's the most important thing: the trick is
to think of depression as cycling. You cycled into
depression while on Wellbutrin. If you had a mood stabilizer on board, you
might not have. But what about now? You're depressed now. How
to get out of this? Well, you're right, Depakote being added might not do
it, Winsberg et al notwithstanding. If you rapid cycle, you might just
cycle out and then again, the name of the game is to prevent cycling down
again. But what if you don't? what if you stay depressed on Depakote and
Wellbutrin? For starters, I'd emphasize the importance of exercise as a
known antidepressant with no risk of inducing mania, although it's hard enough
to do when you're not depressed, let alone when energy and motivation are low as
in depression phases.
But beyond that, you'll have to follow the lead of your
doc'. I lean strongly away from using antidepressants in that circumstance
for fear of inducing yet more cycling, but many would switch you. I'd turn
to lamotrigine then, although it's admittedly slow.
Good luck, and congratulations on what you've learned
already. Stay at it!
Published August, 2002