Unwilling to Prescribe Zoloft & Effexor Together
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Q:  Unwilling to Prescribe Zoloft & Effexor Together

I was diagnosed as bipolar 3 years ago after an overdose of medication.  Before that I was diagosed as depressed for 25 years. I had taken Zoloft for over 7 years before it lost its effect. Since then 4 years ago, the doctors have not been able to find a combination of drugs that make me functionable. Right now I am taking 300 mg of effexor, 300 mg of lamictal and 30 mg of tampzapam (to help me sleep). Recently the nurse practioner wanted to take me off effexor due to high blood pressure and put me on zoloft. I went downhill and went back on the effexor and then took both the effexor and the zoloft 200 mg for 2 weeks. I felt much better and was able to function better. The problem is that the np does not think I should add the zoloft to the effexor and lamictal. My question is: If I can function better with both drugs in addition to the lamictal, why is she unwilling to prescribe the zoloft in addition to the effexor? I have dealt with this for over 30 years and know when my body and moods have leveled out and I can function. Right now I can not hold a job and am barely able to take care of myself and my house. I know this is long, but needed to explain the whole situation.

Dear Ms. F' -- 
Why not go back to the Zoloft plus the Effexor, when it seemed to work?  In my view there's one semi-good reason:  mood experts seem as a group to worry about the possibility that antidepressants can create "treatment resistance", i.e. make it harder to get good results with mood stabilizers, in people with bipolar disorder.  So, the risk of restarting the combo would be that where it took 7 years for Zoloft to "stop working" (I saw a woman recently where her antidepressant worked for 10 years and then even doubling it didn't help, and her anxiety was getting really, really severe -- maybe because of the dose increase?) it might be a much shorter while before the combo stopped working, and you might be in an even worse position then in terms of trying to get symptom control. 

Notice all the "mights". None of this fear is solidly established.  It's a worry we doctors have when there's a risk we could make people worse.  If someone like you was to "make the call", e.g. lived in Mexico and could just walk in and buy Zoloft and Effexor -- would you proceed?  Or would you try to get a consultation from a doctor about how much risk that could pose, relative to more conventional approaches to bipolar disorder? 

Because that's the first question to come back to here:  do you really have a bipolar variation?  if so, then are we really ready to go "off the map" of usual approaches at this point?  or should you come back onto the map, being off it right now with the primary reliance on antidepressant medications, where the map would call for trials of mood stabilizers (with one antidepressant first; and using the antidepressant mood stabilizers first, not just lamotrigine but also lithium, and considering the new evidence on fish oil (omega-3's))....? 

But, if you were my patient, I'd listen hard to your case for going back to the combo; try to present my concerns about the risk, as above; and then let you make the call -- because we don't have enough data to say for sure that your plan is clearly risky.  

Dr. Phelps

Published June, 2003


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