AD's & Depressive Episodes : Tiagabine (Gabatril) : Therapy & Bipolar II
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Q:  AD's & Depressive Episodes : Tiagabine (Gabatril) : Therapy & Bipolar II


Thank you for your letter. Forgive my acronyms. I used EST to describe electroshock therapy, instead of electroconvulsive therapy, and I wasn't certain what term was used for TMS. Your reply was thorough and thoughtful.   I have three more questions for you, if you have the time and energy.
1) Do you feel anti-depressives should be tapered and then discontinued in a bipolar II patient, after a depressive episode?  The patient (my husband) no longer has hypomanic episodes and suffers from depression most of the time. Besides  Effexor and Wellbutrin, he is on Geodon, Neurontin, Klonopine, and Trazadone. In the past, his depressive states have been poorly controlled.
2) Have you heard of a new, non-FDA approved drug for Bipolar, called Gabitril? My husband was on it, grew quite ill and now has elevated liver enzymes( SGOT/AST). They are slowly declining once he stopped the medication (and no, he does not drink).
3) In your opinion, what type psychotherapy is best for bipolar II - psychoanalysis, cognative behavioral  therapy or both? something better?
Again, thank you for your expert advice and free column. We live in a rural area in Vermont and do not have the best available resources. I love my husband dearly and we need help.                   

Dear Ms. F' -- 
Understood (no worries about the acronyms, of course...)

1.  This is a large and controversial question.  There might be one important clue in your story here:  husband suffers from depression "most of the time", i.e. not all the time.  This might mean he's "cycling", in which case there's a general approach to be considered in discussion with his current doc':  if he's really "cycling", then a strategy for dealing with the depression, beyond the current two-antidepressant-plus-Neurontin approach, which appears not to be working sufficiently well (maybe better than before though, from the sound of it?), would be to target "cycling" instead of targeting "depression".  

For that target, from where you are now, the strategy would shift from emphasis on antidepressants to emphasis on mood stabilizers (preferably those with antidepressant potential, or at least emphasizing those in the selection from the mood stabilizer list, thus looking particularly at lithium and lamotrigine, perhaps thinking of them as substitutes for the antidepressants if it was agreed that the AD's weren't working, or not working well enough).  

2. There was a flurry of interest in tiagabine (Gabatril) which died down in a hurry.  I have not used it.  Rumor has it that it's pretty sedating, sort of a substitute for benzodiazepines like Klonopin and Ativan and Valium, no other clear value.  A Pub Med search of "tiagabine bipolar" turns up an open trial on 17 patients by Suppes et al from the Stanley Foundation Bipolar Network, and as will note from their abstract, it didn't look too good there either.  

3. There is no data (to my knowledge) on therapy for bipolar II per se.  There is data on therapy generally, though, showing that cognitive/behavioral; interpersonal; some group approaches; work very well in a wide variety of conditions.  There is no such data for psychoanalysis and there is little reason, in my view, to pursue analysis per se; however, a good therapist will always use some of the psychodynamic principles (such as an understanding of the importance of "transference", for example) which derive originally from Freudian psychotherapy.  In your circumstance, it's going to be tricky to find somebody good.  Here are some ideas on finding a therapist.   Many people, with many different kinds of problems, can benefit from a good therapist -- including people with bipolar II !  

Dr. Phelps

Published April, 2003


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