Mixed States & Mood Stabilizers
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Q:    Mixed States & Mood Stabilizers


I have been diagnosed with cyclothymia and am on 400mg of wellbutrin and 10mg of prozac and neurontin. I have read most of your Q&A and I've not seen anything quite like mine.I have very long periods(weeks to months-which seems to be getting more frquent and longer) of depression where I am not motivated to do anything and want to just literally stay in bed all day long and doing anything seems to require huge effort.During this time I am prone to extreme irritability and EXTREME!! bouts of rage about the smallest things.I have been told that the rage and anger could be my period of hypomania,although that period is also simultaneous with depression. I have done the mood chart,and I do not have periods of hypomania at all(no periods of energy,euphoria,unusual spending etc.)Rather I have periods(getting shorter and shorter) of calmness where I can control my anger and irritability and feel more "normal"and do things.My question: is this a form of bi- olar? I was on   topomax but had to get off because of extreme constipation and tingling.I had to get off depokote because my hair fell out.Is there any medication to stabilize my mood and stimulate me to get out of bed and do normal things without the rages-I have 2 children and a husband and needless to say they are suffering from my problem.I would really appreciate an answer because the meds and psychotherapy do not seem to be helping,and I seem to be getting worse.Thanks

Katherine
 

Dear Katherine

Because your history does suggest "cycling", even thought the ups are not euphoric (but rather sound more like mixed states with the more obvious depression), it does seem appropriate to be looking at mood stabilizers such as are routine in bipolar disorder (as you know, cyclothymia is a version thereof, officially).  Since you have two kids (and a husband), we might wonder if there was some reproductive-hormones-effect mixed in (bipolar symptoms have been shown to shift with the menstrual cycle, for example ).  But that is not something we know how to incorporate into treatment options yet, other than suggesting things like exercise (here's my
not-your-usual-rant about exercise) which help both PMS, most likely, and depression for sure. 

So far your medication regimen is much more reflective of trying to treat the depressive target symptoms than the newer bipolar-variation diagnosis, as you may have learned, where the latter generally follows the maxim of "mood stabilize first, antidepress second -- if still necessary". 

From your history, obviously if there was a "mood stabilizer" with strong antidepressive properties, you'd want to try that as a replacement for one and then another and then finally all three of your current medications (since all of them have the capacity to exacerbate cycling, and cycling is what you are thought to have), since without that surely you'd be worried about just getting more depressed as you tapered the current med's.  

Fortunately, you have several choices there.  First, there's lithium, the old standard, with known antidepressant properties even at very low doses (it has been used, for example, as an "adjunct" to antidepressants for partially-improved depression -- so could be used for you even without invoking the "bipolar" part of the story!  In this role as little as 300 to 600 mg, where the common full doses are more like 900-1200, might show you quite rapid benefit with little in the way of side effects, which tend to come on at the higher doses in most, thought not all folks). 

Second, to go with the medications listed by large psychiatric expert consensus reports (e.g. see my summary linking them), there's lamotrigine.  However, adding lamotrigine to your current regimen as you taper one, then another, then another, may not be the fairest trial of what right now looks like the best medication for your version of bipolar disorder -- because it may not be able to compete with the current medications in terms of stopping cycling.  

By comparison I might have a little more confidence, for that function, in carbamazepine or even it's possibly somewhat weaker but more risk-free cousin oxcarbazepine.  I would lean in this direction if you did see some benefits from Depakote before the hair problem became an issue. 

Finally, there's the new data on fish oil (omega-3 fatty acids) to consider.  Take that link for a review.  

So, in the long run, hopefully you'll have a trial of these several mood stabilizers that have antidepressant potential, without any antidepressant in the picture.  Getting from there to there will take a while.  Please don't stop or even begin to taper any of your current medications until discussion of these ideas (here are some thoughts on presenting ideas to doctors) with your doc'.  You need to have an agreed upon game plan.  As your current regimen is not typical of a regimen one would prescribe for "cyclothymia", you might also look into a second opinion, depending on what happens as you present what you've learned here and elsewhere about the consensus on treatment of bipolar disorder.  

Dr. Phelps
 

Published January, 2004
 

 

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