How could a pregnancy throw me so out of whack that I need all these new meds?Any chance I could get back down to just the Ef...
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Q:  How could a pregnancy throw me so out of whack that I need all these new meds?
Any chance I could get back down to just the Effexor, or is my brain permanently changed?
Any ideas for countering the spaciness?

Until I was 39, I thought I had unipolar depression and attention deficit disorder. Taking just  Zoloft, then just Effexor, worked well for 12 years.  I felt myself going into several depressions during those years, but high doses of Depakote brought me back to normal within a few days, then I'd taper off the Depakote.  Then I had a baby and a hard-to-treat post partum depression.  Now my diagnosis is bipolar II.  I take Effexor, Depakote, Lamictal,  Concerta,  and Aricept to counter the spaciness/memory loss from the Lamictal and Depakote.  If I go down on Lamictal or Depakote, I feel less spacy but my mood worsens.
   A few questions:
How could a pregnancy throw me so out of whack that I need all these new meds?
Any chance I could get back down to just the Effexor, or is my brain permanently changed?
Any ideas for countering the spaciness?  Aricept helps some, but I still feel foggy.

Dear Ms. G' -- 
Some thoughts. That's important to admit: these are thoughts based on your account here, which anyone can see represents a very complicated situation, if only from the number of medications; and presuming each of those is there for a reason, a complicated story as well. Moreover, my main comment here is going to reflect my usual knee-jerk, and not a thought which arises specifically in response to your particular question. When I get my knee settled back down, we'll see if I've got any time left to go on! 

Actually, I can start with one part your question and stick to it, namely  "How could a pregnancy throw me so out of whack that I need all these new meds?" First of all, post-partum depression is common in bipolar disorder, that's very clear. And  I have heard something like this from many women.  I've heard it so many times that I have a pet theory, in fact, namely that it's the second pregnancy when things really change for a lot of women, more so at least than the first, in at least a subset of women (possibly those with less pronounced versions of bipolar disorder, as they're over-represented in my practice). That's when the bipolar symptoms, that might have been there but fairly mild, not requiring treatment, really show up. 

Unfortunately, to my knowledge this has not been studied directly, but it sure seems to me -- based on listening to a lot of patients' stories -- that pregnancy changes people. Well of course their lives change big time, so it would be hard to know if it was the hormonal experience of pregnancy or the life-style change (e.g. getting awakened in middle of the night repeatedly for a few months or longer). On the other hand I think I've heard this from women who've had a late term miscarriage as well, with grief but none of these big lifestyle changes (and, interestingly, it seems to me that I've not heard the same story from women whose miscarriage was early in the pregnancy; I don't have a big enough sample to know where the shift from no-impact to maybe-impact lies in terms of months of pregnancy). 

That's all by way of saying that there is evidence, at least in my experience and practice, that pregnancy does indeed change some women such that their bipolar disorder (or some similar mood phenomenon that may be more closely related in some way to PMS than to "bipolar" per se, in those less directly-affected women) is worse: harder to manage, not responding to the same approaches she was using before that child was born.  

Now for the knee-jerk part. Your recollection of Effexor is understandably fond: things were a lot easier back then. Anyone with that experience would think "can I somehow get back there?" Unfortunately in my experience, it seems this is not common. The only time I've seen such success is when some factor that's been worsening things all along finally goes away. This includes alcohol, problematic ex-husbands, extremely stressful jobs (maybe having young children qualifies there, not sure), shift work, that kind of thing. Instead my experience has suggested, repeatedly, that the antidepressants themselves might be part of what changes people. This is a frightening thought, full of implications, but so important, I published a case reportPhelps of a woman whose response to antidepressants was like yours, though not 12 years: for 7 years, she did beautifully on Zoloft (Prozac and Paxil both were ineffective before that). Then she developed a severe agitation state that only went away when we took the Zoloft out. She too wanted to go back to it, that same logical wish. So she did, on her own, but a quarter of the previous dose induced the same agitation within three days. So somehow she was different. And she had no pregnancy to confuse matters. 

But my jerking knee does have one practical value, perhaps: we have to ask if the antidepressant, in your case, might now be part of the problem, despite having been such an excellent part of the solution for so long. I hope you can see that this is the implication of the case report above. It's also the implication of years of mood experts writing that in "rapid cycling" bipolar disorder, which I'd bet is the pattern you now have (being female increases the likelihood of that being the case; so do the number of medications you're taking, suggesting that controlling cycling has been difficult; and finally, that antidepressant is still in there. I'll bet the dose now is higher than it used to have to be, though if it wasn't, that wouldn't blow my theory), one of the most logical first steps in treatment is to gradually withdraw the antidepressant (gradual in this case means at least 4 months, in my opinion). 

The idea would be to wonder whether the antidepressant might now be part of the cause of cycling such that you now need "all these new meds". Mind you, this is just an idea, one you'd need to discuss with your doctor, and your doctor may not agree. Your doctor could be angry for my even having raised this issue. And it might not apply to you, that's why I emphasized at the beginning of all this my "knee-jerk" reaction, which is to look at any patient who's on multiple mood stabilizers, and not doing well, who's also on an antidepressant, and wonder just this way: could the antidepressant be part of the problem? 

The good news is that thinking like this opens the possibility of a new treatment approach that does not require adding yet another treatment, but rather just the gradual removal of one. Many people with list like yours were on the antidepressant before the rest of the medications were added. In many cases, they've not tried gradually taking the antidepressant out, as one of the options for addressing repeated episodes of mood problems -- including depression. That's not surprising: why should you consider taking the antidepressant out when you're still having so much trouble with depression!? That sounds completely backwards, doesn't it? I admit, it's very counter-intuitive, but it makes sense according to what most mood experts think, which is that antidepressants can cause rapid cycling, or at least make it worse (in other words, this ain't my idea alone, I have a lot of august company on this one.  But this is why I've put a lot of energy into the page on my website about Antidepressant Controversies, because a lot of practicing psychiatrists don't agree with me on this, including perhaps your doctor, in which case I apologize for putting you in an awkward position, but you asked, so I'm trying to answer your question -- including the one specific question, to which I'll finally now turn...)

"Any ideas for countering the spaciness?"  If there's any merit to the whole idea above, then the other good news is that once in a while I see patients whose rapid cycling is actually related to their "spaciness" (poor memory, can't concentrate). See the essay, for example, summarizing a similar line of thought about rapid cycling and mixed states.  If that was true, and if you had less cycling without the antidepressant, then there's one more way this all might address your spaciness, in that you might be able to get away with less of the new medications, one or several of which, or the combination of them, might be part of the problem. 

Good luck trying to deal with all this, including this long answer. 

Dr. Phelps

Published November, 2006

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