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    Treating depression in bipolar disorder: antidepressants versus other medicines?
    Joseph F Goldberg, MD posted:
    Hi all,

    There has been some discussion posted lately about the use of antidepressants and best approaches for treating bipolar depression. Here is a short video link discussing these issues that may be informative.

    - Dr. G.
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    mommaange1 responded:
    Thank you for this. It explains alot. Now I understand better the treatment my pdoc has laid out for me. It sounds as if I am on all the right meds.
    isntitironic responded:
    Doc G,

    So it sounds like the mood stabilizer is more important than the antidepressant in BP's. I however fall into the category of those in the "be careful" category as I am in the depressive phase and have had some alcohol issues (not severe though). To complicate things, I have ADHD comorbid with the BP2.

    I was only recently diagnosed as BP2 and for years thought I only had ADHD. I never recognized the mania in my situation until I was into the depressed phase. Only after a few sessions with the psychiatrist who had been treating me for the depression, did we recognize my recent behavior as hypomania and given the BP2 designation. At this point, I'm wondering what direction I might take as far as medications.

    Currently, for the ADHD, I take 72mg Concerta and 10mg Focalin. There is some concern that the stimulants could have contributed to the hypomania and is still somewhat suspect.

    I had physical side effects with Lexapro and the doctor is hesitant in going the SSRI direction. I'm on Wellbutrin 300mg. I took Wellbutrin in the past for mild depression and help with ADHD instead of stimulants. I worked in the past for me so the doc put me back on it.

    We are now going the mood stabilizer route. Abilify worked, but I had insomnia and came off it. Now trying Seroquel 150mg. Sleep has been an issue for me. I'm waking up in the morning and not able to get restful sleep since I was on the Abilify weeks ago. I'm drowsy from the Seroquel and need increased stimulants to stay awake during the day. Had a sleep study consult today as I have had issues with feeling rested for years, even after full night sleep. I will have the sleep study done in two weeks. If the Seroquel continues to cause me drowsiness (and some weight gain), I am wondering what the next change might be. The doctor at the sleep center (a neurologist), suggested I bring up Lamictal as an alternative. She also suggested Intuniv for sleep issues and ADHD treatment.

    Wondering if you have any thoughts on the approach we are taking.

    Thanks ahead.
    isntitironic responded:
    Thought I would repost a reply that Dr. G. gave to a question I asked regarding this issue:

    Dear Isntitironic,
    In people who have bipolar II disorder (ie, low grade highs, or hypomanias, that don't interfere in themselves with the ability to function), it is almost always the depression that leads to problems -- the minor highs can easily get missed since they don't cause trouble (by definition), and by comparison to depression may feel like a good, enhanced state. Depression predominates over hypomania by a time ratio of about 38:1 according to studies from the NIMH, meaning that depression is the dominant problem. Unfortunately it is also the harder problem to treat. Traditional antidepressants like Wellbutrin may not necessarily work as well in bipolar depression as in unipolar depression -- that is the main concern. One large study found no better antidepressant response to a mood stabilizer Wellbutrin as compared to a mood stabilizer alone, meaning that it isn't clear Wellbutrin necessarily brings a lot more to the table than does just lithium or Depakote. Possibly an advantage, as the name "antidepressant" would lead you to think, but not necessarily.

    In people with bipolar II disorder, there is a low (but not zero) risk that an antidepressant could push one's mood into a hypomania, but this risk is much lower than is the case in bipolar I disorder. The role for mood stabilizers like lithium and Depakote in bipolar II depression also is more debated than is the case in BP I disorder. Frankly, the best-studied treatment for bipolar II depression is the drug Seroquel dosed at 300 mg/day -- it has 5 positive placebo controlled trials and is the only drug approved by the FDA specifically for bipolar II depression. Some doctors still think of it as an antimanic or antipsychotic drug, where is was first used, but for those who keep up with the medical literature, there is abundant evidence to support Seroquel's antidepressant properties in bipolar depression. It can cause weight gain and drowsiness which also dissuades some doctors from using it. The drug Lamictal also has antidepressant properties, in part against preventing relapses but also when used in a regimen (eg, combined with Seroquel). The third drug that has strong data for bipolar depression is Symbyax, which is a combination of Prozac plus Zyprexa. All 3 of these drugs would be considered as especially useful in bipolar depression.
    There is nothing wrong with using antidepressants so long as they are not making your mood elevated or hyper, but if you and your doctor notice no improvement within a few weeks, it may be worth revisiting the question of whether medicines more specific to bipolar depression would be worth considering, such as one of these 3. - Dr. G.
    Joseph F Goldberg, MD replied to isntitironic's response:
    Dear isntitironic,
    Seroquel is one of the best-studied treatments for bipolar depression. If you are taking it in combination with a stimulant, that ought to counteract sedation. Some people think the XR formulation of Seroquel may cause less drowsiness than the immediate release form. In bipolar depression, the antidepressant target dose was 300 mg/day in the research studies that were done. Combining Lamictal with Seroquel also can be a potent and synergistic pairing, so I would not think of them as mutually exclusive options.

    Good luck.

    - Dr. G.
    Joseph F Goldberg, MD replied to isntitironic's response:
    also...Intuniv, approved for ADHD, seems to help more for disruptive or hyperactive behavior (the "h") than attention (the "a").

    I'm not sure I would think of it as a sleep aid.

    Dr. G.
    mommaange1 replied to isntitironic's response:
    What time do you take your serequel? I take mine about 6:00 everynight and do not take any during the day. Usually by 9:30 or 10 I am asleep. I just increased my dose to 600mg so I am getting sleepy a little earlier until I get used to it. My pdoc said to absolutely not take it during the day since it causes extreme sleepiness.
    isntitironic replied to mommaange1's response:
    Haven't been taking it until around 9 or 10. Perhaps I will try now. I so need a good night sleep.
    isntitironic replied to Joseph F Goldberg, MD's response:
    I am taking the Seroquel XR formula in combination with stimulants and Wellbutrin. I just bumped the XR up from 50mg to 150mg yesterday. I've seen you say that there is evidence that Wellbutrin does not help bipolar, however I understand there is evidence it helps with ADHD. With the comorbidity issue of two conditions, finding the right mix is really, um, interesting. The stimulants are counteracting, but not enough and I am on 72mg Concerta and 10mg Focalin. We'll have to see how I do.

    The Intuniv, was recommended as something to look at by the director, a neurologist, of the sleep center. She claims it helps with sleep while also helping ADHD.
    Joseph F Goldberg, MD replied to isntitironic's response:
    Intuniv's most common side effect is sedation, so, I guess one could construe that as helping with sleep.

    - Dr. G.
    outreach1952 responded:
    Dr. Goldberg,
    The video was helpful. How do you go about talking to your MH doctor about these meds for bi-polar disorder?
    The ones I am on is not effective. Zoloft and Busporone? I have asked him about different medication and he says that these are effective.
    margaroo replied to outreach1952's response:
    Dr G.

    Thank you for the link to the video. I could trace back in my mood journal and better understand why the different drugs were given each time.

    Why can it take so long for BP to be diagnosed? I was being treated unsuccessfully for depression for 3 years. I made a trip to the ER for a migraine when the ER doctor made the correct diagnosis of BP II.

    Thanks for your time and attention to this board.

    Joseph F Goldberg, MD replied to outreach1952's response:
    Dear Outreach1952,

    Be direct. Tell your doctor about the depression symptoms you may still be experiencing. Zoloft can be effective for some people, but if you are still having depression or anxiety symptoms, then by definition the current treatment is not fully effective. Take a Beck Depression Inventory ( ) and rate it, then bring it to your appointment. Ask the doctor about FDA-approved treatments for bipolar depression (like Seroquel or Symbyax), or medicines that have been shown in research studies to work better than a sugar pill (e.g., Lamictal, lithium).

    Good luck.

    - Dr. G.
    Joseph F Goldberg, MD replied to margaroo's response:
    Dear Maggie,

    Lots of reasons why bipolar disorder may go undiagnosed when it is present. If only hypomanias occur, patients and doctors alike may not attach clinical importance to them or think of them as simply the resolution of depression. People also seldom "complain" about hypomanias (nobody has ever come to me to ask for help because they feel very productive and charismatic and successful). People with bipolar I disorder often lack insight about the presence of high periods and may conceal them. Doctors sometimes neglect to ask about high periods (or other comprehensive psychiatric symptoms that might go undetected, like psychosis, or substance abuse). Mania is much much easier and obvious to diagnose than hypomania. As it is said, manics get hospitalized and hypomanics gets job promotions.

    - Dr. G.
    lotus responded:
    [TRIGGER] I have bipolar 2. I have bee mostly very depressed and suicidal for the past 12 years. I had a hypomanic period 2002. I had my second ep[isode of hypomanic started 2-3 months ago and it is not getting better. My seroquel has been increased to 800mg qhs and topamax 50mg was added 2 months ago. I am on Cymbalta 60mg QD , Wellbutin XL 300mg QD Trileptal 600 mg BID. Would decreasing my antidepressants help me with my hypomania. I did find your video very informative. thanks Donna

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