Expert: Ivan Goldberg, M.D. - 10/27/2008

Question
Hello!
My husband of 5 years was diagnosed as bipolar 19 months ago by his psychiatrist, whom he was referred to after seeking therapy for issues dealing with a mugging.  He had been previously seen by a different psychiatrist for panic disorder in 2004 who medicated him, did not provide therapy, and later weened him off his meds and discharged him.  He was med free for 3 years.  He was recently hospitalized for 13 days following rapid cycling including suicidal and homicidal thoughts.  He was basically  hospitalized to control the rapid cycling and medication management.  He has been on a whole range of medications in the past 19 months including cymbalta (he was happy but had horrible sweating), abilify (tardive dyskinesia), wellbutrin, effexor, topamax, and some others I Can't remember.  Since being on effexor (the longest med) he was a nightmare...constant rapid cycling, suicidal, etc.  I truly believe it was the effexor, because he had never been like that before.  When he was hospitalized, he was on effexor, wellbutrin, depakote, invega, and topamax.  In the hospital he was weened off the effexor, wellbutrin, and topamax.  He recently started 50mg of pristiq, 1500mg of depakote, and invega (dosage I can't remember).  HE has only been on this combination a week and 2 days.  He is still miserable....just now he's angry all the time.  He also just recently (last night) added omega-3 supplements to his diet.  I am just wondering what to expect with this combination of medications.  How long does it take to reach therapeutic level?  Will we see a difference soon?  I know there is no magic bullet, but I hear so much positive info on pristiq...but most people see a difference right away.    
Thank you very much.

Answer
Hi Paula . . .

Effexor and Pristiq are considered by many psychopharmacologists to be contraindicated in the treatment of people with bipolar disorder.

The following is from the manufacturers official site for Pristiq:

"PRISTIQ is not approved for use in bipolar depression. Prior to initiating treatment with an antidepressant, patients should be adequately screened to determine the risk of bipolar disorder."
Source: http://www.wyeth.com/hcp/pristiq

I think your husband should be transfered to a major teaching hospital where he can be treated by psychiatrists truly expert in the treatment of people with bipolar disorder. A list of excellent psychiatric hospitals may be found at:
http://www.usnews.com/directories/hospitals/index_html/specialty+reppsyc

A list of expert psychiatrists from whom you might seek a second opinion may be found at:
http://www.psycom.net/depression.central.psychiatrists.html

Best regards . . .

Ivan
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