Expert: Ivan Goldberg, M.D. - 2/3/2008

Question
Hello Dr.Golberg,
I am 38 yrs.old. I was diagnosed with bipolar disorder twenty years ago. I have been on fluoxetine for abt. 7 years. I recently started getting depressed (due to several life changes in the last two or three years). One big one was my mother passing on after a long illness in which I was one of her patient advocates. There are several other things within my family that have caused stress/grief as well.
My question is that now I am on Cymbalta (30 mgs)./once a day. I read about the drug in the package it came in from the pharmaceutical co. and it said it was not intended for use with people with bi-polar disease. Why is this? And, also I am on depakote and have been for about 8 years and I am losing some hair now (due to stress & the drug). I was wondering if there is another mood stabilizer that might be just as good as depakote, but w/o the side effect of hair loss? I am very aware of my meds. and want to make sure I take only what will work for me, and find out all I can abt. them.
Thank you,
Kelly

Answer
Hi Kelly . . .

People with any form of bipolar disorder should generally avoid taking antidepressants as antidepressants can lead to episodes of mania, mixed (manic   depressed) states, and rapid cycling between mania and depression.

Generally when someone with bipolar disorder becomes depressed they should be treated with lithium (or another mood stabilizer) plus Lamictal.

See:
http://www.psycom.net/depression.central.lamotrigine.html

Here are some abstracts on the topic of the use of antidepressants in people with bipolar depression:

1: J Affect Disord. 2007 Nov;103(1-3):13-21. Epub 2007 Jul 6.

Bipolar pharmacotherapy and suicidal behavior Part 2. The impact of
antidepressants.

Yerevanian BI, Koek RJ, Mintz J, Akiskal HS.

Department of Psychiatry and Biobehavioral Sciences, David Geffen School of
Medicine, University of California, Los Angeles 16111 Plummer Street, North
Hills, CA 91343, United States. byerevan@ucla.edu

Antidepressant-induced mania and cycle acceleration is a potential risk in
bipolar patients. Another serious risk of antidepressants, that of increasing
suicidal behavior, has been identified in some affectively ill populations.
However, there is a dearth of knowledge about the effects of antidepressants on
suicidal behavior specifically in bipolar patients. METHODS: Retrospective chart
review of 405 veterans with bipolar disorder followed for a mean of three years,
with month by month systematic assessment of current pharmacotherapy and suicide
completion, attempt or hospitalization for suicidality. Chi-squared comparison of
(log) rates of suicidal events during mood stabilizer monotherapy, antidepressant
monotherapy, and combination of mood stabilizer and antidepressant. RESULTS:
Suicidal behavior event rates (per 100 patient years) were greatest during
treatment with antidepressant monotherapy (25.92), least during mood stabilizer
monotherapy (3.48), and intermediate during mood stabilizer   antidepressant
combination treatment (9.75). These differences were statistically significant.
LIMITATIONS: In a clinical setting, antidepressants may have been prescribed
because patients were deemed at greater risk of suicidality. CONCLUSIONS: During
treatment with antidepressants (even when coupled with mood stabilizers),
patients with bipolar disorder have significantly higher rates of non-lethal
suicidal behavior compared to those on mood stabilizers without antidepressants,
and thus require careful monitoring.

Publication Types:
   Research Support, Non-U.S. Gov't

PMID: 17617467 [PubMed - in process]

2: Ann Clin Psychiatry. 2007 Oct-Dec;19(4):305-12.

Differentiating bipolar disorders from major depressive disorders: treatment
implications.

Muzina DJ, Kemp DE, McIntyre RS.

Cleveland Clinic Neurological Institute, Psychiatry