Expert: Ivan Goldberg, M.D. - 5/29/2008

Question
Dr. Goldberg,

First I'd like to thank you for your long time efforts to increase professionals and patients' understanding of mood disorders.  

I actually have several questions in re: to my husband of 25+ years, who in the past 18 months appears to have lost most of the wonderful characteristics that defined him: empathy, compassion, self awareness and insight, ethics, and most of all, the ability to love.  An executive, he is still able to function at work, but has now damaged every single personal relationship with people he has always loved, and who love him.  Please forgive my lengthy post.  

He was diagnosed with Bipolar II some years ago, and every psychiatrist he has seen has insisted on placing him on Prozac, most often without a mood stabilizer, but even during the brief periods when he took a mood stabilizer he was kept on an SSRI.    Now he has chronic mixed state (agitated depression, but he does not "feel depressed"), and rapid cycling (sometimes within minutes).  He alternates between "feeling great" and "feeling dead" within the space of hours.  His now very erratic thoughts, behaviors, and feelings are far beyond anything I've ever seen in him. His psychiatrist and therapist are beginning to believe that something else is going on, not just BP, such as dementia.  But we wonder if the dramatic worsening of his BP symptoms (compared to his history) could be a function of long term use of SSRIs without a mood stabilizer.    

In recent years, he has added sexual and gambling compulsions to the symptoms that have cost him his family and his financial security, so it is hard to know how much addiction itself may be aiding this deterioriation.   The costs to him, or to those he loved, no longer have meaning to him.  

1.  Since early onset dementia can look similar to deterioriating BP II symptoms, what would you as a physician look for to help differentiate between the two, and are there other disorders that can trigger such deterioriation that should be considered?

2.  When he took Lamictal a few years ago (with Prozac and Wellbutrin) after many months he began to experience odd cognitive impairment, with  marked memory loss, inability to "connect the dots", feeling somewhat dazed - he was "spacey" for lack of a better term.  At that time he and his family doc both wondered if he had early onset dementia - but the symptoms abated when he went off Lamictal.  A year or so later he went on Topamax (again with Wellbutrin and Prozac), with similar results, and went off it.  There is little reference in the literature re: these reactions, and I wondered if you have ever seen or read about rare cognitive side effects with Lamictal or Topamax?

3.  After doing a great deal of research, he has gone off Prozac (against his doctor's advice) and just had Depakote SR added to the  Wellbutrin.   He has never had a course of a mood stabilizer alone - would it make sense to ask his psychiatrist if he should try that?  (His psychiatrist is one who believes an antidepressant should always be added to a mood stabilizer for treatment of BP II.)  

4.  Two years ago his psychiatrist added Cytomel to the cocktail to address a Major Depressive episode, which seemed to have great success at least temporarily.  However, some of the research on Bipolar suggests that  it is T4 that should be added, not T3.  What is your own opinion on thryoid medications for the tx of BP II or other depressive disorders? And could Cytomel trigger a significant decline in functioning for a patient with BP despite its initial efficacy?  

Answer
1.  Since early onset dementia can look similar to deteriorating BP II symptoms, what would you as a physician look for to help differentiate between the two, and are there other disorders that can trigger such deterioration that should be considered?

I would refer a patient with suspected early dementia to a university department of neurology for a full evaluation that should include, blood and urine tests, MRI, SPECT or PET scanning, a full neuropsychological evaluation and an examination by a behavioral neurologist.
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2.  When he took Lamictal a few years ago (with Prozac and Wellbutrin) after many months he began to experience odd cognitive impairment, with  marked memory loss, inability to "connect the dots", feeling somewhat dazed - he was "spacey" for lack of a better term.  At that time he and his family doc both wondered if he had early onset dementia - but the symptoms abated when he went off Lamictal.  A year or so later he went on Topamax (again with Wellbutrin and Prozac), with similar results, and went off it.  There is little reference in the literature re: these reactions, and I wondered if you have ever seen or read about rare cognitive side effects with Lamictal or Topamax?

There is nothing rare about the cognitive effects of Lamictal and Topamax (as you may know Topamax is often referred to as "Stupidmax" because of these effects. The bad news is that such effects are mush more likely to occur in someone with an already damaged brain, and as you may know, long term bipolar disease has been shown to have negative effects on brain function. The cognitive effects of Lamictal and Topamax disappear a week or so after the medications are stopped.
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3.  After doing a great deal of research, he has gone off Prozac (against his doctor's advice) and just had Depakote SR added to the  Wellbutrin.   He has never had a course of a mood stabilizer alone - would it make sense to ask his psychiatrist if he should try that?  (His psychiatrist is one who believes an antidepressant should always be added to a mood stabilizer for treatment of BP II.)  

One of the biggest controversies in psychiatry these days is regarding the treatment of depression in people with any form of bipolar disorder. Some academic researchers have proposed that no patients with bipolar disorder should ever receive an antidepressant, while many of us who treat large numbers of people with bipolar depression believe that some individuals with bipolar depression must receive antidepressants to feel well. I have never met a psychiatrist who believes that all people with bipolar-ii should receive antidepressants. I have no idea who is treating your husband but wonder if he needs, at the very least,a consultation for a second opinion with one of the doctors at my list at: http://www.psycom.net/depression.central.psychiatirsts.html
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4.  Two years ago his psychiatrist added Cytomel to the cocktail to address a Major Depressive episode, which seemed to have great success at least temporarily.  However, some of the research on Bipolar suggests that  it is T4 that should be added, not T3.  What is your own opinion on thyroid medications for the tx of BP II or other depressive disorders? And could Cytomel trigger a significant decline in functioning for a patient with BP despite its initial efficacy?

Both T3 and T4 and effective as ways on potentiating antidepressants. There is no way that either of these medications (unless grossly overdosed) would lead to a significant decline in functioning.

Best regards . . .

Ivan
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