Expert: Ivan Goldberg, M.D. - 7/17/2008

Question
I have been suffering with Bipolar II for 5 yrs - I am 25 yrs old. I may have had it at a younger age but was not diagnosed til 20 yrs old. I am currently on Symbyax 6mg/50 mg. I take one pill evry night around 6:00 pm. Here lately I feel very hypomanic. I am doing the same as always drinking 4 cups of coffee throughout the day and other caffeine products always have and I smoke always have. I feel like my child and husband are always going to die - I pray to God why please keep them safe. I am always scared to hold my daughter because I may snap and yell at her when she is not doing anything wrong. I feel like Jekyll and Hyde. What can I do I have a Dr. appt on July 31 to renew my meds. Trust me they work but I use to take Buspar and Prozac instead and the buspar worked well with me. I may ask him to prescribe the buspar again. Due to it being non habit forming. Do you suggest anything that I can do and why I may be feeling this way? Everyone at work are always on my last nerve and I just cannot seem to focus on the tasks at hand.

Answer
While I am not allowed to give personal medical advice I can say something in general about the treatment of people with bipolar disorder.

The most important medications for the treatment of people with bipolar disorder and a group of drugs often referred to as mood stabilizers. There medications include lithium, tegretol, depakote, Trileptal and Lamictal. Many psychiatrists believe that the use of antidepressants to treat people with bipolar disorder is dangerous and drugs such as Symbyax, whiel approved for the treatment of people with bipolar disorder carry the risk of permanent neurological complications (tardive dyskinesia) and a severe condition knows as neuroleptic malignant syndrome.

Below are a few abstracts of articles from medical journals that you may find interesting.

I usually advice my patients with bipolar disorder not to drink any caffeine containing beverages at all as at the very least it increases anxiety and irritability.

I think it might be a good idea for you to get a second opinion regarding your treatment. A list of doctors who are experts when ti comes to the diagnosis and treatment of people with bipolar disorder may be found at:
http://www.psycom.net/depression.central.psychiatrists.html

Abstracts:
1: Am J Psychiatry. 2004 Jan;161(1):163-5. Links
Antidepressant treatment in bipolar versus unipolar depression.Ghaemi SN, Rosenquist KJ, Ko JY, Baldassano CF, Kontos NJ, Baldessarini RJ.
Department of Psychiatry, Cambridge Hospital, MA 02139, USA. ghaemi@hms.harvard.edu

OBJECTIVE: Antidepressant responses were compared in DSM-IV bipolar and unipolar depression. METHOD: The authors analyzed clinical records for outcomes of antidepressant trials for 41 patients with bipolar depression and 37 with unipolar depression, similar in age and sex distribution. RESULTS: Short-term nonresponse was more frequent in bipolar (51.3%) than unipolar (31.6%) depression. Manic switching occurred only in bipolar depression but happened less in patients taking mood stabilizers (31.6% versus 84.2%). Cycle acceleration occurred only in bipolar depression (25.6%), with new rapid cycling in 32.1%. Late response loss (tolerance) was 3.4 times as frequent, and withdrawal relapse into depression was 4.7 times less frequent, in bipolar as in unipolar depression. Mood stabilizers did not prevent cycle acceleration, rapid cycling, or response loss. Modern antidepressants, in general, did not have lower rates of negative outcomes than tricyclic antidepressants. CONCLUSIONS: The findings suggest an unfavorable cost/benefit ratio for antidepressant treatment of bipolar depression.

Expert Opin Pharmacother. 2003 Jul;4(7):1175-83. Links
The combination of olanzapine and fluoxetine (SYMBYAX)in mood disorders.Shelton RC.
1500 21 Avenue, South, Suite 2200, Nashville, TN 37212, USA. richard.shelton@vanderbilt.edu

Depression can occur either with or without alternation with periods of mania. Depression that alternates with mania (bipolar depression) is a particularly difficult problem in clinical practice. The evidence base of the treatment for this condition is not strong and the choices at best are limited. Furthermore, although there are a number of effective antidepressants for the non-cycling variety ('unipolar' major depression), > 50% of patients experience incomplete response to any given drug. Given the proportion of the population involved, these represent fairly sizeable markets. Studies over the last several years indicate that the combination of the novel antipsychotic olanzapine and the serotonin-selective re-uptake inhibitor (SSRI), fluoxetine, may be effective for both conditions. One trial in 28 patients showed that this combination was an effective treatment, compared to the individual components with unipolar depressed patients who had not responded to two antidepressants of different chemical classes. Two subsequent large-scale attempts at replication have resulted in failed trials. Patients randomly assigned to antidepressant monotherapies showed a good response, indicating that the populations being studied were not actually treatment-resistant; therefore, more research is needed. Alternatively, a recent study showed that monotherapy with olanzapine produced a greater effect than placebo in bipolar depression and the combination of olanzapine and fluoxetine yielded an even more robust response. However, important questions remain, e.g., the issue of comparative effectiveness, that is to say, whether the same result could occur with combinations of other novel antipsychotics and SSRIs. In addition, there remain significant concerns regarding the safety and tolerability of olanzapine in these populations. Essential questions about the potential for substantial weight gain, Type II diabetes and for the development of tardive dyskinesia (a syndrome of permanent, disfiguring abnormal involuntary movements) remain. These problems will have to be vigorously addressed in order to achieve a substantial market penetration for these conditions.

Best regards . . .

Ivan
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