Expert: Ivan Goldberg, M.D. - 12/3/2009

Question
I have been on sertraline 100mg. I used to take 50mg but my moods wouldn't respond so well to the treatment, so doc decided that I could try 100mg. This is what I have been doing from the beggining of this year on. My mood is better now, but I feel that I have been more agitated and restless since then. Sometimes I feel that I can't stand still and I frequently need some medicine to sleep when my mind gets too unquiet. If I don't take clonazepan, I enter in a state of excessive alertness and I can't relax, so I catch myself shouting over and over when I have just fallen asleep.
It seems obvious to me that a higher dosage of sertraline is causing those symptoms. The problem is that I don't want to lower the dosage because I am quite sure that if I do this my mood will suffer and I'll get a little depressed, because I have been through this before and I know how my mind reacts with lower dosages of antidepressants. What would be the answer? Could I suggest my doctor to keep me on 100mg and prescribe me Depakote? I have already taken Depakote but never with a higher dosage of antidepressants. Could they be taken together? What could I expect from a therapy like this?

Answer
Hi Bruno . . .

In people with even a slight bipolar aspect to the mood disorder, antidepressants while decreasing depression, can induce agitation, racing thoughts, hyperactivity, irritability, insomnia, manic behavior, and/or  psychosis.

There are some psychiatrists who believe that antidepressants such as sertraline should never be prescribed for people who have any form of bipolar depression, and other psychiatrists who strongly believe that when antidepressants are prescribed for someone with bipolar depression that they should ALWAYS be accompanied by lithium, valproate, or carbamazepine.

If I were treating someone with your story, I'd probably continue the sertraline at the current dose and add lithium, valproate, or carbamazepine.

I hope you are being treated by a psychiatrist familiar with the psychopharmacologic treatment of people with mood disorders and not by a nonpsychiatric physician.

Best regards . . .

Ivan
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