Expert: Ivan Goldberg, M.D. - 1/21/2010

Question
I was admitted to a psych hospital in December for severe depression and put on Molipaxin 300mg nocte because I have been resistant in the past to both Efexor and fluoxetine (and possibly a few others) Within a week I was hypomanic but since my psychiatrist had gone on leave the meds were not changed and I went home til beginning of January on only the Molipaxin. I remained hypomanic about a week and then became depressed again with extreme suicidality and irrational thoughts.

The tests they did in the hospital gave high values for bipolar, borderline and depression. I do have a family history of bipolar - my twin brother is bipolar type 1 and I suspect that my father (and probably my grandfather) were too.

In early January I was put on Tegretol at a gradually increasing dose, but by day 9 I started itching badly and by day 12 I had blisters and ulcers on all my mucous membranes - none of which was terribly painful. I then phoned to get advice and was told to stop the Tegretol so I have again been on only Molipaxin for four days now and only have an appointment in another 5 days time. The itching has gradually improved and while I had new blisters on my eyelids for an additional three days, they seem to be clearing now, but I am starting to feel a lot more paranoid, sleeping worse because of feeling constantly afraid and generally shaky a lot, but I can think of no reason for feeling anxious and am unsure of this could be classified as anxiety even.

My mood is very unstable at the moment - mostly I am mildly depressed, but I do have days when I am having mixed episodes - I run around doing a lot but wanting to cry and my thoughts are racing.

In general I get severely depressed about once a year and this has been the case since 1995. I am also diabetic and have PMDD which varies from month to month. Being hypomainc tends to make my sugar levels low and this leads to tiredness in the middle of a manic phase which is very strange. Being hypoglycaemic also triggers depression so the two conditions make me very frustrated as I cannot find a doctor who will deal with the interactions.

Is it wise for me to stay on the Molipaxin like this as I cannot afford to get angry again with my husband as happened at the end of last year and it does not seem to be preventing the depression (it is better than it was in December, but still very much present) If I am generally depressed much more than manic and cannot handle anything related to Tegretol then what medications would you recommend? I have been on Epilim in 2001 but fainted at least 8 times while on it so that it was affecting my studies - at that stage I was not being treated for bipolar, just for resistant depression.

Thank you for your time.

Answer
Hi Brinwin . . .

As I have not evaluated you, there is no way that I can give you personal medical advice.

BUT . . . I can say a few things about my how I think about and treat patients I see who report experiences such as yours. With a family history of bipolar disorder and any hypomania (spontaneous or antidepressant-induced) I make a diagnosis of a disorder in the bipolar spectrum. When it comes to my treatment of such individuals the only rule is that cast in stone, as far s I am concerned, is that such individuals should never take antidepressants without also taking one or more mood stabilizer. While there are many possible antidepressant - mood stabilizer pairings that can be used the one I most often use is lamotrigine + lithium.

Best regards . . .

Ivan
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