Expert: Ivan Goldberg, M.D. - 3/22/2010

Question
Dear Dr. Goldberg:

I have struggled on and off with depression for 10 years. My mood cycles and, when depressed, I am agitated, ruminate, have difficulty concentrating and struggle with hypersomnia. However, I have never been psychotic, manic and it is unclear that I have ever been hypomanic as I may be mistaking normal moods with elation.

In my early twenties, I tolerated and partially responded to both Remeron and Celexa. However, recent trials with Cipralex and Cymbalta (while on 200 Lamictal) resulted in signifiant mood destabilization and suicidality (but not a manic switch). My doctor and I have discussed whether or not this suggests a diagnosis of BPII. We consulted a specialist in Boston who did not think there was any indication of bipolar II and recommended a course of antidepressants with benzos. I am now trying Moclobemide (without benzos) and have again experienced increased agitation and suicidality but was encouraged by an inpatient specialist to stay on the medication for an 4-6 week period.   

I continue to receive excellent care and am willing to defer to their expertise.  However, a physician friend and my cognitive-behavioural therapist have expressed concerns that these  repeated antidepressant trials may have short and long-term adverse effects. I am wondering if you think 1) I am exhibiting signs of so-called soft bipolarity,  2) you are aware of any long-term adverse effects of antidepressant trials in patients experiencing destabilization and 3) how long you would continue a antidepressant if a patient of yours was experiencing destabilization.

I am currently taking 200 mg Lamictal, 300 mg Moclobemide and 100 mg Modafinil. I did not respond to Lithium or Abilify and was unable to tolerate Zyprexa, Risperidal and Seroquel due to the sedation.

Thank you

Answer
Hi Tom . . .

I am not sure I can answer your question but let me share with you some of my thinking. More often than not when people respond to antidepressants with increased agitation and suicidal thinking, a detailed family history turn up one or more relatives who have what seems like a soft form of bipolar disorder. These are often people who did well in the world while having an irritable temperament or sometimes people with a history of a fluctuating course of successes and failures. Impulsive, uncharacteristic behaviors are often also often reported.

It has been my experience that individuals with an intolerance of antidepressants often do best when treated with a complex cocktail of lithium + divalproex + carbamazepine, sometimes with additional lamotrigine.

There is no way I can say if such a cocktail will work for you as it is impossible for me to make a diagnosis via the internet.

Best regards . . .

Ivan
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