Expert: Ivan Goldberg, M.D. - 9/17/2011

Question
QUESTION: Dear Sir, I was very anxiously waiting for your return, as your replies are authentic.I am 39, a case of Mixed bipolar with severe depressive symptoms. I was not tolerating any medication so I went for ECT.But after 2nd ECT I develop a new severe depression. The new depression did not go after 3rd session, so the doctor stopped ECT.After ECT I tolerated medicines for few days, but they were not working:

1)What is the probability that this ‘New Depression” gone away and I improved, if I had continued ECT till 8-9 sessions?
2)For a case of MIXED bipolar, the TMS should be on Right side or on Left side?
3)Would Moclobemide help a MIXED bipolar case? I have heard MAO help Bipolar depression, but not sure if it will help MIXED case or not. As such I go worse will all classes of anti-depressants (tricyclics,SSRI,stablon,mirtazepine etc..) even with mood stabilizers.
God bless your good soul!!
Karan.

ANSWER: Hi, Karan . . .

Only one of my patients showed an increase of depression following the initial ECTs. The series was not interrupted and by the 18th treatment euthymia was achieved.The patient had a melancholic depression and had a positive dexamethasone suppression test (DST). Depressed individuals with melancholic depression and a positive DST just about always respond positively to ECT.

I have no idea how appropriate TMS is for patients with mixed bipolar states . . . and even less of an idea as to the stimulus parameters that are appropriate.

Quetiapine (300 - 600 mg/day) has been a successful treatment for some people with hard to treat mixed bipolar states.

Best regards . . .

Ivan
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---------- FOLLOW-UP ----------

QUESTION: sir, i know you answer to the best of your knowledge and you are doing great service to mankind but i don't have anything to ask now.
1)medicines - i don't tolerate them , including quatiapine.
2)Left TMS made me extremely worse.i have no other way except to experiment Right TMS.
3)ECT - induced new depression in 3rd session...doctors are not sure if i will improve if given more ECTs.
4)Pranic healing, Reiki - people say they dont work in such illnesses.

only TMS an ECT make me tolerate medicines but only for 4-5 days but they dont work then...

its a bad feeling when i think of suicide leaving my family ,my son back.

if at all i get well..i will inform you of the solution , so that you can use them in your other patients.

God bless you and family!!!

Answer
Karan . . .

This reply will make you unhappy but I think it is important that you read it.

I have been in the private practice of psychiatry since 1963 and have specialized in treating patients with hard-to-treat depressions for the past 25 years. I have seen a number of patients who claimed not to be able to tolerate any medications. In EVERY instance such a claim was NOT based on physiology but rather on the basis of a psychological need. This is clearly demonstrated when such individuals cannot differentiate between capsules containing foods that they can eat with no difficultly and medications that they claim not to be able to take.

Through psychotherapy most of these individuals have become able to take medication and to tolerate placebos.

Best regards . . .

Ivan
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