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Suggest Treatment For Depression And Hypomania
Question: Age 71 . spent say average of 25% of time in depression since age 35 but worked in profession entire adult life. Diagnosed bipolar 2 (about 2010) I think correctly. No manic or psychotic episodes ever but some of hypomania. No rapid cycling,all moods ,normal , depressed or hypomanic continue for extended periods .Current prescriptions Depakote 250mgm 2 per day , Venlafaxine XL 225mgm daily , Mirtazapine 45 mgm daily.
I am in UK ,have a good GP and I think slightly less good psychiatrist.
Would appreciate second opinion (yours -which will be kept confidential by me) on my medications .
I am in UK ,have a good GP and I think slightly less good psychiatrist.
Would appreciate second opinion (yours -which will be kept confidential by me) on my medications .
Brief Answer:
I think venlafaxine should be reduced
Detailed Answer:
Hello,
Thanks for using Healthcare magic.
I read your query and understand your concerns and need for second opinion.
As we know bipolar disorder is mostly misdiagnosed/under diagnosed and on average there is gap of 10 years before correctly diagnosed. I am surprised to note that in a country with robust healthcare system diagnosis was delayed by 35 years.
As per the available information I feel bipolar type 2 is correct diagnosis. The people with bipolar type 2 spend approximately 45% of their time in depression and mostly hypomanic episodes are considered recovery from depression (so called good time) before correct identification.
I second the opinion about treatment except dose of effexor and Mirtazapine currently. Use of antidepressant in bipolar depression is controversial and there is more chance to switch or rapid cycling with use of antidepressants.
Even if they were used I feel at least dose of venlafaxine need to bring down. I do not feel any rationale to provide two antidepressants in bipolar vdepression.
The appproved medication for bipolar depression incliude combination of olanzappine and fluoxetine, lurasidone and quetiapine. Although depakote is not approved but it is useful as per my experience and other learned psychiatrists.
I request you to talk to your psychiatrist about approved treatments and lowering of dose of current antidepressants.
I hope this helps you.
If you have any further query, I would be glad to help you.
If not, you may close the discussion and if possible you may rate the answer for me, so that I get a good feedback.
In future if you wish to contact me directly, you can use the below mentioned link:
http://doctor.healthcaremagic.com/doctors/dr-ashok-kumar/67386
Thanks and regards
I think venlafaxine should be reduced
Detailed Answer:
Hello,
Thanks for using Healthcare magic.
I read your query and understand your concerns and need for second opinion.
As we know bipolar disorder is mostly misdiagnosed/under diagnosed and on average there is gap of 10 years before correctly diagnosed. I am surprised to note that in a country with robust healthcare system diagnosis was delayed by 35 years.
As per the available information I feel bipolar type 2 is correct diagnosis. The people with bipolar type 2 spend approximately 45% of their time in depression and mostly hypomanic episodes are considered recovery from depression (so called good time) before correct identification.
I second the opinion about treatment except dose of effexor and Mirtazapine currently. Use of antidepressant in bipolar depression is controversial and there is more chance to switch or rapid cycling with use of antidepressants.
Even if they were used I feel at least dose of venlafaxine need to bring down. I do not feel any rationale to provide two antidepressants in bipolar vdepression.
The appproved medication for bipolar depression incliude combination of olanzappine and fluoxetine, lurasidone and quetiapine. Although depakote is not approved but it is useful as per my experience and other learned psychiatrists.
I request you to talk to your psychiatrist about approved treatments and lowering of dose of current antidepressants.
I hope this helps you.
If you have any further query, I would be glad to help you.
If not, you may close the discussion and if possible you may rate the answer for me, so that I get a good feedback.
In future if you wish to contact me directly, you can use the below mentioned link:
http://doctor.healthcaremagic.com/doctors/dr-ashok-kumar/67386
Thanks and regards
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank-you doctor. NHS UK is perhaps not as robust as it was . Also my normal personality is outgoing which may have delayed correct diagnosis. Also is it possible I changed from depressive to Bipolar 2 over the course of 35+ years ?
Your advice makes sense to me and I will discuss with my psychiatrist in my next appt. ( about 3 months) and with my GP.
One thing you may not approve of. Depression is the most disabling of my moods (no surprise). Hypomania ,PROVIDED it does not become mania , is OK as I achieve much more (and quality of life better) and at nearly 72 ,there is no guarantee how long my physical health holds up. Having been treated with many antidepressants over the years with until recently no mood stabiliser I believe risk of mania may be low , and may be a risk I would take to avoid long depressive periods when I get little done. Any thoughts. This is my last question and my rating will be good.
Your advice makes sense to me and I will discuss with my psychiatrist in my next appt. ( about 3 months) and with my GP.
One thing you may not approve of. Depression is the most disabling of my moods (no surprise). Hypomania ,PROVIDED it does not become mania , is OK as I achieve much more (and quality of life better) and at nearly 72 ,there is no guarantee how long my physical health holds up. Having been treated with many antidepressants over the years with until recently no mood stabiliser I believe risk of mania may be low , and may be a risk I would take to avoid long depressive periods when I get little done. Any thoughts. This is my last question and my rating will be good.
Brief Answer:
There is no literature which suggests change of depression from bipolar
Detailed Answer:
Hello,
Thanks for reverting back to me.
Your assumption about change from depression to bipolar is not supported by literature. Although recurrent depression, resistant depression is considered indicative of bipolar depression and it is recommended to look for bipolarity.
To say bipolar we need evidence of mania (type 1) or hypomania (Bipolar type 2) and the literature indicates that in their life time people spend just 5% or less time in hypomania/mania which sometimes considered recovery from depression and remains unrecognized leading to misdiagnosis.
In bipolar type 2 mania never happens and the cycles is covered with depression and hypomania.
I understand that mania is not caused by antidepressants but at least propensity to cause mania and rapid cycling increases with SNRI and SSRI class of antidepressants. Venlafaxine is SNRI and there is available literature which suggests it may be more harmful rather than useful in bipolar depression. That is my concern regarding current treatment.
I hope it makes sense now.
Thanks and regards
There is no literature which suggests change of depression from bipolar
Detailed Answer:
Hello,
Thanks for reverting back to me.
Your assumption about change from depression to bipolar is not supported by literature. Although recurrent depression, resistant depression is considered indicative of bipolar depression and it is recommended to look for bipolarity.
To say bipolar we need evidence of mania (type 1) or hypomania (Bipolar type 2) and the literature indicates that in their life time people spend just 5% or less time in hypomania/mania which sometimes considered recovery from depression and remains unrecognized leading to misdiagnosis.
In bipolar type 2 mania never happens and the cycles is covered with depression and hypomania.
I understand that mania is not caused by antidepressants but at least propensity to cause mania and rapid cycling increases with SNRI and SSRI class of antidepressants. Venlafaxine is SNRI and there is available literature which suggests it may be more harmful rather than useful in bipolar depression. That is my concern regarding current treatment.
I hope it makes sense now.
Thanks and regards
Note: For further follow up on related General & Family Physician Click here.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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