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Under depression, told to have bipolar disorder. Having cold attitude, no appetite, blank looks. Suggest?

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Addiction Medicine Specialist
Practicing since : 2002
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My mother is under depression since ttwo years.she was told that she is having bipolar she is under depression and following symptoms we are noticing:
no feelings,cold attitude,no appetite,dont want any physical activities,no XXXXXXX on any news,blank looks
Also recently we noticed that after 7pm in evening she becomes ok and she works properly. But during day she forgets what happened and what she did at night.
kindly suggest
Posted Thu, 3 Oct 2013 in Bipolar Disorder
Answered by Dr. Preeti Parakh 2 hours later
Brief Answer:
Shift mirtazapine to night. Test Valproate level.

Detailed Answer:

Forgetfulness only in the daytime is not a typical symptom of depression. What usually happens is that depression has a diurnal variation. People with depression often feel worse in the morning and feel better as the day progresses. However, this happens with all the symptoms of depression and not just forgetfulness. Probably this is what is happening with your mother. If so, this is not something to worry and will get better as she recovers from depression.

The second possibility is that this issue is medication related. Mirtazapine is always given as a single night time dose as it causes sedation. Since she is taking 7.5 mg in the morning, I feel this may have something to do with it. Discuss with your doctor and consider shifting the entire dose of mirtazapine to a single night time dose. It is possible that this will benefit her day time forgetfulness.

Tryptomer 25 mg is a small dose and unlikely to be responsible for the forgetfulness. Regarding Divaa OD 500 mg, in my opinion, you should get her blood tested for serum valproate level, which ideally should come between 50 and 100. If it is less than 50, then the medication is not working and the dose should be hiked. If it is more than 100, then there is the possibility of side effects, one of which can be forgetfulness. Please remember that this blood test should be done after at least a week of regular dosing and the sample should be collected 24 hrs after the last dose. That is, if she takes Divaa OD at 8 pm daily, then the blood sample should be collected between 7 to 8 pm, before she takes that day's dose. If she has been missing her medicines intermittently, she should take the medicines regularly for at least a week before getting the test done.

Hope this helps you.

Best wishes.

Dr Preeti Parakh
MD Psychiatry

Above answer was peer-reviewed by
Follow-up: Under depression, told to have bipolar disorder. Having cold attitude, no appetite, blank looks. Suggest? 1 hour later
She is also taking nitrest 10 mg daily at night for sleep.
Also she doesn't feel like eating anytime and has constipation..
Kindly suggest medications to recover her fast plz as it has been very long time..
Answered by Dr. Preeti Parakh 2 hours later
Brief Answer:
Continue Nitrest for now.

Detailed Answer:

She should continue with Nitrest for now. However, it might be possible to reduce the dose of Nitrest once you shift the mirtazapine to night dose only as that will improve her sleep.

For constipation, ensure that she takes lots of fibrous foods like fruits and vegetables. Also give her isabgul husk 3 tsf every day with half a glass of water or milk. If she is still constipated, then Tryptomer may need to be stopped.

Please do as suggested and get back to me with the serum valproate report, so that it can be decided if valproate can be hiked or not. Unless it is in the required range, its mood stabilizing action will not be apparent.

Best wishes.

Dr Preeti Parakh
MD Psychiatry
Above answer was peer-reviewed by
Follow-up: Under depression, told to have bipolar disorder. Having cold attitude, no appetite, blank looks. Suggest? 25 hours later
it will take two day time for the report to come.. we testing valporic acid today..
Answered by Dr. Preeti Parakh 1 hour later
Brief Answer:
Request for more information.

Detailed Answer:

Thanks for writing back!

I hope that by now, you have discussed with your doctor and shifted mirtazapine from 7.5 mg twice daily to 15 mg single dose at bedtime. When you get back to me with the report, I would like you to give me the following information:

1) Has her daytime forgetfulness improved after shifting mirtazapine to night?

2) Did she ever have symptoms suggestive of suspiciousness, like falsely suspecting that people were trying to harm her or were talking ill of her? If so, when did it happen and how long did it last? Also let me know if she still has such symptoms.

3) Did she ever have an episode in which she was excessively cheerful, talkative, confident, very social and energetic? If so, when did it last happen and how long did it last?

4) Is her mental illness episodic? That is, she is ill only for a few months and is completely well the rest of the year. If yes, when did the present episode start and for how long was she well before that?

5) Does she have any other illness, like thyroid disorder, diabetes etc? If yes, let me know the current status.

6) Has she ever taken any of the following medicines - escitalopram, sertraline, fluoxetine, venlafaxine? If yes, I'll be able to help you better if you can let me know the dose and duration of the medicine and whether it worked for her or not.

I am asking all this so that I can confirm that she currently has bipolar depression. Many times people label all kinds of mental illness as "depression" and because of the wrong diagnosis, treatment fails.

I am concerned for her and shall try to do the best that is possible in spite of the limitations of not being able to see her and examine her myself.

Best wishes.

Dr Preeti Parakh
MD Psychiatry
Above answer was peer-reviewed by
Follow-up: Under depression, told to have bipolar disorder. Having cold attitude, no appetite, blank looks. Suggest? 42 hours later
Thanks for your advice it is helping us a lot to overcome and undergo the treatment of my mother XXXXXXX XXXXXXX
The report of Valproic acid has come and it is 38.90
In reply to your queries of your last detailed answer we are replying you point wise.
1)     Yes now the problem of forgetfulness has improved but it is still there during the morning.she doesn’t remember what happened after 9 pm during night clearly.
2)     Earlier she was having symptoms of suspiciousness like someone is trying to harm her. It was around 1.5 – 2 years back. Now also she thinks that some external forces are doing something to keep her ill.
3)     Earlier she was excessively cheerful, talkative, more than confident, very social, having a lot of energy during my marriage. It was also 1.5 – 2 years earlier and lasted around 6 months.and it stopped when we gave her resperidone drops without telling her in milk or water as suggested by doctor
4)     Earlier twice she was depressed due to some mishap but it used to be ok after 6-8 months.
5)     Yes, she has thyroid disorder and diabetic. The latest test of Sugar (Fasting)- 120, PP-150.
T3- 164,T4-16.80,TSH-0.05
She is taking throxine 100mg medicine for thyroid
For sugar she is taking janumet 50mg/1000mg - 1tab after breakfast & 1tab after dinner Diamicron xr 60 - one tab before breakfast and one tab after dinner
Ecosprin AV 75 - one tab after dinner

6)     We have tried many medicines till date so I am sorry that I don’t remember which medicine was ok.but all together we dint noticed any good changes in her

Please examine, analyze and suggest us for the betterment and perfect health of my mother. Your suggestion and guideline will definitely lead a blowing light in this dark tunnel of our family.
We are extremely obliged for the concerned for my mother and your effort to do the best has put our family in very high spirit.

Answered by Dr. Preeti Parakh 5 hours later
Brief Answer:
Valproate should be hiked.

Detailed Answer:

Thanks for your kind words and your detailed answer.

Since the serum valproate level has come to be lower than the therapeutic range of 50-100, in my opinion, the dose of valproate needs to be hiked. Please discuss with your doctor if valproate can be hiked to 750 mg or not. The effects of the dose hike will become apparent in around a week.

Since her forgetfulness has improved after modifying drug regimen, it appears that the problem was drug induced. I feel that stopping Tryptomer would be beneficial as at this low dose, it exerts no significant anti-depressant effects but may be contributing to the forgetfulness and constipation. However, please consult your doctor before doing so.

Thirdly, for better antidepressant action, either Mirtazapine would have to be gradually hiked or another antidepressant like escitalopram, sertraline etc would need to be started. Please consult your doctor regarding what his views are about this. If mirtazapine has brought no improvement, then it perhaps would be prudent to start another antidepressant.

Fourthly, please consult the doctor who prescribes her thyroid and diabetes medicines and ask if any change is needed. If thyroid status is abnormal, depression becomes very difficult to treat.

Last of all, she still has some suspiciousness. If it increases, she may need another medicine for the same as the antidepressant will not be of much use in it.

Please reassure your mother that she will get well soon.

Hope this helps you. Please feel free to ask if you need any clarifications. If there are no further queries, please close the discussion and rate it.

Best wishes.

Dr Preeti Parakh
MD Psychiatry
Above answer was peer-reviewed by
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