Concerns About Bipolar Therapy


Q1. I was diagnosed with bipolar disorder about three years ago. I have had symptoms for as long as I remember. I have been taking Depakote (divalproex sodium) for six months, and it is not helping now that I have hit a depressive phase in my cycles. My doctor prescribed Cymbalta (duloxetine) and Depakote to help with the depression. However, I am worried about the fact that Cymbalta is so new and possibly addictive. Also, I am bipolar, so isn't prescribing an anti-depressant a good way to send me into a manic phase? How will these two drugs interact? I am very leery about this and can't imagine what to expect. I just want to be normal-functioning, not a lab rat. What is my best course of action?

Cymbalta is approved by the Food and Drug Administration for the treatment of major depressive disorder, generalized anxiety disorder and also for management of diabetic peripheral neuropathic pain. It belongs to a class of medications called SSNRIs (selective serotonin and norepinephrine reuptake inhibitors). There is no evidence that it is addictive, at least in the physiologic sense (in other words, you need to take more of it to get the same effect, and/or you suffer withdrawal symptoms if you quit taking it).

You are definitely doing the right thing by expressing concerns about the medications you are prescribed, and about drug interactions. Of course, this is something that your doctor should be paying attention to, but sometimes they may forget to take a thorough history. So it is very important that you talk to your doctor about your concerns. In particular, you should not take Cymbalta if you have recently taken a type of anti-depressant called a monoamine oxidase inhibitor (MAOI), or are taking an anti-psychotic called thioridazine (Mellaril).

Your concern about anti-depressants sending you into a manic phase is valid. Recent data from the STEP-BD study (the largest study to date on treatment for bipolar disorder) found that anti-depressants are indeed associated with the potential risk for treatment-emergent mania or hypomania, particularly in bipolar patients with short illness duration, multiple past anti-depressant trials, and past experience of switch with at least one anti-depressant. So you are right to be cautious about this, and should definitely discuss the pros and cons with your doctor.

Q2. My doctor is encouraging me to consider HRT for my bipolar disorder. His thinking is that hormone imbalances will contribute to bipolar disorder instability. I still have periods monthly, though I do experience night sweats. I am 52. Do you think HRT will help? Are there any concerns?

— Vanessa, Virginia

There's no evidence that hormone replacement therapy, or HRT, is beneficial for the treatment of bipolar disorder. In fact, it's not even a recommended treatment for depression, unless the depression is clearly linked to hot flashes, night sweats, or other menopausal symptoms. There's also no clear evidence that hormonal imbalances contribute to bipolar disorder instability, and that this instability can be altered with hormone therapy (unlike SSRIs drugs, which may reduce the instability).

If you have menopausal symptoms that are severe enough to interfere with your sleep and affect your quality of life, you may be a candidate for hormone therapy. (This therapy, however, would be related to the menopausal symptoms rather than the bipolar disorder.) If this is the case, know that you're at an appropriate age for hormone therapy once your periods stop, but double-check with your doctor that HRT makes sense in your particular circumstances.

Q3. From what I hear about bipolar disorder, I fit all the symptoms. I finally went to see my doctor, who referred me to a psychiatrist. What can I expect from my first appointment?

At your first appointment, you should be prepared to answer lots of questions. Your new psychiatrist probably will ask you about all of the symptoms that you have been experiencing recently. He or she will also take a detailed personal history from you, including any past mental health care, where it was provided and by whom; medications and the dosages you currently are taking and/or have taken in the past; significant medical illnesses and family history.

You may also be asked to fill out a questionnaire or provide other written information about your history. So it’s a good idea to write down any and all concerns and important historical information prior to the visit, because this will help your new doctor quickly figure out the best and most appropriate treatment plan for you.

Then it’s on to the next step. After your evaluation is complete, your psychiatrist will develop a treatment plan, which he or she will then discuss with you. If you have any concerns at all regarding suggested medications or other treatment recommendations, you should certainly express those concerns and feel free to ask lots of questions. A good doctor will be receptive to those questions and will not try to rush into a treatment plan you and your family members do not feel comfortable with.

Learn more in the Bipolar Disorder Center.