Tag Archives: mood stabilizers

Medicating for depression: The basics

Today I want to take a few minutes to go back to the basics: Let’s talk about prescribing medication for depression. It’s a process that my colleagues and I engage in every day, but for new patients it’s unfamiliar and deserves an introduction.

When someone comes to me with depression (and we’re talking about regular depression this time–bipolar depression is a whole different topic), the first decision we make together is whether we’ll treat with therapy, medication, or both. In my experience, a combination of the two is the most effective approach, but every patient is different. Today we’ll just talk about the medication side of treatment.

Antidepressants

Once we’ve decided to proceed with medication, we usually start with an antidepressant. There are several kinds of antidepressants, so we choose one that has been shown to best treat your particular symptoms — lack of motivation, irritability, trouble sleeping, sleeping too much, fatigue, trouble concentrating, restlessness, suicidal thoughts, or loss of enjoyment of the things you normally enjoy, for example. We talk about side effects, your family history, your ability and willingness to take pills regularly, other medications you’re taking, and your other health conditions and make a decision from there. We adjust the dosage as we watch your symptoms and side effects over the next several weeks.

If you’d like a breakdown of different types of antidepressants, I recommend this article from the Mayo Clinic.

What I really  want to focus on today is what we do when the antidepressant we choose is not working for you. The largest and best study out there on medicating for depression found that about a third of depressed people are “cured” by the first antidepressant prescribed to them — their depression symptoms go into remission.
If you’re not one of the lucky third, my next step is usually to try another type of antidepressant. In that same study, about 25 percent of the people who tried a second antidepressant went into remission. Those results are good enough to make trying again a strong option.

If the second antidepressant doesn’t work, we can choose to either try a third antidepressant — the study showed 12 to 20 percent of patients are cured by the third antidepressant — or we can try adding another medication on top of what you’re already taking. That’s called augmenting the antidepressant.

There are three main types of medications we can add to your antidepressant regimen: mood stabilizers, thyroid hormones, and antipsychotics. I’ve found that each of these has the potential to activate the antidepressant you’re already taking. Even if you haven’t experienced any improvement with the antidepressant, it can start to work when combined with something else.

Mood stabilizers

When you hear mood stabilizers, think Lithium. Lithium is one of the most studied and proven medications out there. You may think of it as a treatment for bipolar disorder, but it can work well as an augmentation for your antidepressant. I use it when there’s a history of bipolar in a patient’s family or when a patient’s moods are turbulent — maybe they struggle with anxiety and insomnia in addition to depression. There are other mood stabilizers out there that work well, too: I often prescribe Lamictal, for example.

Thyroid hormones

Adding thyroid hormones to antidepressants is a course that hasn’t been studied as well as adding mood stabilizers, but it appears to work well and be tolerated better than lithium in a lot of patients. The most commonly prescribed thyroid hormone for depression is called T3. It’s often used to speed up the effects of an antidepressant, but it works to enhance antidepressants at later stages, too.

Antipsychotics

The third augmentation option is an antipsychotic. Originally designed for treating schizophrenia, this class is becoming more and more popular for treating depression. A lot of my patients have seen huge improvements after adding an antipsychotic. My favorite is Abilify. People tolerate it well and see good results: Two studies from several years ago showed about a quarter of people who added Abilify to an ineffective antidepressant saw a remission of their depression. Abilify can be expensive, though, depending on your insurance, and if it is, I try other antipsychotics first.

There are so many options for treating depression, and different people respond better to different drugs. It’s hard to know in advance which option will work the best, so it can take several tries before we hit on the right strategy.

The good news is that if you’re on medication and it’s not working, that’s not the end of the line. Far from it. There is some combination out there that will work for you; we just have to find it.

Satu Woodland is owner and clinician of Mental Health Solutions, an integrative mental health practice located at Bown Crossing in Boise, Idaho. She sees children, adolescents, and adults.

Differentiating between Bipolar Disorder I and Bipolar Disorder II

Many people have heard about the diagnosis Bipolar Disorder. Formerly this diagnosis was named Manic Depression. Today we differentiate between Bipolar Disorder I and Bipolar Disorder II. Bipolar Disorder I is characterized by periods of depression alternating with periods of manic behavior. What is manic behavior? It is discreet periods of high energy which can be either positive or negative in nature. The positive kind would manifest itself by an unusual burst of energy, not needing much sleep, high amounts of goal directed behavior, happy even euphoric behavior, increased amounts of impulsivity, creativity and sometimes grandiosity. Sometimes people in this state talk rapidly and cut others off. Usually, people experiencing this kind of mania like to be there. They enjoy being happy, productive, highly energetic and creative. The problem is that sometimes this mania is highly unpractical and distructive to theirs and their loved ones life. This is particularly true with Bipolar Disorder I which has higher levels of mania. A manic person may suddenly leave a long happy marriage for a random person they met in a bar. They may leave a good job to go explore the world. At the moment the person in a manic state may not understand or consider the implications of his behavior. They may not realize it is a problem. Its usually later when they are out of the manic state and more settled down when they may come to realize the problem. Frequently, family members are the first to mention the problem. Some patients never recognize the problem in themselves and only get help after family insist on it. While positive manic states are sometimes not recognized as being a problem, alternatively, the negative manic states almost always are. If not by the patient himself, certainly by family members, work colleagues or friends.
Negative manic states are high energy states also. There may be problem sleeping. Instead of happy or euphoric mood, in its place is an angry or highly irritable mood. You see these people driving down the road and in response to someone cutting them off they react in a highly explosive way. They may track down the perceived perpetrator and pull a gun on them or start a fist fight. However, this is more common in men. Negative mania is erratic and often scary to the patient and/or those around him. With women, they may report being highly annoyed and easily provoked emotionally. Family members may report they feel like they are “walking on eggshells.”
Bipolar Disorder II is similar to Bipolar Disorder I in that it has periods of depression but it alternates with lower levels of mania. The mania is not as distructive. A person may appear to be a person who is involved in a lot of things and has a lot of projects going at the same time. They seem to exude more energy and creativity than the average person during these times. We sometimes call this type of mania “hypomania” People who have hypomania may not have problems in this state. For them, the problems come when they are in their depressed phase.
Another thing I would like to mention is that sometimes manic states look like anxiety. Be sure to get your anxiety checked out by a specialist if the standard treatments of anxiety, ie. therapy or antidepressants aren’t doing the job. Manic episodes are often missed by the general primary care provider.
How is Bipolar Disorder treated?
If a person has been treated previously with an antidepressant, a mood stabilizer may be added. Some people with Bipolar Disorder( I or II) cannot tolerate antidepressants at all. They may make them too manic. In that case they may need a mood stabilizer or antipsychotic. The other part of treatment is psychotherapy. In my view, they should both be in the treatment plan for best results. Cognitive Behavioral Therapy (CBT), Interpersonal Therapy, Marriage and Family therapy and psychodynamic types of therapy can be useful. Recent research shows that CBT can be done effectively in short periods of time from 8-16 weeks in duration for some. CBT focuses on the present and doesn’t spend large amounts of time with what happened in the past. It is goal focused and skill building in nature. Other treatment modalities that I have found to be helpful is spirituality exploration and developing healthy health habits such as good sleep hygiene and an exercise routine. I have found herbal remedies are not as effective in Bipolar spectrum disorders. Although some people prove to be the exception to the