Depression and Bipolar Medications

Carol Watkins, M.D., our guest, is board certified in adult and child psychiatry. She has written numerous articles on the treatment of Bipolar Disorder, Manic Depression and Depression in children and adults.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good Evening. I'm David Roberts, the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Depression and Bipolar Medications." Our guest, Carol Watkins, M.D. is board certified in adult and child psychiatry. She is a clinical assistant professor of psychiatry at the University of Maryland and maintains a private practice in Baltimore, Maryland. She is the author of many published psychiatric papers and a frequent lecturer at workshops and seminars. Dr. Watkins has also written numerous articles on the treatment of Bipolar Disorder and Depression in children and adults.

If you are looking for information on particular depression medication or medication for bipolar disorder, you might want to try the HealthyPlace.com psychiatric medications area.

Good evening, Dr. Watkins and welcome back to HealthyPlace.com. We appreciate you being our guest tonight. Lately, we've been hearing a lot about children with depression, teens with depression. What do you think about children under age eighteen receiving antidepressants?

Dr. Watkins: In some cases, medication can be useful for depressed children and adolescents. Depression in young people is often overlooked, sometimes with tragic results. We are generally more cautious when using medications in those under eighteen. In the past decade, we have gotten more safe and effective antidepressants for young people.

David: What makes an individual "qualified" for medication for depression?

Dr. Watkins: It varies depending on the severity of the depression, the individual's medical condition, and the individual's preferences. For milder depression, we are more likely to recommend psychotherapy first. For more severe depression, antidepressant medication is more likely to be necessary.

David: We've heard a lot about "brain chemical" depression, an imbalance in a person's brain chemicals. Are antidepressants the only way to treat that?

Dr. Watkins: The term "chemical imbalance" is misleading. Many things start with a chemical abnormality and become much more. For example, type 1 diabetes seems to be a simple chemical abnormality. The pancreas does not make insulin. The disorder is treated by insulin. However, living with diabetes is much more complex. It involves lifestyle issues, and many behavioral and emotional issues.

David: I was under the impression that antidepressants were primarily used to balance the brain chemicals. Is that not true?

Dr. Watkins: Yes, they are. However, we do not completely understand how the brain chemicals get the way they are. I suspect that there are still a number of factors that we do not yet understand. Non-pharmacological things that make you feel better may themselves alter brain chemistry.

David: We also have a very large Bipolar Disorder community here at HealthyPlace.com. So, I want to touch on that too, before we start taking some audience questions. Can Bipolar Disorder be effectively managed without medications?

Dr. Watkins: I think that Bipolar Disorder is one of the conditions that usually requires long-term medications. Fortunately, we have more and better choices in that area. However, other factors can help the medications for Bipolar Disorder be more effective. For instance, getting the right amount of sleep is very important to a person with Bipolar Disorder.

David: Let's get to some audience questions, Dr. Watkins.

Dr. Watkins: O.K.

Wende: My son does not seem to have the "depressive" traits usually associated with bipolar. It's the manic side that we see more often. What meds do you recommend?

David: Wende's son is four years old.

Dr. Watkins: I can't really recommend specific medications without evaluating your son. It can be difficult to diagnose bipolar disorder in a preschooler. He should have a complete physical, neurological and psychiatric evaluation. Psychological testing may also be useful. You need to be very thorough in a preschooler with manic-type symptoms.

David: We've had a lot of doctors on talking about bipolar in children and many are hesitant to classify a young child as having bipolar. What are your thoughts on that?

Dr. Watkins: I have seen a few that did seem to have bipolar disorder. I feel more confident in making the diagnosis if there is a strong family history of bipolar disorder, and I have had a complete evaluation. I may try to hold off on mood stabilizers for a few years if I can manage things behaviorally. I might get a second opinion if I really thought that a four-year-old might need a mood stabilizer.

nrivkis: On the subject of bipolar disorder in kids, I'm bipolar and am trying to have a baby. Is there any advice you can give me about how to raise a child who may potentially inherit the disorder, what to look for, etc.?

Dr. Watkins: First, love your child, and take good care of yourself. There is some data to suggest that children do better if their parents are in a good frame of mind. You might look back and get information on how you were as a child. Watch for those symptoms in your child and take him or her in for an evaluation, if you have concern about excessive mood shifts or irritability. However, you should not over-react and label normal childhood tantrums.

David: We apparently have a lot of mothers, or women wanting to be mothers in the audience tonight. Here's another pregnancy question.

lobc42: What are the chances of having a baby if you are schizoaffective and take Depakote, Resperidal and Effexor?

Dr. Watkins: You should talk to your psychiatrist and your obstetrician well before you try to become pregnant. Go to an OB who is comfortable dealing with this sort of thing. Make sure that you are aware of the risks and benefits of medication during pregnancy. You should also make sure that you are in a stable time in your illness. It is best if you are married or in a long-term stable relationship. If you have a breakthrough, your partner can help you and the child.

Una: Would you elaborate on the importance of sleep for a Bipolar person?

Dr. Watkins: If you are going into a manic spell, you often begin to sleep less. The sleep deprivation can further charge the mania. It can also increase the chances of paranoia. Many people find that they have fewer breakthrough mood swings if they maintain a regular sleep-wake cycle and a regular amount of activity. Even time shifts and jet lag can set off some mood shifts.

revdave9: Dr. Watkins, I'm David and I'm thankful for HealthyPlace and this opportunity to speak to you. I've been taking Effexor for close to five years now. Because of financial considerations and geographic distance, it is difficult to get professional help. My question concerns side effects of Effexor and long term use of it. I'm currently taking 225 mg of Effexor XR. My side effects are sweating on my upper body with the least amount of activity, and sweating on the sides and back of my head when I rest.

Dr. Watkins: The SSRI medications can cause excessive sweating in some people and I would expect that Effexor might do this also. You could talk to your doctor about a medication change. Alternatively, you could wear loose clothing and turn down the thermostat.

David: In this case, what other medications might prove effective without these side effects?

Dr. Watkins: Most of the SSRIs could cause this. Wellbutrin, Serzone and possibly the tricyclic antidepressants might be less likely to cause sweating.

David: On the subject of side-effects from psychiatric medications, should people taking these meds expect side-effects? Is there any getting away from it?

Dr. Watkins: The SSRI medications generally cause fewer side effects than some of the older antidepressants, but they can cause side effects in some people. Many people, especially those on high doses of SSRIs, get sexual problems from medications; often decreased desire or delayed orgasm. SSRIs can cause sedation. They can cause agitation or restlessness. I see restlessness more in children and adolescents. That is why I am less likely to use Prozac as my first choice for an SSRI in some children. There are a number of other side effects of SSRIs including weight gain and headaches.

If you have decreased sexual desire on an SSRI, there are several options. You might switch to another class of medications such as Wellbutrin or Serzone. If despite the sexual side effects, you wanted to stay on the SSRI, you could lower the dose, or you could add Ritalin or Wellbutrin. Sometimes these help, sometimes not.

David: Here's an audience comment, then we'll continue:

batiking: Sweating excessively is why I switched from Paxil to Zoloft, then to Celexa. Sweating is one of the side effects listed for Effexor in Healthy Place psychiatric medications list.

Dr. Watkins: The sweating is usually more annoying than serious. If it were accompanied by confusion, excessive salivation or other bad side effects, then call the doctor.

princessdez: Every month, I seem to stabilize and then extreme PMS throws me off. What can help this?

Dr. Watkins: Some women with PMS, take a higher dose of an SSRI the five or six days before their menstrual period. Before you do this, you and your doctor should chart your moods daily for about three months. See if there is a correlation between your monthly cycle and your moods.

Moody Blue: What do you think about the drug Topamax being used for patients with mixed states?

Dr. Watkins: It has been used for Parkinson's and I have heard that some people are using it as an adjunct for mood states, but I have not used it yet.

vetmed00: Are there any natural remedies for depression and bipolar that can be used in conjunction with antidepressants?

Dr. Watkins: I have used St. Johns Wort in a few patients who did not do well on several other antidepressants. I have also used Fish Oil (Omega 3 Fatty Acids) for mood swings. However, I prefer to try more established medications first. Since we have very little data on mixing these herbal compounds with traditional medications, I prefer the person to be off other antidepressants before we try the alternative treatments for depression or bipolar disorder.

Rasha: I have a ten-month-old son and Depression seems to run in my family and on my husband's. Is it possible my son can get depression, and are there ways I can help prevent serious depression?

Dr. Watkins: You should be sure that your son gets a lot of affection from family. Encourage him to develop a mindset that he can solve problems and that life is not a helpless situation. Some people think that one's cognitive mindset can be protective against depression. If he does get depression, you may be in a good position to see it and get him help early.

I recommend that children with a family history of depression or bipolar disorder get education about drug abuse and responsible sexual behavior. They are at increased risk for these problems, and a lot can be done for prevention.

David: How important a role does nutrition play in maintaining mood stability?

Dr. Watkins: My patients sometimes say that I act like their mother: Eat your breakfast, eat a balanced diet and exercise regularly. I believe that there was a recent study out of Duke that suggested that regular exercise helped depression. I am not a fan of extreme diets. I have sometimes thought that the extreme Ketogenic diets make some people more irritable.

David: Here's the link to the HealthyPlace.com Bipolar Community. You can click on this link, sign up for the mail list at the top of the page so you can keep up with events like this. Then, here's the link to the Depression Community.

Also, here is the link to Dr. Watkin's site.

nrivkis: I've heard a lot about St. Johns Wort is dangerous in combination with certain foods, much the way the MAOIs are. I've also heard this is nonsense. What's the real story?

Dr. Watkins: Initially, there was a suggestion that St. Johns Wort acted like a MAO Inhibitor. At this point, I don't think that we are worried about having a crisis when you take St. Johns Wort and eat Tyramine-containing foods. The jury is still out on combining it with other medications. One could get a build up of Serotonin. Also the herbal compounds are not tightly regulated like regular medications. The dose of St Johns Wort can vary from pill to pill. That could influence interactions too.

David: Here's an audience comment relating to that:

batiking: I am a chemist, and wish to address "natural" remedies for depression. There is an active ingredient in SJW that is a chemical, just like the active ingredient in traditional meds are chemicals. Just because something is labeled natural doesn't mean that it is safe.

armand: I have been diagnosed with Bipolar since1976. I have never stayed on medications for long. I am forty-eight and I am feeling alright under the doctor's care, but not following up. I have Hepatitis C and I am worried about the effects that Lithium will have on my liver.

Dr. Watkins: With Lithium, we keep track of the kidneys and the thyroid. Some people develop low thyroid functioning while on Lithium. If not corrected, this can exacerbate rapid cycling. One can either switch to another mood stabilizer or add thyroid.

Sometimes Lithium can affect the kidneys. Diabetes insipids (not sugar diabetes) can be a side effect. The kidneys cannot concentrate the urine and the individual needs to drink and urinate a lot. One can switch to another mood stabilizer, or sometimes you add a diuretic medication.

batiking: I am BPII, Rapid cycler. I was recently treated with Topamax as an adjunct to Lamictal (400 mg). I had incredibly bad side effects, including suicidal depression. Is this a typical response to such a promising medication?

Dr. Watkins: I haven't heard of that. Lamictal is a good medication for Bipolar II disorder because it helps the depression without causing a mania. If your mania is well-covered with the Lamictal, you might ask your doctor about cautiously adding Wellbutrin. It has the potential to cause a manic breakthrough, as do all antidepressants. However, it may be less likely to do so than Tricyclics or MAOIs.

dayna: How long should you stay on one antidepressant before you should try a new one?

Dr. Watkins: If you are not getting a good result in 4-6 weeks, consider a switch. If you are getting bad side effects, you may need to switch earlier.

princessdez: I just discovered my 80-year-old grandmother has Bipolar. How do I explain that she needs medication after all these years?

Dr. Watkins: If an elderly person gets their first symptoms of Bipolar disorder at that age, she may need a neurological work up. Sometimes other illnesses can mimic depression or bipolar disorder.

blink7: I am on Zyprexa as a mood stabilizer. Is that a good move? The confusion is getting me out of my teaching job. It is hard to focus on anything.

Dr. Watkins: The newer atypical antipsychotics such as Zyprexa can help stabilize mood. Often they are used in conjunction with a mood stabilizer such as Depakote. The Zyprexa might have some antidepressant qualities. If the Zyprexa is causing mental cloudiness, or slow thinking, you might want to talk to your doctor about whether the dose is high or whether a mood stabilizer such as Lithium or Depakote might be helpful.

David: With wintertime coming on, I'm sure there are some people who are concerned about their depression levels increasing. They may suffer from seasonal affective disorder (SAD). What do you recommend for that?

Dr. Watkins: For winter depression, (seasonal affective disorder, SAD) I often prescribe a light box. You are better off using one from a legitimate company because you have to make sure that the light filters out any ultraviolet rays. Since the light is so bright, home made ones may have damaging bright spots. The reputable ones are fairly safe. It is better to use one under medical supervision. There is a clear dose/response curve depending on time and duration of light exposure. If you do not want to use the light, Prozac or another SSRI can work for SAD. I think that the lights have fewer side effects. It is just that some people do not have the patience to sit with one for 20 minutes a day.

David: One of our audience members would like to know if a tanning bed would be effective in treating seasonal affective disorder, SAD?

Dr. Watkins: Do not use a tanning bed. The UV rays could harm your eyes. The conventional light boxes have the light striking the open eyes. You do not want to look at the tanning lights. You also would not know the exact amount of light you were receiving.

Alohio: My mate is bipolar; how can I best help her?

Dr. Watkins: Educate yourself about the disorder. Some couples therapy can also be useful. You and your mate might make up an advance plan about how each of you will recognize and react to the beginning of a mania or a depression. You need to watch out for breakthroughs, but do not go too far and label each minor mood change as a mania.

jsbiggs: Recently, I experienced a violent reaction while making a transition from Epeval to Limictal and I have been without meds except for Omega 3. I feel the need to go back on a more conventional medication. Do you have any advice?

Dr. Watkins: I don't know what you have tried before. Some people use an Antipsychotic or a Benzodiazepine temporarily while waiting for a mood stabilizer (like Tegretol or Neuroltin) to take effect.

glow: What is normally the maximum dose of Effexor - XR?

Dr. Watkins: I usually do not go much beyond 300mg. I check blood pressure fairly often when I am using it in the higher range. You can go up to 375, but I am a bit cautious because I have had a few people have elevated blood pressure on higher doses.

karensue76: One of my diagnoses is major depression for which I take Prozac and Neurontin. Are these medications for clinical depression only, or can they be helpful in situational depression?

Dr. Watkins: If you have an adjustment disorder, minor depression, temporally related to a stress, we often don't medicate. If your symptoms are severe enough to merit the diagnosis of major depression, then medication could be helpful.

Maggie2: Can depression be treated with drugs only?

Dr. Watkins: In some cases, depression responds to medication alone. I like to use a combination, so that the person can develop the cognitive tools to cope better. However some people prefer not to use therapy and do well.

AMtDew4Me: A few months ago, I decided to use St. Johns Wort because I had taken so many quizzes for depression online and tested majorly depressed. I could tell the change in my moods and the way I acted and so could my friends. Recently my mom was diagnosed positive for depression and anxiety. I'm thinking of going back on St. Johns Wort now because my moods, and the way I'm acting, are starting to go crazy again . Do you think that I should consult a doctor first? Or should I trust my previous experience?

Dr. Watkins: There is the saying among doctors, "A doctor who treats himself has a fool for a patient." That may be a bit harsh, but there is a moral in it. Someone else can be more objective. If one of my children became depressed, I would not treat him myself. I could not be objective.

David: AMtDew4Me brings up an important thing here. The online tests for depression or any other mental health disorder are really just a very initial screening. We have them, but please don't take them and think you are getting a diagnosis. For a real diagnosis, please see your doctor or therapist.

breanne: Dr. Watkins, I was wondering if you could tell me whether the drug Topiramate will bring up the drug level of Desipramine. The reason I ask is because I am currently taking 150 mg of Desipramine with that drug and I want to increase it by 50 mg.

Dr. Watkins: A better way to increase the Desipramine level is to take more Desipramine. Have you and your doctor decided that 150 is the right level for you?

David: I know it's getting very late. Thank you, Dr. Watkins, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others. http://www.healthyplace.com/.

Also, Dr. Watkin's website is here.

Thank you again for coming tonight, Dr. Watkins.

Dr. Watkins: Thank you, it was a pleasure and thanks to everyone for the good questions.

David: Good night everyone, and I hope you have a pleasant weekend.

Disclaimer: That we are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.