Ask Dr Ivan:7

A: The Lancet recently published a report of the effects of estrogen patches on women with post-partum depressions. It was found that women using estrogen patches improved within the first month of using the patches and remained undepressed for at least six-months. Women randomly assigned to use placebo patches showed a significantly lower rate of improvement.

While replication of this result is needed, the estrogen treatment for women with post-partum depression looks promising

Ref: Gregoire AJP et al. The Lancet 1996, 347, 930-933.

Q: I have seen a number of patients being treated for hypothyroidism with T-4 in whom the addition of T-3 leads to a distinct improvement in mood. Has this been reported in the literature?

A: While many physicians believe that T-3 and T-4 are equivalent in their ability to treat hypothyroidism, others have come to believe that many patients require supplementation with both thyroid hormones. There is at least one published report that adding T-3 to T-4 in patients being treated for hypothyroidism leads to an improvement in mood. Whether a similar improvement could have been brought about by increasing the dose of T-4 is not known.

Ref: Cooke R et al. Journal of Clinical Psychiatry 1992, 53, 16-18.

Q: Is there a role for the use of methylphenidate in patients with post-stroke depression?

A: Post-stroke depressions are under recognized and under treated. As most of the people with such depressions are elderly, physicians are often reluctant to prescribe antidepressants, because of the side-effects associated with antidepressant use. While antidepressants can be used, methylphenidate has also been found to be effective, and often is better tolerated. Treatment should be initiated with a dose of 5 mg. In the morning, and the dose can be gradually increased to a maximum of 1 mg per kg of body weight. Most patients do best with doses on the lower end of the dosage range.

Ref: Johnson M et al. American Journal of Physical Medicine and Rehabilitation 1992, 71, 239-241.

Q. With use over many years, is there any evidence that there is a reduction in the effectiveness of the bright light treatment of patients with Seasonal Affective Disorder?

A. Many people with Seasonal Affective Disorder continue to get benefit from bright light therapy for many years. However, some people with this disorder do best when bright light therapy is supplemented by the use of antidepressant medications. Slightly more than one-third of 59 patients treated for Seasonal Affective Disorder at the National Institutes of Health for an average of 8.8 years required antidepressants in addition to light treatments. Tricyclic antidepressants, MAO inhibitors, and SSRIs were all found to be useful for some of these patients.

Ref: Schwartz PJ et al. American Journal of Psychiatry 1996, 153, 1028-1036.

Q: Patients maintained on long-term SSRIs frequently have recurrences of their depressions despite the therapy. What is the best way for such recurrences to be managed?

A: Patients who have depressant recurrences while taking one of the SSRIs should first have the dose of the antidepressant increased to the maximally tolerated dose. If this leads to no improvement, within 6-weeks, the SSRI should be stopped and the patient switched to a drug of another class. If increasing the dose to the maximally tolerated dose leads to some, but insufficient, improvement, its actions should be potentiated by the addition of lithium, a tricyclic antidepressant, thyroid hormones, or buspirone. If there is a significant risk of suicide, ECT should be considered.

Ref: Nierenberg AA American Society For Clinical Psychopharmacology Progress Notes, 1996, 7, 1-3.

Q: What would you prescribe for a 32 year old physician who finds it hard to function because of rapid cycling between moderately severe depression and hypomania. Various combinations of lithium, carbamazepine, and valproate have failed to control the cycling process.

A: People with rapidly cycling Bipolar Disorder can be very hard to treat. Many do not respond to lithium and while some will respond to carbamazepine and/or valproate, others will not. I have recently treated 14 people with treatment-resistant rapidly cycling Bipolar Disorder with lamotrigine and have found it to be highly effective and well tolerated. In patients not taking valproate the starting dose is 25 mg at bedtime, and the dose is increased in 25 mg steps every 5-days until a dose of 150 mg or 200 mg. is reached. Nine of the 14 people, who had previously failed to respond to carbamazepine and/or valproate, responded to treatment with lamotrigine.