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Q: Mood is Good Yet Feels Lethargic
Dear Dr. Phelps,
I've been diagnosed bipolair II in the end of 2003. In the six years before I
experienced 2 episode of true mania, retrospectively induced by antidepressants,
a few periodes of hypomania, and quit a few more episodes of depression.
I'am using lithium 1200 mg and moclobemide 450 mg right now. I used venlafaxine,
fluoxetine and paroxetine before, but the sexual problems I experienced with the
SSRI and SNRI category were bothersome. The combination is doing just fine, as
far as my mood is concurned. I was amazed that a mood stabilizer could extually
prevent the (hypo)mania ... for the first time in 5 years my mood was good and
... reactive to the (emotional) stimuli around me. Great!
So what's the problem then? Well, I have to say that although the mood part is
doing great, I still feel the need to sleep so much. It is not that I'am tired,
it's more sleepiness, the same thing I experience during a depression in a very
sever manner (the term "letheragy" would be more applicabele then. I can
litterally sleep for days). So in other words, there is some kind of "remnent"
of the "physical" component of depression, it seems too me.
What could be the cause/what could be done about that? I noticed that
moclobemide is more of an "energizer" than the other AD's ... is something even
more energizing? I'm very content with it actually, so few side-effects as it
has.
PS lab findings are normal. TSH = 2.60 (before lithium 1.01), free T4 = 15.9
(European Units prob. mmol/l)
Thanks for your time
Dear Matthew --
That was smart of you to include the thyroid numbers: that was my first thought
("I wonder what his TSH is"). As you may see discussed in another letter of
this date, there is very good reason to think that thyroid hormone is a safe
thing to try, as long as you don't take so much you become hyperthyroid.
Getting your TSH back down around 1.0, where it used to be; which you probably
have learned is an inverse marker for your total thyroid situation (it goes down
when thyroid goes up, as explained in this essay on
Thyroid and
Bipolar disorder); not only is a very safe thing to try but has also
implicated in one study to be related to depression response in bipolar
disorder. (Cole
and colleagues).
When considering thyroid hormone, some psychiatrists
would also consider using the T3 version as well as the T4 version, as you'll
see discussed in my essay linked above, and some might consider using just T3
alone though that's based mostly on some old work by Bob Joffe (here's his
review) (and here are his studies,
1 and
2).
As for other explanations, basically I'm not sure. As
you imply, usually when someone's bipolar depression improves, so does
their energy. To have this little energy after your mood has substantially
improved is puzzling and so you're right to wonder if it's really coming from
bipolar disorder.
And finally, as you've probably also been told or
considered, when all else fails (re: trying to effectively explain it),
there's always just trying to treat it. And one tool to keep in mind
there is modafinil (Provigil), which I've now seen have a remarkable positive
effect (not at 100 mg, but at 200 mg; haven't gone higher yet) in one patient
with no side effect problems. However, since it's new, who knows what will turn
up down the road (i.e. there aren't that many folks ahead of you finding out the
long-term problems); and you and your doc' would have to check very carefully to
see if there's any problem using it with an MAOI.
Dr. Phelps
Published October, 2004
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